Failure to Secure Controlled Drugs and Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure controlled medications were secured with a dual lock system and failed to discard an outdated insulin pen. During an observation of the 100-200 hall medication room, an LPN opened the medication room and the resident medication refrigerator was found with an open lock hanging on the latch, leaving it unlocked. Inside the unlocked refrigerator was a new box of Methadone Oral Concentrate, a Schedule II controlled substance, for a resident who had a physician’s order for Methadone 10 mg/ml, 4 ml by mouth once daily for pain. The DON confirmed that the medication room refrigerator should be locked. The facility’s Medication Storage Policy stated that all drugs and narcotics must be stored in a locked storage area with limited access by authorized personnel. In a separate incident, a resident’s Humalog KwikPen insulin was observed with a written expiration date that had already passed. An RN stated that the insulin pen should have been thrown away and explained that nurses label insulin with a “use by” date 30 days from when it is opened. The resident’s records showed a diagnosis of diabetes and an active order for Humalog KwikPen to be administered before meals and at bedtime per a sliding scale. The facility’s Insulin Pen Policy specified that insulin pens should be disposed of after 28 days, indicating that the insulin pen in use was outdated according to the facility’s own policy.
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