Crushing of Extended-Release Medication Without Physician Order
Penalty
Summary
A registered nurse (RN) prepared and administered medications to a resident, including Klor-Con M20 Extended-Release tablets, by crushing all large pills and mixing them with applesauce at the resident's request. The nurse did not provide education to the resident regarding the risks associated with crushing an extended-release tablet. The clinical record did not contain a physician's order authorizing the crushing of the Klor-Con M20 Extended-Release tablet for this resident. During an interview, the RN acknowledged that extended-release medications should not be crushed. The facility's pharmacy-provided 'Medications Not To Be Crushed' list and the facility's own policy both indicated that extended-release medications, such as Klor-Con, should not be crushed. Despite these guidelines, the medication was crushed and administered in this manner, contrary to established standards and facility policy.