Failure to Label Insulin Pens with Open Dates on Medication Carts
Penalty
Summary
Surveyors observed that the facility failed to properly label insulin pens with the date they were opened on two medication carts. Specifically, several insulin pens for multiple residents were found in use without an open date, despite instructions on the pens indicating they should be discarded 28 days after opening. Both direct observation and interviews with nursing staff confirmed that it was the nurses' responsibility to label insulin pens with the open date to ensure proper tracking of expiration, but this was not consistently done. The Director of Nursing also acknowledged that insulin pens and vials needed to be dated upon opening due to their limited shelf life after being opened. Record review of the facility's own policy confirmed that insulin products should be labeled with the date when first used. The pharmacy consultant was noted to check the carts monthly, and the DON reported conducting random checks, but these measures did not prevent the observed lapses. The lack of open dates on insulin pens could result in the use of insulin beyond its effective period, as the pens were observed to be in use without proper labeling.