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F0760
D

Crushing and Administering Extended-Release Medication Without Order

Muscoda, Wisconsin Survey Completed on 08-25-2025

Penalty

No penalty information released
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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 significant medication error occurred when a registered nurse crushed and administered an extended-release Divalproex (Depakote) tablet to a resident, despite the medication being prescribed in its extended-release form for seizure management. Facility policy specifies that medications should be administered as ordered and in accordance with manufacturer specifications, which includes not crushing medications labeled as 'do not crush.' The resident's physician orders did not include instructions to crush the Divalproex extended-release tablet, and the Director of Nursing confirmed that there was no such order and that it is not acceptable to crush this medication. The error was directly observed by the surveyor during medication administration.

See complete original report
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