Improper Crushing and Administration of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and administered an iron tablet to a resident, despite facility policy stating that only medications which may be crushed should be altered in this way. The facility's policy requires nursing staff to use available references to determine which medications are safe to crush. According to the National Library of Medicine, iron tablets are enteric coated and should not be crushed, as the coating is intended to protect the stomach. The resident in question had a physician's order for iron 25 mg and tamsulosin hydrochloride 0.4 mg, both of which were administered on the day of the incident. The resident, who had severe cognitive impairment as indicated by a BIMS score of three, began coughing and choking after the LVN attempted to administer the whole pill with water. In response, the LVN crushed all of the resident's medications, including those that should not be crushed according to reference materials. The Director of Nursing (DON) was informed and acknowledged these findings during the investigation.