Failure to Administer Acarbose as Ordered Before Meals
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed medication, acarbose 25 mg, as ordered to a resident with hypoglycemia, diabetes, and diabetic chronic kidney disease. The resident was admitted on 10/17/25 and readmitted on 10/31/25, with an acarbose order dated 11/20/25 for administration by mouth before meals at 7:30 AM, 11:30 AM, and 4:30 PM. Review of the Medication Audit Report for the ordered acarbose doses over multiple days showed repeated late administrations significantly outside the scheduled times, including morning doses given several hours after the ordered time and evening doses given hours late. On one date, two separate scheduled doses (7:30 AM and 11:30 AM) were documented as administered at the same time. The Nursing Home Administrator reported during interview that the facility did not have a policy regarding medication administration. The DON stated the expectation that medications are given as ordered and, upon reviewing the Medication Audit Report, acknowledged that the documented administration times were outside the normal administration leeway and that nurses should document when medications are given outside parameters due to meal delivery time. Reference material from the National Institute for Health indicated that acarbose should be administered three times daily with the first bite of each meal to delay carbohydrate digestion and slow glucose absorption. A message was left with the Medication Technician who worked most of the relevant dates and times, but no return call was received, leaving the late and irregular administration times unexplained.
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