Failure to Assess and Authorize Resident Self-Administration of Glucose Tablets
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy for resident self-administration of medications, specifically glucose tablets. The facility’s policy required that residents may only self-administer medications after an IDT assessment, documented on a Medication Self-Administration Safety Screen, with corresponding care plan documentation and physician orders. The policy also required periodic reassessment at least quarterly, annually, with significant change, or after a medication error. For the resident in question, the Medication Self-Administration Safety Screen on file indicated the resident required supervision to take medications and did not list glucose tablets as a medication that could be stored and taken independently. No updated self-administration assessments had been completed since 2023. The resident, who had type 1 DM, partial left-sided paralysis, and ataxia following a stroke, was observed with a bottle of glucose tablets on his desk and stated he took them whenever he felt his blood sugar going low. A physician progress note documented that the physician had seen the resident for low blood sugars and referenced that the resident was taking glucose tablets whenever his blood sugar was in the 60s. Despite this, there were no IDT assessments, physician orders, or care plan documentation authorizing or addressing self-administration of glucose tablets. The CRN and DON confirmed there were no Medication Self-Administration Safety Screen assessments related to the resident’s ability to self-administer glucose tablets, resulting in unmonitored treatment of hypoglycemia and unsafe medication practices.
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