Failure to Administer Diabetic Medication as Ordered
Penalty
Summary
Resident #81, who had a diagnosis of type two diabetes mellitus and was at risk for pressure injuries, was not administered his prescribed diabetic medication, Mounjaro, according to physician orders. The resident was admitted with intact cognition and required substantial assistance with mobility. Physician orders specified a weekly subcutaneous injection of Mounjaro, but review of the Medication Administration Record (MAR) showed missed doses on three separate occasions. The MAR comments incorrectly indicated the medication was discontinued or on hold, and the resident only received one dose during the period in question. Further review and interviews revealed that a nurse erroneously documented the discontinuation of Mounjaro when only the resident's Lantus insulin had been discontinued. Additionally, after the initial dose was administered, the pharmacy did not send further doses, and facility management was unaware of the missing medication until several weeks later. As a result, the resident missed multiple scheduled doses because the medication was not available in the facility, and the issue was not identified or addressed in a timely manner.