Improper Labeling and Dating of Insulin Pens on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that insulin pens stored on a secure male unit medication cart were properly labeled and dated in accordance with professional standards and the facility’s own medication administration policy. During an observation of one of two medication carts, surveyors and an LVN identified a Basaglar KwikPen and a Lantus KwikPen without open dates, and another Lantus KwikPen without both a resident name and an open date. Facility policy required that multi-dose containers be dated when opened and that insulin pens be clearly labeled with the resident’s name or other identifying information prior to administration. Multiple LVNs interviewed confirmed that insulin should be dated as soon as it is opened, that opened insulin is considered expired after 28 days, and that each nurse is responsible for checking their medication cart to ensure insulin is properly labeled and dated. One LVN stated that insulin without a resident name needed to be labeled to ensure the correct resident received the medication. Another LVN stated that undated insulin could be expired and could cause residents to be hypoglycemic or hyperglycemic. The interim DON stated that nursing staff were responsible for checking their medication carts on every shift and that opened insulin was considered expired after 28 days, underscoring that the undated and unlabeled insulin pens on the cart were not in compliance with facility policy and accepted professional principles.
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