Esophageal Obstruction After Multiple Pills Given at Once and Improper Positioning
Penalty
Summary
The deficiency involves the facility’s failure to provide safe medication administration consistent with physician orders, speech therapy recommendations, the resident’s expressed preferences, and facility policy, resulting in an esophageal obstruction during medication administration. The resident involved was cognitively intact, dependent for transfers, turning, and repositioning, and required setup/supervision with eating. Speech therapy documentation showed the resident had swallowing difficulties, including mild lingual weakness and coughing several minutes after oral intake, and that she could safely swallow only one pill at a time with applesauce. The resident had been receiving speech therapy for swallowing difficulties since mid-2025, and therapy notes indicated she was specifically concerned about swallowing multiple pills when agency staff were present. On the date of the incident, the resident reported in writing that an RN administered multiple medications at once, despite her preference and need to take one pill at a time with applesauce. The resident stated she attempted to signal the RN by raising her hand to indicate she needed one pill at a time, but the RN left the room while the resident was still swallowing the medications. Shortly thereafter, a CNA entered the room to provide incontinence care and began to lay the resident’s head of bed from an elevated position to flat while the resident was still trying to swallow the pills. The resident then began coughing, drooling, gasping, and showing signs of choking. Nursing documentation shows that when the RN was called back to the room, the resident’s lips were cyanotic, her oxygen saturation was 64%, and she indicated she could not breathe and was choking. The RN assessed the airway, did not see a visible obstruction, and initiated the Heimlich maneuver. The resident became unresponsive briefly, then expelled applesauce and undigested food, and later vomited a second time after being repositioned. The facility’s medication administration policy required qualified staff to position the resident appropriately for medication administration and to observe the resident consuming medications, but the resident’s account and the sequence of events indicate that multiple pills were given at once, her expressed need for one pill at a time was not followed, and she was repositioned to a flat position while still swallowing, leading to the choking episode and esophageal obstruction.
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