Failure to Provide Ordered Diabetes Medication Due to Lack of Pharmacy Follow-Up
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diagnoses including type II diabetes mellitus and muscle weakness. The resident had a physician's order for Ozempic, to be administered subcutaneously every Sunday for diabetes management. Review of the Medication Administration Record (MAR) for June 2025 showed that on two Sundays, nursing staff documented 'other/see note,' but there was no further documentation in the progress notes or clinical record to indicate that the medication was administered on those dates. Additionally, there was no evidence that the facility received the medication or that any follow-up was conducted regarding its absence. An interview with the Director of Nursing (DON) confirmed that the pharmacy had never dispensed the Ozempic to the facility, and the DON could not provide additional information about the missing medication. Further review of the clinical record revealed no documentation that the physician was notified about the unavailability of the medication or that any follow-up actions were taken. The Nursing Home Administrator stated that staff are expected to follow up with the pharmacy and physician when medications are not available, but this was not documented in the resident's record.