Unsecured and Improperly Labeled Insulin and Injectable Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to secure and properly manage insulin and other injectable medications on a medication cart. During continuous observation of medication administration with one nurse on Medication Cart #1, four insulin injector pens were left unattended on top of the cart while the nurse twice walked away and out of eyesight of the cart. On both occasions, a resident was seated beside the cart waiting for medication while the unsecured insulin pens remained on top. The nurse later stated the pens belonged on another cart, acknowledged she had placed them on Cart #1 earlier when administering insulin because the medication aide could not give insulin, and admitted she did not realize she had left them unsecured when she walked away. Further observation of Medication Cart #1 revealed multiple issues with labeling and expiration of injectable medications. One Novolog pen for a resident had 12 units remaining and a blank label with no open date or expiration date. One Lantus pen for another resident had 80 units remaining and a blank label with no open date or expiration date. A Novolog pen for a third resident had 100 units remaining and a blank label with no open date or expiration date; the nurse later stated she had opened it at noon the same day and forgot to date it. An Aspart pen for another resident was labeled as opened on 01/08/26 with an expiration date of 02/04/26, despite manufacturer directions stating Aspart pens should be discarded 28 days after opening. A Liraglutide injection pen for another resident was labeled as opened on 01/10/26 with an expiration date of 02/06/26, although manufacturer directions indicated it should be discarded 30 days after opening. The DON and Administrator confirmed that staff are expected to keep medications secured, label injector pens with open and expiration dates at the time of opening, and remove expired medications from use.
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