Inaccurate MAR Documentation for Ordered Semaglutide Therapy
Penalty
Summary
The facility failed to maintain accurate medication administration records for a resident with type 2 diabetes who had an order for semaglutide. Physician orders and the MAR showed an order dated 11/25/25 for semaglutide (0.25 mg or 0.50 mg) to be given subcutaneously once weekly on Mondays. The MAR reflected that semaglutide was administered on 12/01/25 at 8:00 AM, was refused by the resident on 12/08/25, and was not given on 12/15/25 due to awaiting delivery from the pharmacy, all documented by the same nurse. However, the resident, who was assessed as cognitively intact on a quarterly MDS, reported that although the PA ordered semaglutide on 11/25/25 to help regulate blood sugars and assist with weight loss, the medication was not actually administered until January 2026. In an interview, the nurse assigned to the resident on day shift stated that semaglutide was not available on 12/01/25, 12/08/25, or 12/15/25 and was not administered on those dates. She acknowledged that her MAR entries indicating administration on 12/01/25 and refusal on 12/08/25 were erroneous and that she should have documented the medication as unavailable. The pharmacist reported that the original order sent on 11/25/25 lacked dosage information, and a new order specifying semaglutide 0.25 mg was later sent, after which the medication was delivered. The Administrator stated she was not aware that the resident had not received semaglutide as ordered because it was not delivered and unavailable, and confirmed that when a medication is not administered it should be documented accurately in the resident record and on the MAR.
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