PLAINFIELD, IN - A recent health inspection at Plainfield Health Care Center revealed critical medication management failures, including expired insulin and undocumented COVID-19 vaccinations, raising concerns about patient safety protocols at the 3700 Clarks Creek Road facility.
Expired and Undated Insulin Posed Risk to Diabetic Residents
Inspectors documented multiple instances of improper insulin storage and labeling across medication carts and rooms during the April 7, 2025 inspection. The findings revealed a pattern of medication management deficiencies that could have serious consequences for residents with diabetes.
Three insulin pens belonging to Resident 41 were found in the 500-hall medication cart without dates indicating when they were first opened. Similarly, Resident 96 had two undated insulin pens—one containing admelog insulin and another containing lispro insulin—stored in the same cart. Most concerning, inspectors discovered an expired vial of insulin lispro belonging to Resident 27 in the Caring Heart medication room, dated from a previous month.
Insulin is a time-sensitive medication that requires precise management. Once opened, insulin pens and vials have limited shelf lives—typically 28 to 42 days depending on the type—after which their potency degrades. Using expired or improperly stored insulin can result in unpredictable blood glucose control, potentially causing dangerous fluctuations that lead to hyperglycemia or hypoglycemia.
When insulin loses effectiveness due to age or improper storage, residents may receive inadequate doses without staff realizing the medication has degraded. This can cause blood sugar levels to rise dangerously high, leading to diabetic ketoacidosis, a life-threatening condition. Conversely, if staff increase doses thinking the insulin is ineffective when it actually retains some potency, residents could experience severe low blood sugar episodes resulting in confusion, seizures, or loss of consciousness.
Staffing Concerns Cited for Medication Management Failures
When questioned about the undated and expired insulin, RN 5 stated there were "too many nurses working on 500 hall to keep up." This explanation raises questions about whether the facility's medication management systems were adequate regardless of staffing levels.
Proper medication management requires systematic protocols that don't depend solely on individual nurse workload. When insulin pens are removed from refrigeration and first used, they must be dated immediately to ensure they're discarded before losing potency. This is a basic safety measure that protects residents from receiving ineffective medication.
The facility's own policy on medication storage, revised in 2024, explicitly states that "outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to the procedures for medication destruction, and reordered from the pharmacy, if a current order exists."
Missing COVID-19 Vaccination Documentation
The inspection also identified gaps in COVID-19 vaccination documentation. Resident 55, who had multiple complex medical conditions including migraines, muscle weakness, chronic pain syndrome, and acute respiratory failure, had no documentation in her record showing she had received COVID-19 vaccination or declined it.
The Minimum Data Set consultant confirmed during an interview that she searched the system for vaccination records or declination forms for Resident 55 but "could not find either one." This documentation gap is particularly concerning for a resident with acute respiratory failure, as COVID-19 poses elevated risks for individuals with underlying respiratory conditions.
Federal regulations require nursing homes to educate residents about COVID-19 vaccination, offer the vaccine to eligible residents after providing education, and properly document each resident's vaccination status. This documentation serves multiple purposes: it helps facilities track vaccination rates, enables appropriate medical response if residents contract COVID-19, and ensures continuity of care.
For residents with compromised respiratory systems, COVID-19 vaccination status becomes critical medical information. Unvaccinated residents may require different monitoring protocols, isolation procedures during outbreaks, and treatment approaches if they develop symptoms. Without proper documentation, staff cannot make informed decisions about infection control measures or medical interventions.
Industry Standards for Medication and Vaccination Management
Healthcare facilities are expected to maintain robust systems for tracking medications with limited shelf lives. Best practices include using pre-printed labels with date fields, implementing barcode scanning systems that track medication expiration, and conducting regular audits of medication storage areas. Many facilities use automated dispensing cabinets that alert staff when medications approach expiration dates.
For vaccination records, facilities should maintain both electronic and paper documentation systems with backup verification. This redundancy ensures that critical immunization information remains accessible even if one system fails. Standard protocols include scanning vaccination cards into electronic health records, maintaining separate immunization logs, and conducting periodic audits to identify gaps.
The Centers for Disease Control and Prevention recommends that nursing homes integrate vaccination status into daily clinical workflows, ensuring that immunization information is readily available during care planning, infection control activities, and medical emergencies.
Additional Issues Identified
Beyond the major violations detailed above, the inspection narrative referenced the facility's infection prevention and control program policy for COVID-19, which indicated the facility would follow CMS and CDC guidance "to mitigate the spread of COVID-19 and manage outbreaks in the facility." However, the documentation failures suggest gaps between written policies and actual implementation.
The inspection classified these violations as causing "minimal harm or potential for actual harm," though the medication management issues affected multiple residents. The COVID-19 vaccination documentation deficiency was noted as affecting "few" residents based on the sample reviewed.
Facility Information: - Inspection Date: April 7, 2025 - Location: 3700 Clarks Creek Road, Plainfield, IN 46168 - Facility ID: 155215
These findings highlight the importance of systematic approaches to medication management and health record documentation in long-term care settings, where residents depend on staff to maintain accurate, up-to-date medical information that directly affects their safety and wellbeing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plainfield Health Care Center from 2025-04-07 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.