Failure to Protect Resident's GLP-1 Medication from Staff Misappropriation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's GLP-1 (Ozempic) injection medication from staff misappropriation. The resident, who had diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Failure, Heart Failure, and Obesity, was prescribed Ozempic as part of her diabetes management regimen. The medication was stored in a secured medication room refrigerator, as per facility protocol. However, a discrepancy was noted when the medication could not be located during routine preparation for administration, and subsequent review of the medication administration record (MAR) and narcotic log did not account for the missing medication. An internal investigation, including review of video surveillance footage, revealed that an RN who was not assigned to administer the medication was observed removing two Ozempic pens from the medication refrigerator. The RN was seen taking the pens, removing one from its packaging, and leaving the medication room with both pens without documenting the removal in the MAR or shift count sheet. There was no documentation of a need for a second dose, nor any record of medication return or disposal in accordance with facility policy. The RN initially denied taking the medication but later admitted to the act when confronted with video evidence. The resident involved did not recall missing any medications and did not experience blood sugar complications during her stay. Interviews with the resident and her family indicated some confusion regarding her medication regimen, but the primary issue was the unauthorized removal of the medication by staff. The incident was reported to local authorities and the state, and the facility conducted an audit to ensure no other medications were missing.