Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
A resident was found with multiple self-administered medications, including Primal Harvest Hair Growth Complex, Immuneti Advanced Immune Defense, and Primal Multivitamins, at their bedside. The resident reported self-administering these supplements since admission. The resident's medical record indicated a history of suicidal ideations, alcohol abuse, and opioid use. No self-administration assessment was completed for the resident, and there was no documentation of the resident's desire to self-administer medications. Additionally, there were no interdisciplinary team notes or care plan entries regarding self-administration, despite facility policy requiring assessment, documentation, and care planning for residents who wish to self-administer medications. Nursing staff and facility leadership confirmed the absence of required documentation and assessments.