Failure to Immediately Notify Physician of Missed Diabetes Medication
Penalty
Summary
A deficiency was identified when the facility failed to immediately inform or consult with a resident's physician regarding a significant change in the resident's treatment, specifically related to the administration of Trulicity (Dulaglutide) for diabetes management. The resident, who had diagnoses including orthopedic aftercare following amputation, Type 2 diabetes mellitus, and morbid obesity, reported missing three weeks of Trulicity injections upon admission. Medical record review showed that the medication was not administered as scheduled on multiple occasions due to pharmacy delivery issues and lab results, with documentation indicating delays and missed doses. Despite these missed doses, there was no immediate notification to the resident's physician at the time the medication was unavailable. Provider notification occurred 24 hours after a scheduled dose was missed, and in other instances, the medication was either awaited from the pharmacy or arrangements were made for a family member to bring it in. Interviews with facility staff, including an LPN and the DON, confirmed that the physician was not promptly notified as required when the medication was not available, and the DON was unaware that multiple doses had been missed.