Inadequate Nurse Competency in Sublingual and Slurry Medication Administration
Penalty
Summary
The facility failed to ensure nurses were timely and competently trained on the administration of oral and sublingual medications for a resident with complex needs. The resident had frontal lobe brain cancer, was significantly cognitively impaired, dependent for ADLs, had difficulty or pain with swallowing, and was receiving scheduled and PRN pain medications. Hospice notes documented that during the early morning hours, a facility nurse contacted hospice to request discontinuation of all medications because the resident was having difficulty swallowing, including Synthroid and morphine. Hospice staff educated the nurse that lorazepam and morphine were comfort medications and could still be administered. Later that morning, hospice documented that the resident’s family requested morphine and lorazepam be given as a slurry, and provider orders were written for lorazepam soluble and morphine solutab, including an order allowing the medications to be slurried in a small amount of water and given sublingually. Despite these orders, hospice documentation and interviews showed that facility staff did not understand how to properly administer solutab and sublingual medications or slurries. Hospice reported that staff were providing solutab comfort medications mixed with applesauce, which drained out of the resident’s mouth when the resident was unable to swallow, and that staff had requested discontinuation of comfort medications because they did not know the medications dissolved in the mouth without swallowing. The resident’s family member reported witnessing staff trying repeatedly to get the resident to swallow morphine solutabs, during which the resident coughed and gurgled. Multiple licensed nurses interviewed later stated they did not know what sublingual medication was, confused it with liquid medication, and did not know what a slurry was. One nurse stated that for hospice patients she had them swallow medications ordered to be slurried and given sublingually. The DON described how a slurry should be prepared and administered but the facility’s pain management policy did not contain instructions on sublingual or slurried pain medication administration, and a medication administration policy was requested but not provided.
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