Crushing of Extended-Release and Labeled 'Do Not Crush' Medications
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical diagnoses, including dementia, chronic kidney disease, atrial fibrillation, and hypertension, was administered medications in a manner inconsistent with physician orders and manufacturer instructions. During a medication pass, an LPN crushed and administered Metoprolol Succinate ER 100 mg and Potassium CL ER 20 mEq tablets, both of which were clearly labeled 'do not crush,' along with Eliquis, by mixing them into pudding for the resident. The resident's Medication Administration Record (MAR) specified the use of these medications for hypertension and hypokalemia, with additional instructions to hold Metoprolol if systolic blood pressure was below 110. The resident was noted to have severely impaired cognitive skills and was rarely or never understood, as documented in the Minimum Data Set (MDS). The error was confirmed through direct observation, staff interview, and consultation with a pharmacist, who verified that both Metoprolol Succinate ER and Potassium CL ER tablets should not be crushed. Facility policy required staff to adhere to the '10 rights' of medication administration, including verifying the correct form of the drug, and to consult pharmacy or prescriber if there was any doubt. The facility's policy on medication-related errors also required notification of pharmacy and physician if a medication error occurred. The failure to follow these protocols resulted in the resident receiving medications in a form that was not intended, constituting a significant medication error.