Failure to Develop Person-Centered Care Plan for Crushed Medications
Penalty
Summary
The facility failed to develop a person-centered care plan addressing the need for crushed medications for a resident with a diagnosis of dysphagia, dementia, and COPD. Although the resident's care plan included an approach to adhere to strict aspiration precautions due to increased nutrition/hydration risk, it did not include specific goals or interventions for dysphagia or the requirement for medications to be crushed. A physician's order was in place for medications to be given crushed in pudding or applesauce until cleared by speech therapy, but this was not reflected in the care plan. An LPN provided the resident with whole medications after the resident requested them, following a recent change in diet order. The resident began coughing and experienced respiratory distress, leading to a fatal aspiration event. Staff attempted emergency interventions, but the resident was pronounced deceased. Facility leadership confirmed that a person-centered care plan related to the need for crushed medications was not developed for this resident.