Expired and Improperly Labeled Medications and Insulin Pens
Penalty
Summary
Surveyors identified a failure to properly store and manage medications, including expired and undated drugs, in a medication room and on a medication cart. Review of the facility’s policy "Storage of Medications F761" stated that discontinued, outdated, or deteriorated drugs or biologicals must not be used and must be returned to the pharmacy or destroyed. During an observation of the A/B/E-Hall medication room on the second floor with a unit manager RN, five floor-stock 50% Dextrose injection 25 g/50 mL units were found in a box under the counter with an expiration date of 07/2025. The RN confirmed the medications were expired and stated she was not aware they were in that box. During a separate observation of the B-Hall medication cart with an LPN, surveyors found multiple issues with insulin pens. One insulin Aspart pen had an open date of 1/1/2026 and an expiration date of 1/31/2026, indicating it had been in use for more than 28 days and was expired as of 1/28/2026. One Lantus Solostar insulin pen was open and in current use with no documented open date or expiration date. One insulin Lispro (Humalog) KwikPen was labeled with an open date of 1/28/2026 and an expiration date of 2/5/2026, reflecting a 7-day expiration instead of the manufacturer-recommended 28 days after opening. The LPN confirmed the labeling issues, stated that multiple nurses use the carts and that she did not open or label those pens, and acknowledged that insulin removed from refrigeration should be dated and assigned a 28-day expiration. The DON later stated that nurses are required to verify the MAR three times before administration, unit managers are responsible for weekly cart checks and daily medication room checks, and that all insulin on carts must be labeled with the date opened and a 28-day expiration, with undated or expired insulin to be discarded, and that use of expired medications may be harmful with unknown potential side effects.
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