Undated Open Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage when they observed an opened, undated multi-dose insulin isophane human/insulin regular human 70/30 pen assigned to Resident #55 in the 200-hall medication administration cart. Manufacturer instructions for this insulin specify that once opened, the pen may be stored at room temperature for 31 days, which requires clear dating of the opening to determine usability. During the observation of the 200-hall cart with Nurse #1, the insulin pen was found without an open date label. In interviews, Nurse #1 stated that insulin pens should be dated when opened and acknowledged she was unaware that this particular pen was not dated. She also stated that nurses were supposed to check their medication carts daily but admitted she had not checked the cart that day and did not provide an explanation for this omission. The consulting pharmacist reported that she reviews at least two medication carts every two months, including checking labels and open dates on insulin, and stated that open insulin should have an open-date label and that carts should be inspected monthly. The DON stated that nurses are responsible for daily checks of their assigned carts and Nurse Managers for monthly inspections, specifically to look for open and expired medications, and the Administrator confirmed that nurses are responsible for labeling and dating insulin pens when they are removed from refrigeration and opened, and that multiple parties are responsible for checking medication carts.
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