Failure to Label and Date Opened Insulin Pens in Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to properly label and date opened insulin pens stored in one of its medication carts. Specifically, two opened insulin pens, Lantus 100 unit/ml and Insulin pro 100 units/ml, were found without patient labels or dates indicating when they were opened. This was identified during an observation of the 600-hall medication cart. During interviews, a nurse confirmed that it was the responsibility of nursing staff to ensure all insulin pens and vials had patient labels and open dates, and acknowledged that the pens in question were not labeled or dated as required. Further interviews with the Director of Nursing (DON) confirmed that all insulin pens and vials should be labeled and dated upon opening, as insulin expires 28 days after being opened. The DON stated that it was the responsibility of every nurse to check for proper labeling and dating before administering insulin. The facility's policy also requires that medications be stored safely and properly, and that outdated or improperly labeled medications be immediately removed. However, the audit process for medication carts was not conducted on a set schedule, and the pharmacist only audited the carts monthly.