Expired Insulin Pen Not Removed From Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication storage and labeling when they found an expired multi-dose insulin glargine injector pen on one of five medication carts reviewed (Station 2 medication cart #1). The insulin pen had a manufacturer’s instruction to be discarded 28 days after opening, with labeling indicating an opened date of 1/20/26 and a handwritten expiration date of 2/17/26, yet it remained on the cart when observed on 2/26/26. The pen was open and still stored on the cart beyond the 28-day discard date specified by the manufacturer. During interviews, the medication aide assigned to that cart stated she did not administer insulin injections but acknowledged the insulin glargine pen should have been discarded after 28 days. The nurse covering that cart confirmed the expired insulin pen should have been removed and discarded and stated that nursing staff, including medication aides, were expected to check medication carts daily for expired medications. The Pharmacy Consultant also confirmed the pen should have been discarded 28 days after opening. The DON and the Administrator both stated that floor nurses and nursing staff, including medication aides, were responsible for checking medication carts daily and ensuring there were no expired medications, indicating that this expected practice had not been followed for the insulin pen found on Station 2 medication cart #1.
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