Cardinal Home Health Care

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure medication reconciliation and administration were conducted for one of seven sampled patients (Patient 1) when a Licensed Vocational Nurse (LVN 1) administered an expired insulin (a synthetic hormone that turns food into energy and manages the blood sugar level). This failure had the potential to cause ineffective drug therapy to Patient 1, significant side effects, and noncompliance with the treatment. During a review of Patient 1’s face sheet (a document that gives a summary of patient’s information), it indicated a start of care date of November 4, 2025, with a recertification period of January 3, 2026, to March 3, 2026. Patient 1 had diagnoses that included Type 2 diabetes mellitus (a chronic condition where the body cannot effectively use insulin). During a home visit on January 21, 2026, at 10:00 AM, with LVN 1, an observation of Patient 1’s medications available at home were compared with Patient 1’s most current Medication Profile (MP). During a concurrent observation and interview on January 21, 2026, at 10:15 AM, with LVN 1, LVN 1checked Patient 1’s rapid acting insulin (starts working within 15 minutes, peaks in 1-2 hours, and lasts 2-4 hours) Insulin pen (a disposable, pre-filled, insulin pen used to mange blood sugar levels in patients with type 2 diabetes). The label on the pen indicated, “(brand name) KwikPen…EXP (expiration): 2025-DEC-19 (December 19, 2025-medication had been expired for 33 days)”. LVN 1 then checked Patient 1’s MP which indicated “(name of brand) (short acting insulin) per sliding scale 3X (times) day breakfast/lunch/dinner with meals BS (blood sugar) less than 99mg/dl (unit for milligrams per deciliter): HOLD/ BS (blood sugar) level of 100-200mg/dl administer 1 unit subcutaneously / BS level of 201-300mg/dl administer 3 units subcutaneously / BS level of more than 300mg/dl call M.D (Medical Doctor).” LVN 1 proceeded to administer 1 unit of insulin on Patient 1’s abdomen, without checking the expiration date. During an interview on January 21, 2026, at 10:30 AM, with LVN 1. LVN 1 stated, “I should have checked the insulin pen expiration date prior to administering insulin to patient (patient 1), I did not check it”. The LVN 1verified and confirmed insulin pen had been expired for 33 days, the LVN 1 further stated that administering expired insulin will put Patient 1 at risk of ineffective blood glucose control. During a follow up interview and record review on January 21, 2026, at 3:00 PM with Designated Administrator (D-ADMIN), the agency’s policy and procedure (P&P) titled, “Identification of Medications for Administration”, dated April 2018, was reviewed. The P&P indicated …”PROCEDURE 2. The nurse will review the written physician (or other authorized licensed independent practitioner) order prior to medication administration. 4. Medications should be properly labeled with that patient’s name, an additional patient identifier, name of drug, dosage, diluent date of preparation, expiration date, initial of preparer, and any special instructions, as applicable”. The D-ADMIN stated that LVN 1 should have checked the expiration date of the Insulin pen prior to administering insulin to Patient 1. D-ADMIN further verified and confirmed that insulin pen has been expired for 33 days, and the patient may not receive the intended dose, even if the correct units are administered which can lead to poor blood glucose control and LVN 1 did not follow the P&P by administering expired insulin to Patient 1. During a concurrent interview and record review on January 22, 2026, at 1:30 PM with Quality Coordinator (QC), the agency P&P titled, “Identification of Medications for Administration”, dated April 2018, was reviewed. The P&P indicated …”PROCEDURE 2. The nurse will review the written physician (or other authorized licensed independent practitioner) order prior to medication administration. 4. Medications should be properly labeled with that patient’s name, an additional patient identifier, name of drug, dosage, diluent date of preparation, expiration date, initial of preparer, and any special instructions, as applicable”. The QC stated LVN 1 did not check the expiration date on the insulin pen (expired 33 days) and administered it to Patient 1. The QC further stated that administering expired medication is a medication administration error, it reflects failure to follow the “five rights” of medication administration and standard nursing practice.”