F0684

D

Failure to Administer Ordered Testosterone Injections as Scheduled

Phoenix, Arizona Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer physician-ordered testosterone therapy as prescribed for Resident #2 and to document appropriate follow-up when a dose was missed. Resident #2, who had testicular dysfunction and was cognitively intact with a BIMS score of 15, was re-admitted with an order for Testosterone Cypionate 200 mg IM every 14 days in the afternoon for supplementation. The January Medication Administration Record showed the resident received the injection on January 15, 2026, but there was no documentation that the scheduled dose on January 29, 2026, was given. A nursing note documented that the next testosterone injection was administered on February 8, 2026, which exceeded the 14-day interval specified in the order, and the clinical record did not contain documentation supporting administration outside the ordered schedule.

Interviews with staff confirmed that the ordered testosterone injection was not administered on January 29, 2026, and that there was no documentation that the provider was notified of the missed dose. The RN stated that testosterone therapy is important for maintaining the resident’s mood and overall well-being and that if a medication is not available, staff should notify the provider and pharmacy, document the notifications, and inform the resident. The ADON and Interim DON both stated that facility expectations are for staff to follow physician orders as written and to promptly notify the provider when medications are unavailable or cannot be administered as ordered, which did not occur in this case. The resident reported changing back to receiving injections at the urology clinic due to concerns that the facility had not reliably administered the injections as scheduled.