Failure to Follow Medication Administration Orders Results in Resident Death
Penalty
Summary
The facility failed to implement its policies and procedures to protect a resident from neglect, resulting in actual harm. A resident with diagnoses of dementia, COPD, and dysphagia had a physician's order requiring all medications to be crushed and administered in pudding or applesauce due to swallowing difficulties. The resident's care plan included strict aspiration precautions but did not contain specific goals or interventions for dysphagia or the need for crushed medications. Despite these orders and precautions, an LPN provided the resident with whole medications after the resident requested them, following a recent diet order change. The LPN confirmed administering the medications uncrushed, after which the resident began coughing and experienced respiratory distress. Additional staff responded, and a finger sweep was performed, removing food matter and whole pills from the resident's mouth and throat. The resident, who was a DNR, subsequently ceased to breathe and was pronounced dead after resuscitation efforts were unsuccessful. Facility leadership confirmed that policies and procedures were not properly implemented to protect the resident from neglect, which led to aspiration, respiratory failure, and death.