Failure to Follow Medication Administration Protocols for Resident with Swallowing Disorder
Penalty
Summary
Facility staff failed to demonstrate competent nursing skills in the administration of medications for one resident with multiple diagnoses, including schizophrenia, hypertension, major depressive disorder, and anemia. The resident had severe cognitive impairment, a swallowing disorder, and was on a mechanically altered diet. Physician orders specified oral administration of Ferrous Sulfate and Potassium Chloride ER tablets, both of which were labeled 'Do not crush.' During a medication pass, an LPN was observed crushing these medications and mixing them with applesauce for administration, despite the clear labeling and absence of a physician's order to do so. The LPN explained that all medications were being crushed for the resident due to her swallowing issues and thickened liquid diet. However, the medical record did not contain any current physician order authorizing the crushing of these medications. The facility's policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in this instance. The deficiency was confirmed through observation, record review, and staff interviews.