Medication Administration Errors: Crushing ER Tablets and Missed Dose
Penalty
Summary
A medication administration deficiency occurred when a nurse crushed and administered extended release (ER) tablets of potassium chloride and verapamil to a resident, contrary to manufacturer guidelines and accepted standards of practice, which specify that ER tablets should not be crushed. The nurse stated that the resident was unable to swallow whole pills and believed the resident also crushed pills at home. However, there was no evidence that the physician had been consulted regarding alternative formulations or the appropriateness of crushing these medications. Additionally, the nurse failed to administer a prescribed multivitamin (PreserVision AREDS) in the morning as ordered, citing unavailability on the medication cart. The facility's medication error rate was calculated at 10.7%, with three errors identified out of 28 opportunities during observation. The errors affected one resident who had a history of swallowing difficulties, as documented in a hospital discharge summary, which recommended crushing pills only if they were crushable. The nurse and another staff member later confirmed that ER tablets are generally not to be crushed, and medication information sources suggested considering liquid alternatives for residents with swallowing difficulties.
Plan Of Correction
Resident #5 was assessed by RCS on 6/26/25 with no ill effects related to medications being crushed or missed vitamin administration. MD was notified with orders to change medications to crushable form and to discontinue the PreserVision AREDS as she was on a multivitamin with minerals on 6/26/25 by the floor nurse. By 7/14/25, all residents with a need for medications to be crushed will be audited by RCS to ensure medications ordered were able to be crushed. Any negative findings will be addressed. An initial audit of all residents' medication administration records will be completed by RCS to ensure medications are administered as ordered. Any negative findings will be addressed. By 7/14/25, LPN #100 was educated by RCS related to crushing medications, forms that cannot be crushed, and administering all medications as ordered. All nurses will be educated by 7/14/25 by the DON or designee on medication administration to include crushing medications, medications that are not crushable, and administering all medications as ordered. Audit of 5 residents per week who require medications to be crushed will be completed weekly for 4 weeks by the DON or designee to ensure medications ordered are allowed to be crushed. Medication pass observations will be conducted by the DON or designee for 5 nurses per week for 4 weeks to ensure proper medication administration. Any negative findings will be addressed immediately. The DON or designee will complete medication pass audits for 5 nurses per week for 4 weeks to ensure all medications are appropriately ordered and administered. The DON will be responsible for ongoing compliance. Results of audits will be reviewed at QAPI for adjustments as needed.