Failure to Prevent Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary medications. One resident was administered Ozempic, a medication used to manage type 2 diabetes, despite having no diagnosis of diabetes mellitus (DM) as confirmed by the resident’s history and physical examination and a normal hemoglobin A1c level. The resident’s care plan did not address the use of Ozempic or include monitoring for its side effects. The Assistant Director of Nursing (ADON) confirmed that there was no care plan or monitoring in place for this medication and was unsure if the order had been clarified with the physician. Additionally, the same resident was given oxycodone 10 mg, prescribed for severe pain (pain level 7-10), on multiple occasions when the documented pain level was below the prescribed threshold, including several instances where the pain level was recorded as 0. The ADON verified that the medication should not have been administered when the resident had no pain and acknowledged that the medication should be given only as prescribed by the physician. The facility’s policy requires medications to be administered safely and as prescribed, but these requirements were not met in this case.