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Based on observations, staff interviews, and policy and procedure review the facility failed to label the opened date or date of expiration on multiuse vials of insulin on six (6) out of eight (8) insulin vials.

Findings Include:

Observations of the medical surgical medication room refrigerator on 08/22/2022 at 3:15 p.m. revealed there were six (6) open multi-use vials of insulin in the medication refrigerator open without an open date or a beyond use date.

Interview with the Registered Nurse (RN) #1 on 08/22/2022 at 3:20 p.m. revealed the multiple use vials should be labeled and dated for 28 days from the open date. RN #1 reported that she would expect the staff to follow the policy for multiple use vials.

Interview with the Pharmacist on 08/23/2022 at 3:20 p.m. revealed that the nurses are provided stickers to use on the multiple dose vials when they are opened. Pharmacist reported that the multi-dose vials are not being labeled with a date to expire 28 days after opening like the policy says and that this has been an ongoing problem at the facility.

Review of the facility's policy " ..."Multi-dose Vials", dated July 2013," revealed that " ...All stored medications should be labeled with the expiration date. DO NOT label the vial with the date it was opened ...Multi-dose vials are to be discarded 28 days after first use unless the manufacturer specifies otherwise ...".

During exit conference on 08/25/2022 at 12:30 p.m. with the Chief Executive Officer, survey findings were discussed and no further documentation was submitted for review.