Medication Error Rate Exceeds 5% Due to Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% out of 25 opportunities. During medication administration, an LPN was observed crushing and administering two extended-release medications—Metoprolol Succinate ER 25 mg and Klor-Con M20 (Potassium Chloride Extended Release)—to a resident by mixing them in pudding. The physician's order allowed medications to be crushed or diluted as needed unless contraindicated. However, both medications are extended-release formulations, and crushing them is contraindicated according to standard drug references. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that extended-release tablets should not be crushed, and alternative formulations should have been sought if the resident was unable to swallow the tablets whole. The facility's policies require medications to be administered as prescribed and for any deviations or concerns to be documented and communicated to the prescriber. These procedures were not followed in this instance, resulting in a medication error that contributed to the facility's elevated error rate.