Failure to Clarify and Obtain Ordered Diabetic Medication From Pharmacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and clear prescription for a new diabetic medication and to respond to repeated pharmacy requests for clarification, resulting in the medication not being dispensed. A resident with type 2 diabetes, weight gain of approximately 15 pounds over three months, and noncompliance with a diabetic diet was evaluated by a Physician Assistant, who ordered semaglutide 0.25 mg once weekly to help regulate blood sugars and assist with weight loss. The physician order entered on 11/25/25 in the EMR read semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays, which the pharmacist later identified as lacking complete dosage information. The order was verified and sent to the pharmacy by the unit manager nurse on 11/28/25 without recognizing the incomplete dosage. The MAR showed one administration documented in error, one refusal, and one missed dose due to awaiting pharmacy delivery, and the order was discontinued on 12/22/25. Nursing staff did not ensure the medication was available or follow up appropriately when it was not in the medication room. The nurse assigned to the resident on the relevant dates reported that semaglutide was not available and that she assumed the new medication had not yet been delivered; she did not call the pharmacy to check the status and did not recall notifying the Physician Assistant, though she stated the unit manager nurse was aware. The unit manager nurse stated she believed the medication was not delivered because it was unavailable and did not follow up with the pharmacy. The pharmacist reported that the pharmacy attempted to contact the facility multiple times by phone, fax, and email on four separate dates to obtain clarification of the semaglutide order so it could be dispensed, but the facility did not provide a corrected order until 12/29/25. The Administrator stated she did not receive the pharmacy’s emails and could not confirm whether the former DON had received or acted on them, while also indicating that when a medication is not available, the assigned nurse, unit manager, and/or DON should contact the pharmacy or send a refill request in the EMR to ensure medications are available and administered as ordered.
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