Crushing of Extended-Release Potassium Tablet Results in Significant Medication Error
Penalty
Summary
A deficiency occurred when a registered nurse crushed and administered a potassium chloride extended-release 20 milliequivalent tablet to a resident with multiple diagnoses, including chronic diastolic heart failure, vascular dementia, and severe cognitive impairment. The resident had a physician's order to crush medications unless contraindicated, and a separate order for potassium chloride extended-release. During medication preparation, the nurse crushed all of the resident's medications, including the extended-release potassium tablet, and administered them in applesauce. Interviews with the nurse and the facility pharmacist confirmed that extended-release potassium chloride tablets should never be crushed. Facility documentation and policy also specified that this medication form was not to be crushed. The facility's medication administration policy required staff to follow proper procedures and referenced a list of medications that should not be crushed, which included potassium chloride extended-release tablets.