F0761

D

Failure to Date and Remove Expired Multi-Dose Insulin Pens From Medication Cart

Eden, North Carolina Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to properly date and remove multi-dose insulin pen injectors from a medication cart on the 500-hall. During an observation of the cart with a nurse, two open and undated Lantus insulin pen injectors were found. Review of the manufacturer's instructions showed that Lantus multi-dose vials are to be discarded 28 days after opening, but there was no way to determine when these pens had been opened due to the lack of dating.

Further inspection of the same cart's second drawer revealed additional issues with expired insulin pens. One opened Lispro insulin pen was marked as expired on 2/10/26, one opened Aspart Flex insulin pen was marked as expired on 1/15/26, and one opened Glargine insulin pen was marked as expired on 2/9/26, yet all remained in the cart. In interviews, the nurse stated that nurses assigned to the carts were responsible for discarding open and undated multi-dose vials and that training required dating vials upon opening, but she acknowledged she had not checked opening or expiration dates at the start of her shift. The DON also stated that nurses were responsible for checking opening and expiration dates on medications in the carts at the beginning of each shift and expected that no expired items remain in the carts.