Unlabeled Insulin Vial Found on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were properly labeled and stored according to professional standards on one of two medication carts reviewed (the 300/400 hall medication cart). During an observation, surveyors found a vial of insulin on this cart that was not in a box and lacked a pharmacy prescription label and resident name, although it had an open date. The LPN responsible for the 300/400 medication cart stated that if a medication does not have a label, they usually discard it or contact the nurse previously in charge of the cart, and acknowledged that residents’ names should be on medications to track usage and prevent sharing among residents. In a separate interview, the DON stated that insulin should be labeled with the medication name, resident’s name, directions, and the date it is opened, and confirmed that the nurse is in charge of the medication cart while the pharmacy is responsible for labeling medications. The DON indicated that if a medication does not have a label, staff must contact the pharmacy for one, and acknowledged that an unlabeled insulin could result in giving the wrong person the wrong insulin. Review of the facility’s “Medication Labeling and Storage” policy, revised February 2023, showed that medication labels must include, at a minimum, the medication name, prescribed dose, strength, expiration date when applicable, resident’s name, route of administration, and appropriate instructions and precautions, which was not met for the unlabeled insulin vial found on the 300/400 medication cart.
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