Failure to Notify Physician When Resident Unable to Swallow Medications
Penalty
Summary
The deficiency involves the facility’s failure to consult the physician when a resident was unable to swallow ordered medications. The resident had a recent history of hospitalization for altered mental status related in part to multifocal stroke, and also had multiple myeloma, atrial fibrillation, chronic pain, depression, and a documented history of dysphagia. On admission, the resident was alert but confused and was ordered several oral medications, including apixaban for atrial fibrillation. On the day after admission, staff documented that the resident received morning and evening medications, with one medication aide reporting she crushed the medications in applesauce and another nurse reporting the resident took medications without specifying if they were crushed. The following morning, the assigned nurse documented on the MAR that the resident’s scheduled medications, including apixaban, were not administered. That same day, the nurse documented in a progress note that the resident refused all medications due to difficulty swallowing. In interview, the nurse described that the resident held water and then applesauce with crushed medications in his mouth without swallowing, with pooling of fluids and medications in the mouth, and that she and the responsible party ultimately removed the medications from his mouth. She stated she then held the medications for the rest of the day and did not contact the provider about the missed doses or the swallowing difficulty. Later that evening, another nurse documented administering the resident’s evening medications, reporting she crushed them in applesauce and, after taking time and going slowly, the resident was able to swallow them with sips of water. The physician and the corporate nurse consultant both stated in interviews that the physician should have been contacted when the resident could not swallow his medications.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.