**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, a review of Fundamentals of Nursing, Ninth Edition, and a review of the manufacturer's information for Lantus insulin, the facility failed to ensure Resident Identifier (RI) #39 was not administered expired insulin on 03/19/18 and 03/20/18. This affected one of one sampled resident reviewed for expired medication. Findings Include: A review of Fundamentals of Nursing, Ninth Edition, copyright 2017, page 654, revealed: .SAFETY GUIDELINES FOR NURSES .Verify expiration date of every medication during preparation. Do not administer expired medications . A review of the manufacturer's information for Lantus insulin revealed: Discard all containers in use after 28 days, even if there is insulin left. Also discard all insulin products after the expiration date on the package . RI #39 was readmitted to the facility on [DATE] with diagnoses of Type 2 Diabetes and Long Term Use of Insulin. A review of RI #39's March 2018 Physician Orders revealed an order for Lantus insulin 25 units to be given subcutaneously every night. A review of RI #39's March 2018 Medication Administration Record (MAR) revealed RI #39 was administered the Lantus insulin on 3/19 and 3/20/18, after its expiration. On 3/21/18 at 12:41 p.m., during an observation of a medication cart with Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), a vial of Lantus insulin for RI #39 was observed with an open date of 2/18. The vial was also labeled with a written expiration date of 3/20, exceeding the 28 day expiration date specified by the manufacturer. The expiration date of the insulin opened on 2/18 would be 3/18. On 3/22/18 at 3:31 p.m., EI #4, LPN, was interviewed and asked what was found on the medication cart during observations on 3/21/18. She replied one vial of insulin was labeled with an open date of 2/18 and expiration date of 3/20, which was more than 28 days. EI #4 was asked how long after insulin was opened did it expire. EI #4 replied 28 days after it was opened. EI #4 reviewed RI #39's March 2018 MAR and stated the resident received two doses of expired Lantus insulin. EI #4 stated two medication errors were made. On 3/22/18 at 3:48 p.m., EI #5, the LPN that initialed administering RI #39's Lantus insulin on 3/20/18, was interviewed . When asked how long a vial of opened insulin was safe to use, EI #5 stated 28 days. EI #5 explained RI #39's insulin should not have been administered because it expired on 3/19/18. When asked what was the potential concern for a resident receiving expired insulin, EI #5 said it may not work properly, inadequate control, and the resident may not get the correct dose. EI #5 said expiration dates of insulin should be checked prior to administering the medication. After reviewing RI #39's March MAR, EI #5 stated RI #39 had received expired insulin on 3/20/18. She further stated she got confused because February had fewer days than other months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, including facility policies titled, PREPARATION FOR MEDICATION ADMINISTRATION and VIALS AND AMPULES (INJECTABLE MEDICATIONS), the facility failed to ensure outdated insulin vials were not on a medication cart. This was observed on one of four medication carts in the facility observed by the surveyors. Findings Include: A review of a facility policy titled, 6.1 Preparation For Medication Administration, dated 01/12, revealed: .6. Multi-dose medications, like injectables .should be dated when opened and discarded according to manufacturer's specifications. A review of a facility policy titled, 7.13 Vials and Ampules (Injectable Medications), dated 01/12, revealed: . 2. The initials of the first person to use the vial and the date opened are recorded on multidose vials 3. A. When opened, most multidose vials of insulin may be used (refrigerated or at room temperature) for four weeks. See specific package labeling. A review of the manufacturer's prescribing information on page 32 of 43 revealed: . Do Not use LANTUS after the expiration date stamped on the label or 28 days after you first use it. A review of the manufacturer's prescribing information on Humalog 100 revealed, Throw away all insulin lispro in use after 28 days, even if there is insulin left. Also throw away all insulin products after the expiration date on the package. A review of the manufacturer's prescribing information on Novolog 100 revealed, Throw away all insulin lispro in use after 28 days, even if there is insulin left. On [DATE] at 12:41 p.m., an inspection of a medication cart was conducted with EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse). A vial of LANTUS insulin with a resident's name on it was observed on the medication cart with an open date of 2/18. The vial was also labeled with an expiration date of 3/20. If opened on 2/18, the expiration date would be 3/18, 28 days per manufacturer's information. On [DATE] at 12:50 p.m., an empty vial of HUMULIN 70/30 insulin labeled for a resident was observed on the medication cart with no date or initial on the vial or the box. On [DATE] at 12:53 p.m., a vial of HUMALOG 100 insulin labeled for a resident was observed on the medication cart with an opened date of [DATE] and an expiration date of [DATE]. On [DATE] at 1:00 p.m., a vial of NOVOLOG insulin labeled for a resident was observed on the medication cart with an opened date of [DATE] and a written expiration date of [DATE]. On [DATE] at 3:31 p.m., EI #4, LPN, was interviewed and asked what was observed with the surveyor on the medication cart during the inspection on [DATE]. EI #4 stated expired insulin vials, two vials of opened insulin were both dated with an expiration date of 57 days. EI #4 stated one vial had no dates but was opened. EI #4 further stated one vial had an open date of 2/18 and an expiration date of 3/20, which was more than 28 days. EI #4 was asked how long after insulin was opened did it expire and EI #4 replied 28 days after it was opened. On [DATE] at 3:48 p.m., EI #5, a LPN, was interviewed. EI #5 was asked how long was an opened vial of insulin safe to use and EI #5 replied 28 days. EI #5 was asked if a vial of LANTUS insulin was opened on 2/20 when would it expire. EI #5 responded, on 3/20. EI #5 was asked again if this was correct and EI #5 stated, Well, you have 8 days in February and 20 days in March. EI #5 was asked if the insulin was dated 2/20 how many days in February was the insulin used. EI #5 responded 9 days and then it expired on 3/19. EI #5 was asked if the vial of LANTUS insulin was dated with an open date of 2/20 was it safe to administer to the resident on 3/20. EI #5 said no, it expired on 3/19. When asked what was the concern if a resident was administered expired insulin, EI #5 stated it may not work properly, inadequate control and the resident may not get the correct dose. EI #5 was asked if she checked opened and expired dates prior to administration of insulin and EI #5 responded yes. EI #5 was asked if there was an expiration date on the vial of insulin did she verify it was correct prior to administering to the resident and she responded yes. When asked why, EI #5 stated to make sure it was the correct date.