Lack of Physician Order for Self-Administered Glucose Tablets
Penalty
Summary
The facility failed to ensure a resident had an active physician’s order for a medication the resident was self-administering. A resident who had been readmitted with multiple diagnoses, including type 1 diabetes, partial paralysis of the left side, and ataxia after a stroke, was observed with a bottle of glucose tablets on his desk and stated he took the tablets whenever he felt his blood sugar going low. A physician’s 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. However, a review of physician’s orders for the relevant period showed no order for glucose tablets, and the CRN and DON confirmed there were no current physician orders related to glucose tablets. This deficient practice created the potential for adverse outcomes when the resident self-administered a medication not ordered by a physician.
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