Failure to Monitor Medication Fridge Temperatures and Date Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to ensure drugs and biologicals were stored and monitored according to professional standards, specifically related to medication refrigerator temperature logs and insulin pen dating. During observation of the locked medication room, the refrigerator temperature log forms for the months of September through November 2025 were found to be incomplete, indicating that temperatures were not being routinely monitored as required. This was confirmed in an interview with the DON, who stated that nurses are expected to complete the fridge temperature log once each shift, and acknowledged that this did not occur. In addition, during observation of a nurse medication cart, insulin pens assigned to multiple residents were found without dates indicating when they were first used and without discard dates 28 days after first use. In an interview, an RN confirmed that the insulin pens were not dated when first used and were not dated for discard after 28 days, and stated that undated insulin pens are considered expired and should be disposed of appropriately. The DON also confirmed that undated insulin pens are considered expired and should not be present in the medication carts.
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