Failure to Properly Label and Remove Expired Insulin from Medication Carts
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically insulin pens and vials, were properly labeled and stored according to professional standards. During observations of three medication carts, surveyors found insulin pens that had been opened and not dated, as well as insulin pens that remained in use beyond their manufacturer-recommended expiration period after opening. Nursing staff present during the inspections acknowledged that the insulin pens should have been removed once expired and that opened vials should have been dated. The staff indicated that it was each nurse's responsibility to check their assigned medication carts for expired or undated medications, but these checks were not consistently performed. Interviews with the DON and Administrator confirmed that the facility's expectation was for nursing staff to date insulin products upon opening and to discard them after the recommended period, typically 28 to 30 days. Facility policy also required dating insulin pens when placed into use and discarding them after 28 days at room temperature. The deficiency was attributed to nursing staff failing to inspect their medication carts as required, resulting in expired and undated insulin remaining available for resident use.