Failure to Administer Medications as Ordered and Remove Expired Insulin Pens
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for residents. Specifically, a male resident with multiple diagnoses, including protein-calorie malnutrition, diabetes, and cerebrovascular disease, did not receive his prescribed dose of vitamin C as ordered by his physician. The physician's order required two 500 mg tablets of ascorbic acid to be administered once daily, but only one tablet was given on at least one occasion. The nurse responsible acknowledged the error, stating she missed the correct dosage during medication administration. Additionally, the facility did not ensure the timely removal of expired aspart insulin pens from a medication cart. Three insulin pens were found in use beyond the recommended 28-day period after opening, with one pen expired for 31 days, another for 9 days, and a third for 5 days. Nursing staff were expected to check medication carts daily for expired medications, but these insulin pens were overlooked and remained accessible for use. Interviews with nursing staff and the DON confirmed that the facility's procedures required adherence to prescriber orders and timely removal of expired medications. The facility's policies outlined the need for safe and timely medication administration, including verifying the correct dosage and removing outdated medications. However, these procedures were not followed, resulting in medication errors and the presence of expired insulin pens on the medication cart.