Crushing of Extended-Release Medication by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) prepared to administer medications to a resident diagnosed with generalized idiopathic epilepsy and epileptic syndromes. The RN was observed crushing seven medications, including two tablets of Levetiracetam ER (an extended-release anticonvulsant), despite facility policy and manufacturer instructions that specifically prohibit crushing extended-release medications. The facility's policy requires medications to be administered as ordered and in accordance with manufacturer specifications, including not crushing medications labeled as 'do not crush.' The RN admitted to crushing the Levetiracetam ER tablets based on an assumption that the resident, who had a history of stroke and difficulty swallowing, required all medications to be crushed. The resident's chart did not specify administration instructions for these medications. The error was identified by surveyors before the medications were administered, and the RN acknowledged that she would not have caught the error without their intervention.