Failure to Assess and Plan for Resident Self-Administration of Medication
Penalty
Summary
A resident was observed with approximately ten bottles of pills and liquid supplements stored openly on their nightstand, including MCT oil, Nugenix Thermo X, weight loss probiotics, veggie capsules, testosterone boosters, and fruit dietary supplements. The bottles were open, and the resident reported self-administering these supplements daily due to dissatisfaction with the facility's food and a personal goal to lose weight. During the observation, the resident informed the LPN about the supplements after receiving their scheduled medication from the nurse. Interviews with facility staff, including the Director of Nursing, confirmed that the resident had not been assessed by the interdisciplinary team for self-administration of medication, nor was there a care plan in place for this practice. Review of the clinical record showed no documentation of such an assessment or care plan, despite facility policy requiring physician and care team approval for residents to self-administer medications. The facility was aware that residents were not permitted to store medications at their bedside without proper assessment and planning.