Crushing and Administering Extended-Release Medications
Penalty
Summary
A certified medication technician (CMT) crushed and administered two extended-release medications, glipizide ER and metoprolol ER, to a resident diagnosed with diabetes and hypertension. The medications were intended to be taken whole, as per physician orders and manufacturer instructions, to ensure gradual release over 24 hours. The CMT was observed removing the tablets from the medication cart, crushing them, mixing them with yogurt, and administering them to the resident. Documentation in the Medication Administration Record confirmed that both medications were given in the morning as prescribed, but in crushed form. During interviews, the CMT stated they were unaware that the medications were extended-release and should not be crushed, acknowledging that crushing such medications would result in the entire dose being absorbed at once rather than over 24 hours. The Director of Nursing and the Administrator both confirmed that extended-release medications should not be crushed, as this practice is inconsistent with facility policy and standard medication administration protocols. The facility's policy and drug information resources also specify that extended-release medications must be swallowed whole and not crushed.