Failure to Follow 'Do Not Crush' Medication Order
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A registered nurse prepared and administered medications to a resident, including Potassium Chloride Extended-Release 10 MEQ, by crushing all the medications together and mixing them with applesauce before administration. The physician's order for the Potassium Chloride specifically instructed that the tablet was not to be crushed, but rather placed in applesauce and allowed to dissolve. The nurse did not follow these instructions and crushed the tablet. The Director of Nursing confirmed that medications with 'do not crush' instructions should not be crushed. Facility policy also required staff to administer medications as ordered and not to crush medications labeled with 'do not crush' instructions.