Crushing of Delayed and Extended Release Medications and Incorrect Dosage Administration
Penalty
Summary
During a medication pass observation, an LPN prepared and crushed several medications, including one delayed release and two extended release medications, before administering them to a resident. The medications that were crushed and placed into applesauce included Zunveyl (Benzgalantamine Gluconate) Oral Tablet Delayed Release 10 mg and Metoprolol succinate 100 mg ER, both of which should not be crushed according to facility policy and standard medication guidelines. Additionally, a cranberry tablet was administered at an incorrect dosage (450 mg given instead of the ordered 400 mg). These actions resulted in a medication error rate of 12.12% out of 33 medications observed during the survey. The resident involved had diagnoses of dysphagia and Alzheimer's disease, required a mechanically altered diet, and needed substantial to maximal assistance with eating. The facility's policy on medication crushing, dated June 2019, specifically states that timed release tablets should not be crushed due to their design for sustained release and to reduce stomach irritation. The DON was made aware of the errors at the time of observation, and the Nurse Practitioner confirmed that delayed and extended release medications should not be crushed and was not previously aware that this practice was occurring.