Improper Labeling and Expired Insulin and Haloperidol on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to properly label and discard medications in accordance with its own policies and accepted professional standards. Review of the facility’s “Storage of Medication” policy dated January 2025 and its appendix “Medications with Shortened Expiration Dates” (2007) showed that medications and biologicals must be stored to maintain integrity, insulin vials and pens must be dated when first used, and lispro insulin must be discarded 28 days after opening. During observation of the South Wing B Hall medication cart with a registered nurse, surveyors found an opened 1 ml single-dose vial of haloperidol lying loose in a plastic bin with insulin pens, without a resident name or date on the vial. The nurse confirmed the vial was not labeled or dated and acknowledged it should have been discarded after single use. On the South Wing C Hall medication cart, observed with an LPN, surveyors identified a lispro insulin pen for Resident 74 dated as opened on February 16, 2026, which exceeded the 28-day discard timeframe specified in the facility’s policy. They also found a Lantus insulin pen for Resident 5 that had been opened but was not dated, although the pharmacy label showed it had been dispensed on March 13, 2026. The LPN confirmed that Resident 74’s insulin pen was beyond the 28-day expiration and should have been discarded, and acknowledged that the Lantus pen should have been dated when opened and that she may have been the nurse who opened it without dating it. In a subsequent interview, the DON stated she expected medications to be labeled and stored properly and discarded when expired per policy or manufacturer guidelines.
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