F0684

D

Failure to Administer Medications in Accordance With Crush Orders for Resident With Dysphagia

North Logan, Utah Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

A resident with fractures of the right and left pubis, sacrum fracture, dysphagia, and age-related osteoporosis was admitted with a history of choking episodes, including a documented choking event on toast during a recent hospital stay. A hospital SLP evaluation identified severe dysphagia with pills/medications, including difficulty initiating the oral stage, coughing after swallow, and watery eyes, and outlined swallow strategies such as upright positioning, small bites and sips, slow rate, head turn for solids, adding moisture, and chasing with liquid. Subsequent facility diet and communication orders specified a regular diet with thin liquids and an order that medications were to be crushed in puree, and a physician order directed that medications be crushed every shift due to choking risk, with nurses documenting administration on the MAR twice daily.

Despite these orders, the facility’s own investigation, initiated after the resident’s family reported the resident was receiving whole pills instead of crushed medications, revealed that several prescribed medications were not able to be crushed and had nonetheless been administered in that form until the end of the month. These medications included Align capsules, cholecalciferol tablets, celecoxib capsules, vitamin E tablets, tamsulosin capsules, and PreserVision AREDS 2 capsules. The Administrator later stated that the facility had a process for SLP evaluation of medication swallowing after admission and that the physician was responsible for specifying whether medications should be crushed, but the record review and interviews showed that, for this resident, medications that could not be crushed were still given contrary to the physician’s order for crushed medications related to choking risk.