Failure to Date Opened Insulin Pens and Vials on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multi-dose insulin pens and an insulin vial were dated when opened, as required to comply with manufacturer instructions for safe use. During observation of the 400-hall medication cart with a medication aide, surveyors found opened Humalog and Lantus prefilled insulin pens without an opened date, despite manufacturer directions to discard them 28 days after opening. The medication aide stated that nurses and medication aides were responsible for checking medication carts for expired medications but explained that, as a medication aide, she could not administer insulin and did not check dates on insulin products. The unit manager for that hall stated that nurses should be checking the carts to ensure there were no expired medications and that all insulin pens were dated once opened, and she identified from the pharmacy labels that the Lantus and Humalog pens had been received on 01/12/26 and had been used without being dated when opened. On the 100-hall long-term care medication cart, observed with a nurse, surveyors found an opened Tresiba prefilled insulin pen, an opened Lispro insulin vial, and an opened Insulin Glargine prefilled insulin pen, all without opened dates, even though manufacturer instructions required discarding Tresiba 56 days after opening and the Lispro vial and Insulin Glargine pen 28 days after opening. The nurse stated that all nurses were responsible for checking their medication carts for expired medications and ensuring insulin pens and vials were dated when opened, and acknowledged that these insulin products should have had an opened date so staff would know when they should be used by. On the 100-hall skilled care medication cart, observed with another medication aide, an opened Lantus prefilled insulin pen was found without an opened date, despite manufacturer instructions to discard after 28 days once opened. This medication aide stated that all nurses and medication aides were responsible for checking medication carts for expired medications but, as a medication aide who could not administer insulin, she did not check opened dates on insulin pens. The overseeing unit manager stated she should have checked the cart at the start of the shift to ensure all insulin pens were dated once opened. The DON reported that her expectation was that once an insulin pen or vial was opened, nurses should place an opened date on it so they could determine if the medication was still good for use according to manufacturer instructions.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.