F0658

D

Failure to Clarify Semaglutide Order and Obtain Medication as Prescribed

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a new medication order for semaglutide was clarified and processed so the medication could be obtained and administered as ordered. A physician assistant evaluated Resident #75, who had type 2 diabetes, weight gain of approximately 15 pounds in three months, and varying blood sugars, and entered an order on 11/25/25 for semaglutide to be given weekly. The order in the physician orders and MAR was written as semaglutide (0.25 mg or 0.50 mg) weekly, and the MAR showed an entry that it was administered on 12/01/25, refused on 12/08/25, and unavailable on 12/15/25, with discontinuation on 12/22/25 and a new order on 12/29/25 for semaglutide 0.25 mg weekly. The resident’s MDS documented that she was cognitively intact, had an active diagnosis of diabetes mellitus, and was receiving insulin injections daily, and her care plan identified risk for hypo- and hyperglycemic episodes with monitoring interventions.

Resident #75 reported that semaglutide was ordered in late November to help regulate blood sugars and assist with weight loss but was not actually administered until January, and she did not question the delay because she believed it usually took a while for the facility to obtain new medications. She confirmed refusing the first two January doses because she had questions for the physician assistant about possible reactions, and stated that the medication was administered as ordered later in January. Nurse #2, who was assigned to the resident on day shift, stated that semaglutide was not available on three December dates and therefore was not administered, and she could not recall whether she notified the unit manager or provider about the unavailability. She further acknowledged that she documented in error on the MAR that the medication was administered on one date and refused on another, and that she should have documented that the medication was unavailable.

Nurse #1, the unit manager, explained that new medication orders are entered into the EMR, verified, and sent electronically to the pharmacy, and that she verified the semaglutide order and sent it to the pharmacy but was not aware that the dose was missing or that clarification was needed. The pharmacist reported that the facility sent an order for semaglutide without dosage information and that the former DON was notified on four separate dates that the order needed to be resent with the dose before the medication could be dispensed and delivered. The pharmacist stated that a new order specifying semaglutide 0.25 mg weekly was finally sent on 12/29/25 and the medication was delivered on 12/31/25. The physician assistant and medical director both stated they were not informed that the pharmacy required clarification or that the resident had not received semaglutide until mid-January, and both stated that medications should be administered as ordered. The administrator stated that when the pharmacy notified the former DON that the order lacked dosage information, the former DON should have clarified the order with the physician assistant and sent an updated order to the pharmacy so the medication could be obtained and administered as ordered.