Expired Insulin Pen and Eye Drops Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication storage and labeling related to expired multi-dose medications on East Annex Medication Cart #1. During an observation, they found one open insulin lispro injector pen with an opened date of 11/3/25 that remained in use beyond the manufacturer’s recommended 28-day discard period. They also found one bottle of latanoprost 0.05% eye drops with an opened date of 10/29/25 and a handwritten discard date of 12/10/25, and one bottle of dorzol/timolol eye drops with an opened date of 11/13/25 and a handwritten discard date of 12/11/25, both still present on the cart after those dates. Manufacturer instructions specified that insulin lispro pens and dorzol/timolol eye drops should be discarded 28 days after opening, and latanoprost eye drops should be discarded 6 weeks after opening. During the medication cart observation, the nurse present acknowledged that the insulin pen should have been removed after 28 days and that the eye drops should have been discarded on the expiration dates written on the bottles. In a phone interview, the Pharmacy Consultant confirmed the discard time frames for each medication based on manufacturer instructions. The DON stated that Unit Managers and floor nurses were responsible for checking medication carts daily for expired medications and discarding them, and the Administrator stated that her expectation was that nursing staff would check the carts daily and ensure there were no expired medications in the carts. Despite these stated responsibilities and expectations, expired medications remained on East Annex Medication Cart #1 at the time of the survey.
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