Failure to Obtain Orders for Crushed Medications in Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dysphagia, as identified by a speech therapy evaluation, received appropriate orders for crushed medications. Despite the speech therapy evaluation documenting the need for crushed medications due to swallowing difficulties, there was no corresponding physician order in place from the time of the evaluation until nearly two months later. The resident's care plan did not include interventions for dysphagia or the need for crushed medications, and the medical record lacked a documented diagnosis of dysphagia during this period. Observations and interviews revealed that the resident was receiving crushed medications without a current physician order. Multiple nursing staff members confirmed that medications were being crushed and administered to the resident, but they were unaware of the specific reason or lacked knowledge of the resident's swallowing issues. Staff interviews consistently indicated that an order is required before crushing medications, and the absence of such an order was acknowledged as a deviation from facility policy and professional standards of practice. The speech pathologist confirmed the resident's need for crushed medications and swallowing precautions, stating that these requirements should be reflected in the care plan and supported by physician orders. The administrator and nursing staff acknowledged that the lack of orders for crushed medications could place residents at risk, and that the facility's policy requires medications to be crushed only with appropriate orders and documentation. The deficiency was identified through record review, staff interviews, and direct observation.