Improper Administration of Extended-Release and Delayed-Release Medications
Penalty
Summary
The facility failed to ensure proper administration of delayed-release and extended-release medications for a resident with chronic diastolic congestive heart failure, type II diabetes mellitus, and aphasia following cerebral infarction. A registered nurse was observed crushing Potassium Chloride Extended Release (ER) and Omeprazole Delayed Release (DR) tablets, mixing them with pudding, and administering them to the resident. The nurse confirmed during interview that both medications were crushed prior to administration. Review of FDA guidance and the facility's own policies revealed that both Potassium Chloride ER and Omeprazole DR are not to be crushed, as this can affect the efficacy and safety of the medications. The facility's policy required staff to check a 'Do Not Crush' list and consult with a pharmacist or physician if a medication could not be crushed. Both medications administered in this manner were listed on the facility's 'Medications Not To Be Crushed' list, indicating a failure to follow established protocols and safe medication administration practices.