Failure to Administer Crushed Medication as Ordered for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a stroke was not administered her prescribed medication in accordance with physician orders and care plan instructions. The resident was assessed as having moderate cognitive impairment and was dependent on staff for all activities of daily living. Her care plan and physician orders clearly indicated that all medications were to be crushed due to her swallowing difficulties, as confirmed by a swallow study and special instructions in her medical record. On the date of the incident, an RN who was not regularly assigned to the building administered two non-crushed acetaminophen tablets to the resident, despite the clear instructions to crush all medications. The RN did not review the resident's chart or special instructions prior to administration and was unaware of the requirement to crush medications. Upon administration, the resident began coughing uncontrollably, refused additional water, and expressed fear and discomfort as a result of the incident. The RN later acknowledged that the medication should have been crushed and that failure to do so could result in choking. Interviews with facility staff, including the DON, speech therapist, and social worker, confirmed that the expectation was for staff to review special instructions and physician orders before administering medications. The DON and other staff reiterated that the special instructions are prominently displayed in the electronic medical record. The resident herself reported feeling scared and terrible after the incident, and staff noted that her cognitive status made it unlikely she could reliably communicate her medication needs, emphasizing the importance of staff following documented instructions.