Expired and Unlabeled Insulin Pen Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications when an Insulin Lispro KwikPen on the Mill Place medication cart was found to be both expired and unlabeled. Manufacturer guidance from 2023 specified that the Insulin Lispro KwikPen must be discarded 28 days after opening, yet the pen observed on 12/10/25 had been opened on 10/16/25 and remained available for use. The pen had no label and did not display any information identifying the resident’s name or room number. Nurse #4, who was present during the observation, confirmed that the insulin should have been discarded 28 days after opening and acknowledged that all nurses using the cart were responsible for checking and removing expired medications. In a follow-up interview, Nurse #4 identified the unlabeled insulin pen as belonging to Resident #36 and stated that both the KwikPen and its storage box should have been labeled with the resident’s name and room number. The interim DON reported that nurses assigned to the medication cart were responsible for identifying and removing expired medications and that the third shift (11 p.m. to 7 a.m.) was designated to check one cart per week. The interim DON also stated that the KwikPen should have a pharmacy label with the resident’s name and room number. The Administrator stated that nursing staff must follow the manufacturer’s guidelines and audit both the medication cart and the medication room during their shifts.
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