Failure to Obtain Physician Orders for Crushed Medications
Penalty
Summary
The facility failed to obtain physician's orders for the administration of crushed medications for 29 out of 33 residents who required this modification. According to the facility assessment, speech therapy services are provided, and the speech therapist confirmed that while they adjust diet consistency orders, they do not address the need for physician's orders for crushed medications. During interviews, it was revealed that nursing staff relied on assumptions rather than formal orders to determine which residents needed their medications crushed. A review of clinical records showed that only four residents had proper physician orders for crushed medications, while a speech therapy audit identified 29 additional residents needing this intervention without corresponding physician orders. The Nursing Home Administrator and Director of Nursing confirmed this oversight.