Failure to Timely Provide and Administer Diabetic Medications
Penalty
Summary
A deficiency occurred when a resident with a history of diabetes, stroke, and transient ischemic attack was not provided with two prescribed diabetic medications, Jardiance and sitagliptin (Januvia), in a timely manner following admission. The resident was admitted with physician orders for both medications to be administered daily at 8:00 AM. However, documentation in the medication administration record showed that Jardiance was not administered at all from the time of admission through several days, and sitagliptin was also not administered on two days due to the medications being unavailable. Progress notes indicated that the pharmacy was contacted regarding the missing medications, and it was noted that the medications would be sent, but delays persisted. During this period, the resident experienced elevated blood sugar levels, with seven out of ten readings above 200 mg/dL. The resident expressed concern about their blood sugar control and was unsure about the names of all their diabetic medications due to memory issues following a stroke. Staff interviews revealed that the pharmacy had not supplied Jardiance and that there was uncertainty about the reason, possibly related to authorization requirements. An inspection of the medication cart confirmed the absence of pharmacy-supplied Jardiance and the presence of home-brought sitagliptin, which was not initially available for administration. The facility's pharmacy agreement required the pharmacy to notify the facility if a medication was unavailable, but there was no documentation of such notification for Jardiance. The lack of timely provision and administration of these essential diabetic medications constituted a failure to meet the pharmaceutical service requirements for the resident.
Plan Of Correction
The facility provides diabetic medications as ordered by the physician for residents. 1. Resident #151 no longer resides at the facility. 2. Each diabetic resident's orders/MAR were audited on 3/19/25 by the ADON to ensure all ordered medications are available and are administered per MD orders. 3. A policy for Unavailable Medications was developed on 3/20/25 and approved by the QAA team on 3/25/25. The DON or designee reviewed the policy guideline with the licensed nursing staff by 4/7/25. 4. The DON or designee will conduct weekly audits of Performance Monitoring related to the availability of medications, including but not limited to diabetic medications, weekly x 4, then monthly. Any identified areas of concern will be addressed and immediately corrected. Results of the audits will be taken to the QAPI Committee for review and recommendation and for determination of continued monitoring. The DON will be responsible for monitoring sustained compliance.