Failure to Investigate Choking Incident and Adhere to Medication Administration Policy
Penalty
Summary
The facility failed to implement its policies and procedures to investigate a choking incident involving one resident, thereby not ruling out possible neglect. According to the facility's abuse policy, all allegations, suspicions, and incidents of abuse, neglect, and injuries of unknown source must be investigated. The resident in question had diagnoses of dementia, COPD, and dysphagia, with a care plan that included strict aspiration precautions but lacked specific goals and interventions for dysphagia or the need for crushed medications. A physician's order was in place for medications to be given crushed in pudding or applesauce until cleared by speech therapy. Despite this, an LPN provided the resident with whole medications after the resident requested them, leading to a choking event. The resident began coughing, experienced respiratory distress, and ultimately ceased to breathe. Staff attempted emergency interventions, including a finger sweep, which removed food matter and whole pills from the resident's mouth and throat, but resuscitation was unsuccessful. Interviews with staff and administration confirmed that no investigation was conducted into the incident, as required by facility policy.