F0658

D

Failure to Administer Ordered Ozempic Doses Due to Medication Handling and Communication Breakdowns

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer a prescribed medication, Ozempic (semaglutide), as ordered for a cognitively intact resident with Type 2 diabetes mellitus. The physician’s order directed that the resident receive 1 mg subcutaneously every 7 days, starting in late October and continuing through mid-December. Pharmacy records showed that a 28‑day supply of Ozempic was delivered to the facility and signed for by a nurse, who stated she would have passed the medication to the nurse assigned to the resident. The ADON reported receiving the medication and placing it in the medication refrigerator because the dose was not due on her shift. The resident later reported that she was supposed to receive her first dose in October but did not receive a dose until December.

The October Medication Administration Record (MAR) contained documentation by one nurse that the Ozempic dose was administered, but that nurse later stated this entry was an error and that she had not been able to locate the medication and did not call the pharmacy as she should have. On another October date, the MAR showed the dose was not given with a direction to see a progress note, but no corresponding progress note existed to explain the omission. Another nurse reported that on multiple occasions when the medication was due, it was not available despite searching medication storage areas, and that she had been told by the pharmacy that a 28‑day supply had already been sent and no additional supply could be sent at that time. She acknowledged not notifying anyone that the medication was unavailable.

In November, the MAR showed one documented administration of Ozempic by another nurse, who could not recall where she obtained the medication or what happened to the pen afterward. Subsequent November MAR entries by different nurses documented that the medication was not administered, sometimes with instructions to see a progress note, but in several instances there was no corresponding progress note explaining why the dose was missed. One nurse documented speaking with the pharmacy and learning that a 28‑day dose had been sent in October and that a new supply could not be sent until mid‑November, and she reported this to the resident. In late November and early December, additional MAR entries showed the medication was not given with no explanatory notes. The DON and ADON later stated that nurses had documented the medication as unavailable and, in some cases, contacted the pharmacy, but had not notified facility leadership or a provider, and there was no established process for handling pharmacy preauthorization forms related to this medication, contributing to ongoing missed doses.

The Medical Director stated he had been made aware that the resident had not been receiving Ozempic as ordered by the NP and reported that the resident had not experienced specific adverse outcomes such as blurred vision, recurrent UTIs, or hospitalizations related to this incident. The pharmacist reported that after the initial 28‑day supply was delivered, the next fill was delayed because a required preauthorization sent to the facility was not returned, and the next supply was not sent until December. The Administrator and DON both indicated that nurses documented unavailability of the medication and, at times, contacted the pharmacy, but did not escalate the issue to leadership or ensure follow‑through on pharmacy communications and preauthorizations, resulting in repeated missed doses of the ordered medication.