Expired Insulin Pen Administered Due to Failure to Check Expiration Date
Penalty
Summary
Surveyors identified a failure to meet professional standards of quality related to insulin administration for one resident with type 2 diabetes mellitus. The resident was cognitively intact, used insulin, and had a care plan directing finger stick blood sugars as ordered, medications as ordered, and monitoring for signs and symptoms of hypoglycemia. Manufacturer instructions for the resident’s glargine insulin pen required it be discarded 28 days after opening. Review of the Medication Administration Record showed the resident received a glargine insulin injection on 2/25/26 at 8:00 p.m. by a nurse. Observation of the medication cart the following day revealed an open glargine insulin pen for this resident dated as opened on 1/20/26 with an expiration date of 2/17/26, indicating it had been used beyond the 28‑day period. A second glargine pen for the same resident was present, unopened and undated. In an interview, the nurse who administered the insulin on 2/25/26 stated she was unaware the pen had expired on 2/17/26 because she did not check the expiration date prior to administration and acknowledged she should have discarded the expired pen. The Pharmacy Consultant confirmed the pen should have been discarded 28 days after opening due to decreased potency after the expiration date. The Nurse Practitioner stated she was unaware the resident had received expired insulin and indicated nursing staff were expected to check medication carts daily for expired medications. The DON and the Administrator both stated that floor nurses were responsible for checking medication carts daily for expired medications, discarding any expired medications, and ensuring no expired medications remained in the carts.
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