F0761

E

Failure to Label Insulin Pens per Facility Policy

Saint Louis, Missouri Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The facility failed to ensure insulin pens were labeled in accordance with its Insulin Labeling and Storage policy, which required all insulins removed from the refrigerator to be dated and labeled with the resident’s name and an expiration date, and specified that insulins are only good for 28 days after opening. During observation of the medication cart used for all residents receiving insulin, a nurse identified the drawer containing insulin pens in use and surveyors observed 10 insulin pens, each with a sticker intended for documenting the date opened and date expired. Of these, nine pens (including insulin aspart, insulin degludec, Lantus, and Humalog) had no date opened and no expiration date recorded. The LPN interviewed at the time stated that all insulin pens should be labeled when removed from the refrigerator and acknowledged they would not know when these unlabeled pens were opened or placed on the cart, despite the policy and the 28‑day usability limit after opening. In a subsequent interview, the administrator and DON stated they would expect staff to follow the facility’s insulin labeling and storage policy.