F0761

D

Failure to Label Opened Insulin Vial Before Administration

Pompano Beach, Florida Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own policy requiring that opened insulin vials be labeled with the date they are opened. The facility’s written policy on insulin administration, dated 06/15/20 and reviewed on 07/20/25, specifies that opened insulin must be labeled with the date. During a medication administration observation, a RN (Staff E) retrieved an insulin vial that did not have an open date on the label. When questioned, Staff E stated that she was allowed per facility policy to administer insulin without an open date and acknowledged that she had administered insulin from vials without open date labels before. She then drew up insulin based on the resident’s blood sugar reading and administered it to Resident #3 using this unlabeled vial.

Resident #3’s record showed admission on a specified date with diagnoses including Disseminated Intravascular Coagulation (Defibrination Syndrome), a personal history of endocrine and metabolic diseases, peritoneal abscess, and COPD with acute exacerbation. The most recent MDS assessment documented a disabled BIMS score and noted the use of hypoglycemic and anticonvulsant medications. In contrast to Staff E’s practice, another RN (Staff F) reported that her responsibility for insulin administration includes checking expiration dates and ensuring vials have an open date label, and she stated she would not administer insulin from a vial without an open date. A third RN (Staff G) similarly stated that all medications, including insulin, are labeled with opening dates and that he would not administer insulin from a vial lacking an opening date. The DON also stated that all insulin vials are labeled with opening dates, which conflicted with the observed practice involving Resident #3.