Staff Nurse #6 at Complete Care at Springbrook told inspectors on December 17 that the handwritten room number was "enough to identify the resident" and that he "did not require a label." Federal inspectors found the unlabeled Humalog insulin pen during a medication cart review on December 16.
The facility's own insulin pen policy, dated 2025, states that all pens "must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date." Staff Nurse #6's pen met none of these requirements.
The violation occurred on the West Wing medication cart, one of three carts inspectors reviewed for medication storage compliance. The opened and used insulin lispro pen contained no identifying information beyond the room number written by hand.
During interviews the following day, both the facility's pharmacist and Director of Nursing contradicted the nurse's assertion that room numbers were sufficient identification.
The pharmacist told inspectors on December 17 that "all insulin pens must be labelled with the patient's name, physician name and date opened." The consultant emphasized that opened insulin pens require date labeling and that "any opened, unlabeled insulin pens should not be used."
Instead, the pharmacist said, facilities should "notify pharmacy and order a new insulin pen" when labeling violations are discovered.
The Director of Nursing echoed this guidance during her December 18 interview. She told inspectors that "nursing staff should discard any unlabeled insulin pens and notify pharmacy to reorder new insulin pens that have labels."
Both the pharmacist and nursing director's statements directly contradicted Staff Nurse #6's practice of relying solely on handwritten room numbers for insulin identification.
Insulin misidentification poses significant risks to nursing home residents. The medication requires precise dosing based on individual patient needs, medical conditions, and physician orders. Using insulin intended for one resident on another could result in dangerous blood sugar swings.
The inspection occurred as part of a complaint investigation at the 12325 New Hampshire Avenue facility. Federal regulations require all medications to be properly labeled and stored in locked compartments to prevent mix-ups and unauthorized access.
Complete Care at Springbrook's insulin pen policy includes six specific labeling requirements: resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date. The unlabeled pen found by inspectors met zero of these standards.
The pharmacist's emphasis on date labeling reflects another safety concern. Once opened, insulin pens have limited shelf lives and can lose potency over time. Without date markings, staff cannot determine whether the medication remains effective.
Staff Nurse #6's confidence that room numbers provided adequate identification suggests a fundamental misunderstanding of medication safety protocols. Room assignments change frequently in nursing homes as residents are admitted, discharged, or transferred between units.
The violation occurred despite clear facility policies and professional standards. The pharmacy consultant stated unequivocally that unlabeled insulin pens "should not be used" under any circumstances.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the incident reveals broader medication management concerns when staff openly disregard established safety protocols.
The Director of Nursing's instruction to discard unlabeled pens and reorder properly labeled replacements indicates the facility recognized the severity of the violation. Her guidance directly contradicted the nurse's assertion that handwritten room numbers met labeling requirements.
Complete Care at Springbrook must now demonstrate how it will prevent similar medication labeling violations and ensure all nursing staff understand insulin pen identification requirements.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At Springbrook from 2025-12-19 including all violations, facility responses, and corrective action plans.