Medication Error Rate Exceeds 5% Due to Improper Crushing and Mixing of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and mixed all of a resident's prescribed medications together in one cup of pudding and administered them without a physician's order to do so. The medications included bismuth/metronidazole/tetracycline capsules, Renal-Vite, and vitamin C. The LVN was observed preparing and administering the medications in this manner, and during an interview, admitted to not being aware that a physician's order was required to crush and mix the medications. The LVN also stated that she had been crushing and mixing the medications for the resident since admission without verifying the need for an order. The resident involved was a male with severe cognitive impairment, as indicated by a BIMS score of 5, and had diagnoses including pneumonia and chronic kidney disease. Review of the resident's records confirmed there was no physician order to crush and mix the medications. Facility leadership, including the ADON and DON, confirmed that staff are expected to have physician orders for crushing and mixing medications, and that the standing order for crushing was not present on the resident's medication administration record. The facility's training materials also specified that medications should not be crushed without an appropriate order.