Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for semaglutide (Ozempic) injections were followed for a resident with obesity and diabetes. The resident was admitted in 2025 and had a physician order dated 9/23/25 for weekly semaglutide injections. However, medication administration records and treatment administration records for October, November, and December 2025 showed that the resident did not receive the medication on multiple scheduled dates. Progress notes indicated that the medication was not administered due to reasons such as the prescription not being filled, a new order being needed, the prescription having ended, or the resident requesting a prescription, with some notes left blank. Staff interviews confirmed that the medication was not given as ordered, with one LPN stating she did not administer the medication because she believed it needed refrigeration and was unaware it was kept in the medication cart once opened. The Director of Nursing Services acknowledged the missed doses.