Failure to Report and Investigate Possible Misappropriation of Tirzepatide
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding reporting and investigating a suspected misappropriation of a resident’s medication. The facility’s written policy required immediate investigation when there was suspicion or reports of abuse, neglect, exploitation, or misappropriation of resident property, and mandated reporting all alleged violations to the Administrator, State Agency, Adult Protective Services, and other required agencies within specified timeframes. Despite these requirements, when empty tirzepatide (Mounjaro) pens belonging to a resident were discovered, the facility did not initiate an abuse/misappropriation investigation or report the incident to the State Agency or other required entities. The resident involved was cognitively intact and had a diagnosis of diabetes mellitus, with a physician’s order for weekly subcutaneous tirzepatide injections for Type 2 diabetes. The resident reported that on one occasion a nurse attempted to administer the weekly tirzepatide injection, but the syringe was empty, and when another syringe was obtained from the refrigerator, that syringe was also empty. The resident stated that she ultimately received her weekly injection, but it was administered two or three days late after medication was obtained from the pharmacy. She also reported that she had not previously experienced an issue with empty syringes when nurses attempted to give her the injection. Staff interviews confirmed that on the morning in question, the nurse assigned to the resident retrieved a tirzepatide pen from the refrigerator and found it already unlocked with the purple cap depressed, indicating it was empty. The Unit Manager, who was acting as DON at the time, verified that both remaining pens for this resident were empty by comparing them to another resident’s unused tirzepatide syringe. The Unit Manager notified the Administrator and Regional Clinical Manager and contacted the pharmacy, but she did not consider the possibility of misappropriation and did not initiate an investigation into how or why the pens were empty. The Administrator acknowledged being informed of the empty pens but did not seek further details, did not ensure an investigation was conducted, and did not recognize or report the situation as a potential misappropriation, despite the facility’s policy requiring such reporting and investigation.
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