Failure to Follow Physician Order for Timing of Diabetes Medication
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality when staff did not follow a physician’s medication order for a resident with type 2 diabetes. Record review showed a physician’s order dated 11/04/25 for Rybelsus 7 mg to be given by mouth once daily, 30 minutes before any food or drink. During a medication administration observation on 01/06/26 at 8:41 a.m., an LPN administered the Rybelsus dose while the resident was finishing breakfast, contrary to the ordered timing. In a subsequent interview at 8:43 a.m., the LPN stated she did not know the medication should be given 30 minutes before any food or drink. This deficient practice was cited for one resident reviewed and was identified as a failure to follow physician orders, which the report states is likely to result in residents not maintaining their optimal health as planned by their medical provider.
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