Improper Storage of Insulin Pen on Medication Cart
Penalty
Summary
The deficiency involved the facility’s failure to properly secure and store a resident’s insulin Lispro pen in a locked medication cart as required by facility policy and professional standards. Surveyors observed three medication carts on the 300 Hall, with the middle cart having an insulin Lispro pen sitting on top of the cart counter, labeled with Resident #2’s name, rather than being locked inside the cart. Record review showed that this resident was a cognitively intact male with type 1 diabetes and dependence on renal dialysis, with active orders for insulin Lispro via pen-injector for use before dialysis sessions and per sliding scale with meals. During interview, LVN E reported that she had obtained and administered a dose of insulin Lispro to this resident earlier in the day and had written the open date on the insulin cap. She stated she believed the insulin pen may have been left on top of the cart by the previous shift because the counter area where it was found was not her assigned cart, and she could not recall whether she had failed to lock the insulin pen in her own cart. LVN E acknowledged that all medications should always be locked in the medication cart. The DON confirmed that medications, including insulin, were required to be locked in the medication cart immediately after use, that only nursing staff were allowed to administer insulin, and that an unlocked insulin pen was considered a safety concern. Facility policy on Medication Storage in the Facility stated that medications and biologicals must be stored safely, securely, and properly, and that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.