F0580

D

Failure to Notify Provider When Ordered Medication Not Administered

Shelby, North Carolina Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the Physician/Physician Assistant when a resident did not receive a prescribed medication. A resident admitted with type 2 diabetes had an order written on 11/25/25 for weekly subcutaneous semaglutide (0.25 mg or 0.50 mg) on Mondays. The MAR showed the medication as administered on 12/01/25 at 8:00 AM, refused by the resident on 12/08/25, and not administered on 12/15/25 due to awaiting delivery from the pharmacy, with the order discontinued on 12/22/25. Review of the medical record revealed no documentation that the Physician/Physician Assistant had been notified that the semaglutide was not administered as ordered.

During interview, the nurse assigned to the resident stated the semaglutide was not available in the medication room on 12/01/25, 12/08/25, or 12/15/25 and that she did not administer the medication on those dates. She acknowledged documenting in error on the MAR that the medication was given on 12/01/25 and that the resident refused it on 12/08/25, and stated she should have documented that the medication was unavailable. She reported that she generally notified providers when a resident did not receive a prescribed medication but could not recall notifying the Physician Assistant in this case. The Physician Assistant reported entering the semaglutide order in the EMR on 11/25/25 and notifying a nurse that it was ready to be sent to the pharmacy, and stated she was not informed that the order sent lacked a dose or that the medication was not delivered until 12/29/25. The Administrator stated that the Physician/Physician Assistant should be notified whenever a resident is not receiving a prescribed medication, whether due to unavailability or refusal.