Failure to Administer Prescribed Diabetes Medication Due to Lost Supply and Communication Breakdown
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with type 2 diabetes, morbid obesity, and Alzheimer's disease. The resident was prescribed glimepiride, an oral medication for diabetes management, which was not administered for five consecutive days as documented in the Medication Administration Record (MAR). The MAR indicated the medication was unavailable on those days, and multiple medication aides confirmed they did not administer the drug due to its unavailability. The resident's responsible party reported that a 90-day supply of glimepiride had been delivered to the facility, but staff lost the medication, and the facility did not follow through with obtaining a new supply as promised. Interviews with medication aides revealed that they notified charge nurses about the missing medication and that it was common practice to retrieve medications from the emergency kit (E-kit), but it was unclear if this was attempted. The aides could not recall which charge nurse was informed, and there was no documentation of further action to secure the medication from the E-kit or other sources. The responsible party was told by staff that the medication was in stock and being administered, but this was not the case according to the MAR and staff interviews. The Director of Nursing (DON) was unaware that the resident had missed five days of glimepiride until informed by the surveyor. The DON confirmed that a staff member had signed for the medication delivery, but the medication could not be located. The facility's policy required medications to be administered as prescribed and outlined procedures for handling unavailable medications, but these procedures were not effectively followed in this instance, resulting in the resident missing multiple doses of a critical medication.