Incorrect Insulin Storage Labeling and Unsigned Physician Order Recaps
Penalty
Summary
The facility failed to ensure accurate storage instructions on medication labels for insulin injection pens belonging to three patients with type 2 diabetes mellitus. During an observation of the medication cart, it was found that the labels on one Novolog and two Lantus Solostar insulin pens incorrectly instructed staff to keep the pens refrigerated after opening. Licensed staff acknowledged that insulin does not require refrigeration after opening and that the labeling should have been clarified with the pharmacist. The facility's policy required proper and safe storage of drugs, including correct labeling, but this was not followed for these medications. Additionally, the facility failed to ensure that monthly physician's order recapitulation reports were signed and dated for two patients. This omission was identified through interview and record review, and it was noted that the lack of proper documentation had the potential to result in patients not receiving accurate medication and treatment as ordered. The facility's policy required that physician orders be correctly recapitulated, signed, and dated, but this was not done for the affected patients.
Plan Of Correction
Pharmaceutical Service--General How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 9/25/25, the Novolog 100 U/ml and two Lantus Solostar 100 injection pens for patients 10, 11, and 12 were immediately discarded. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with insulin orders are considered at risk of being affected. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with insulin orders to identify any instances of improper insulin storage. - Following the audit, it was determined that no other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/26/25, the Director of Nursing (DON) conducted an in-service with LVN#1 regarding accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with an emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - On 10/10/25 and 10/16/25, the Director of Nursing (DON) conducted in-service training for all licensed nurses on the facility's policy and procedure for accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with particular emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - Starting 10/16/25, the DON and/or ADON will conduct random audits 2-3 times per week for 3 months to ensure proper insulin storage. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON and/or ADON will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and develop an action plan to prevent any further deficient practices. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - All residents with insulin orders are considered at risk. - On 10/10/25, the Director of Nursing (DON) conducted an audit of all residents with insulin orders to identify any instances of improper insulin storage. - Following the audit, it was determined that no other residents were affected by this deficient practice. What measures will be put into place or what systemic changes will the facility make to ensure that the identified practice does not recur: - On 9/26/25, the Director of Nursing (DON) conducted an in-service with LVN#1 regarding accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with an emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - On 10/10/25 and 10/16/25, the Director of Nursing (DON) conducted in-service training for all licensed nurses on the facility's policy and procedure for accurate medication storage practices. - The education included a detailed review of the medication labeling instructions, with particular emphasis on the proper storage requirements for insulin to maintain potency and efficacy. - Starting 10/16/25, the DON and/or ADON will conduct random audits 2-3 times per week for 3 months to ensure proper insulin storage. How the facility plans to monitor its performance to make sure that solutions are sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The POC is integrated into the quality assurance system: - The DON and/or ADON will be reporting the results of the monitoring to the QA committee monthly for 3 months for review and recommendations and to ensure substantial compliance is sustained. - Any deficient practices will be corrected immediately and discussed during QA committee meetings to identify root cause and develop an action plan to prevent any further deficient practices. Content of Health Records How corrective action will be accomplished for those residents found to have been affected by the identified practice. Immediate Corrective action(s) for resident(s) found to have been affected by the deficient practice: - On 09/24/25, the monthly Physician's Order Recapitulation Reports for Patients #7 and #8 were reviewed, signed, and dated by the physician. How the facility will identify other residents having the potential to be affected by the same identified practice and what corrective action will be taken: - On 9/26/25, the Medical Records Director conducted a facility-wide audit to verify all Physician's Order Recapitulation Reports were named, signed, and dated. - No other residents were affected by this finding.