Failure to Safeguard Resident’s Tirzepatide Pens From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s right to be free from misappropriation of medication, specifically tirzepatide (Mounjaro) prescribed for Type 2 diabetes mellitus. The resident had a physician’s order for a weekly subcutaneous injection of tirzepatide 5 mg/0.5 ml on Fridays. Pharmacy records showed that four tirzepatide injections (2 ml total) were delivered and charged to the resident’s insurance. The pens were stored in a locked box in the medication room refrigerator and treated like narcotics. Multiple nurses confirmed that the pens were received and placed in the refrigerator, with at least one nurse stating she visually confirmed that the pens contained medication at the time of delivery. On the scheduled administration date, the assigned nurse retrieved a tirzepatide pen from the refrigerator to give the resident her weekly injection and found the pen already unlocked with the purple cap depressed and no medication available to inject. After involving the Wound Nurse and the Unit Manager, they inspected the remaining tirzepatide pen for the resident and discovered that it was also empty, with the purple cap depressed and the plunger visible, indicating the medication had already been expressed. The resident reported that the nurse attempted to give the weekly tirzepatide injection but found the syringe empty, then obtained another syringe that was also empty. The resident stated she ultimately received the injection two or three days later after additional medication was obtained, and that while she had previously experienced delays waiting for pharmacy delivery, she had never before encountered empty pens when nurses attempted to administer the medication. The Unit Manager, acting as DON at the time, compared the two empty pens to another resident’s tirzepatide pen and confirmed that the empty pens appeared used, with the purple caps depressed, unlike the unused pen. The Unit Manager notified the Administrator, Regional Clinical Manager, and NP that the pens were empty and contacted the pharmacy to request replacement medication. The pharmacy manager stated that the resident’s insurance was billed for the pens, that the pens are individually labeled and repackaged by the pharmacy, and that any damaged or empty pens would typically be identified before shipment. A manufacturer representative also stated that while pens could potentially leak, such issues would likely be noticed by the pharmacy during repacking. Multiple nurses, including those who had administered prior and subsequent tirzepatide doses, reported no prior issues with empty pens and could not explain why the two pens for this resident were empty. The Unit Manager and Administrator both acknowledged they did not initially consider misappropriation of medication when the empty pens were discovered, despite the medication being described as expensive and highly sought after.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.