Failure to Label Opened Insulin Pen in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically insulin, were labeled in accordance with accepted professional principles and facility policy. During an observation of a medication cart, an insulin pen assigned to a resident with type 2 diabetes mellitus and hyperglycemia was found without a label indicating the date it was opened or removed from refrigeration. The only information present was the pharmacy label. The LVN assisting with the observation was unable to confirm when the insulin pen was opened or removed from the fridge and stated that the facility's process is to label insulin pens and vials with the date of opening, keeping them for 29 days after removal from refrigeration before discarding. The LVN was also unsure if the resident had been administered insulin from the unlabeled pen that day. The DON confirmed that facility policy requires insulin to be dated when opened and discarded after 28 days. Review of the facility's policy on medication labeling and storage corroborated this requirement, stating that multi-dose vials must be dated and discarded within 28 days unless otherwise specified by the manufacturer. The failure to label the insulin pen with the date of opening or removal from refrigeration constituted noncompliance with both professional standards and facility policy.