Failure to Monitor Change in Condition and Administer Ordered Medication
Penalty
Summary
The facility failed to provide necessary care and services for a resident who experienced difficulty swallowing medications. After the resident coughed and choked when given a whole medication tablet with water, the nurse crushed the remaining medications and informed speech therapy (ST) of the change in condition. However, there was no documented evidence that the resident was assessed or monitored following this event, nor were care and safety measures provided as required by facility policy. The resident's care plan was not reviewed or revised to address the new swallowing problem, and meal intake documentation was incomplete for the day of the incident. Additionally, the facility did not administer warfarin sodium, an anticoagulant, as ordered by the physician. The medication was unavailable because the pharmacy required recent laboratory results, which had not been obtained or ordered. The nurse responsible acknowledged that the medication was not given and that follow-up with the pharmacy and physician was not completed due to being occupied with another emergency. The resident's medical record did not contain a physician's order for the necessary blood tests (prothrombin time and INR) required for warfarin dosing. Interviews with staff confirmed these lapses in care and documentation. The Director of Nursing (DON) verified that the resident was not monitored after the change in condition and that the warfarin sodium was not administered as ordered. The DON also confirmed the absence of a care plan update and the lack of orders for required laboratory tests, as well as incomplete documentation of the resident's meal intake.