Federal inspectors found the unlabeled Humalog insulin pen on December 16 during a medication cart review at Complete Care at Springbrook. The pen contained no patient name, physician name, or opening date as required by the facility's own 2025 insulin policy.
Staff Nurse #6 told inspectors he had used the unlabeled pen to give insulin to a patient. The nurse said the room number written in black marker on the pen was "enough to identify the resident" and that he "did not require a label."
The facility's insulin policy explicitly states that pens "must be clearly labeled with the resident name, physician name, date dispensed, type of insulin, amount to be given, frequency, and expiration date." The policy was provided by the Director of Nursing during the inspection.
Inspectors discovered the violation at 11:49 a.m. while reviewing the West Wing medication cart in the presence of Staff Nurse #6. The opened Humalog pen was stored alongside other medications without proper identification beyond the handwritten room number.
The pharmacist consultant told inspectors that "all insulin pens must be labelled with the patient's name, physician name and date opened." The consultant emphasized that once an insulin pen is opened, it requires a date label and that "any opened, unlabeled insulin pens should not be used."
Instead of using unlabeled pens, the pharmacist said the facility should "notify pharmacy and order a new insulin pen" when proper labeling is missing.
The Director of Nursing acknowledged the violation during a 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."
Insulin pens require precise identification because different types of insulin have varying onset times and durations. Humalog, the insulin found unlabeled, is a rapid-acting medication that begins working within 15 minutes of injection.
The violation occurred despite the facility maintaining a current policy specifically addressing insulin pen labeling requirements. The 2025 policy covers all aspects of insulin storage and identification that the unlabeled pen lacked.
Staff Nurse #6's reliance on a handwritten room number contradicted both facility policy and pharmaceutical standards. Room numbers can change, and patients can be transferred between rooms, making such identification unreliable for medication administration.
The pharmacist's guidance was clear about disposal procedures for improperly labeled insulin. Rather than using questionable medications, staff should remove them from circulation and request properly labeled replacements from the pharmacy.
This medication labeling failure represents a breakdown in the facility's drug storage protocols. The insulin pen was discovered during a routine inspection of medication carts, suggesting the practice may have been ongoing.
The Director of Nursing's response indicated awareness of proper procedures but highlighted a gap between policy and practice. Her instruction to discard unlabeled pens came only after inspectors identified the violation.
Federal regulations require all drugs and biologicals to be properly labeled and stored in locked compartments. The unlabeled insulin pen violated these standards by lacking essential patient identification information.
The inspection found the violation affected few residents but represented potential for actual harm. Insulin administration errors can cause dangerous blood sugar fluctuations, particularly when medications lack proper patient identification.
Complete Care at Springbrook's insulin policy contained comprehensive labeling requirements that staff failed to follow. The gap between written procedures and actual practice created unnecessary medication safety risks for diabetic residents requiring insulin therapy.
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.