Improper Administration of Duloxetine DR Capsule
Penalty
Summary
A Licensed Vocational Nurse (LVN) administered Duloxetine Delayed Release (DR) 30 mg capsules to a resident by opening the capsule, pouring the contents into a medication cup, mixing it with applesauce, and giving it to the resident. The medication packaging was clearly labeled with a 'Do Not Crush' sticker, and the manufacturer's medication guide specified that the capsule should not be opened, broken, or chewed, but swallowed whole. The nurse stated that the resident had difficulty swallowing medications, so nurses routinely crushed her medications for administration. The resident involved had a history of anxiety, ataxic gait, and muscle weakness, and was assessed as having severely impaired cognition and being unable to make medical decisions. The resident's medication orders included instructions to crush and mix all crushable medications with applesauce, but did not specify that Duloxetine DR capsules should be opened. The nurse acknowledged during the interview that opening a delayed release medication could cause stomach upset and affect absorption, indicating awareness of the error after the fact.