Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors observed that an opened and used Humalog (insulin lispro) pen was stored on the West Wing Medication Cart without a label indicating the patient name, physician name, or date used. The only identifying mark on the insulin pen was a room number handwritten with a black marker. Staff Nurse #6 confirmed that he administered insulin using this unlabeled pen and believed that the room number was sufficient for identification. The facility's policy, as provided by the Director of Nursing, requires that insulin pens be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. Further interviews with the Director of Nursing and the pharmacy consultant confirmed that all insulin pens must be labeled with the patient's name, physician name, and date opened. The pharmacy consultant also stated that any opened, unlabeled insulin pens should not be used and that the facility should notify the pharmacy to order a new, properly labeled pen. The failure to label the insulin pen as required by both facility policy and professional standards led to the identified deficiency.