Improper Crushing and Administration of Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate preparation and administration of medications for one resident. During medication administration, an LPN was observed crushing and administering several medications that, according to both manufacturer specifications and facility policy, should not be crushed. These included enteric-coated aspirin, extended-release bupropion, finasteride, and extended-release guaifenesin. Additionally, the LPN opened omeprazole and tamsulosin capsules and mixed their contents with the other crushed medications. The LPN stated that these actions were based on an order for crushed medications, but a review of the resident's physician orders revealed no such authorization. The orders specifically indicated that these medications should not be crushed, chewed, or opened, and in the case of aspirin, a chewable form was ordered but an enteric-coated tablet was administered instead. Interviews with other nursing staff, including another LPN, an RN, and the DON, confirmed that crushing extended-release or enteric-coated medications, or opening capsules that should be swallowed whole, constitutes a medication error. The facility's own policies and a reference list of medications not to be crushed were not followed in this instance. The incident was observed directly by the surveyor, and the staff interviewed acknowledged that the actions taken were medication errors according to both facility policy and professional standards.