Failure to Administer Ordered Atorvastatin and Insulin and Notify Physician for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide routine biologicals and pharmacy services, including administering medications as ordered, for a newly admitted resident. The resident was admitted from a general acute care hospital with diagnoses including type 2 DM, hemiplegia and hemiparesis following CVA affecting the right dominant side, and unspecified glaucoma. The resident’s MDS indicated moderately impaired cognition and dependence on staff for eating, oral hygiene, toileting hygiene, and personal hygiene. On admission, the nurse practitioner and physician were notified, and the resident’s medication orders were faxed to the pharmacy. The physician’s orders included Atorvastatin 40 mg by mouth at bedtime for hyperlipidemia and Semglee (insulin glargine) 8 units subcutaneously at bedtime for DM, both with a start date of 1/6/2026. The facility’s pharmacy delivery manifest showed that these medications were delivered the following day at 3:22 a.m. Review of the resident’s January MAR revealed that the 9:00 p.m. doses of Atorvastatin and Semglee on the admission date were not administered, and code 8 (medication not available) was documented for both medications. RN 2 stated that the facility receives pharmacy deliveries three times a day and confirmed that the medications were not given at the scheduled time because they had not yet been delivered. RN 2 further stated that the charge nurse assigned to the resident should have called the physician to inform them of the missed doses and to clarify whether additional orders were needed, but review of the progress notes for that date showed no documentation that the physician was notified. The DON confirmed that for newly admitted residents, medication orders are sent to the pharmacy and that once medications are delivered, licensed nurses administer the first dose per the physician’s orders, and that the nurse should have clarified with the physician whether medications could be initiated the following day given the late admission time. Facility policies required regular and reliable pharmaceutical services, including that new medication or admission orders be available for administration of the next dose, and required documentation of services provided and changes in the resident’s condition in the medical record to facilitate communication among the interdisciplinary team.
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