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F0755
D

Failure to Provide Ordered Diabetes Medications Due to Pharmacy and Order Issues

Millsboro, Delaware Survey Completed on 07-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide medications as ordered for a resident with diabetes. Upon admission, the resident had a physician's order for Ozempic injections, which was later changed to Bydureon and then to Exenatide due to medication availability issues. The facility's policy required timely receipt of medications from the pharmacy, but documentation showed that Ozempic was not administered on two scheduled dates, and Bydureon was not administered as ordered. The resident's Medication Administration Record (MAR) confirmed these missed doses. Interviews with facility staff and the consulting pharmacist revealed that the pharmacy did not dispense the ordered medications due to order changes and product discontinuation. The pharmacist acknowledged a missed opportunity to dispense the second order and confirmed that Bydureon was unavailable due to manufacturer discontinuation. The resident reported not receiving their prescribed medication, and facility leadership confirmed the lack of evidence for medication delivery from the pharmacy.

See complete original report
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