Crushing of Extended Release Potassium Tablet During Medication Administration
Penalty
Summary
A deficiency occurred when a medication aide crushed and administered a potassium chloride extended release (ER) tablet to a resident, despite facility policy and manufacturer guidance indicating that ER medications should not be crushed. The aide prepared the resident’s medications by crushing all except an esomeprazole capsule, mixing them into pudding, and administering them. The aide was unaware of a 'Do Not Crush' list on the medication cart and did not consult available resources to verify which medications could be safely crushed. The resident involved had a history of chronic kidney disease, stroke, and dementia, and was moderately cognitively impaired. The resident’s care plan allowed for medications to be crushed when appropriate, but the physician’s order specified potassium chloride 10 mEq ER tablet, which was not to be crushed. The facility’s own documentation and pharmacy guidance confirmed that this specific ER tablet should be administered whole, as crushing it could alter its intended release properties. Interviews with staff revealed inconsistent knowledge and practices regarding which medications could be crushed. Some staff believed ER medications could sometimes be dissolved, while others were unaware that the resident was receiving an ER potassium tablet. The facility had resources such as a drug reference book and a 'Do Not Crush' list, but these were not consistently located or utilized by staff during medication administration.