Improper Crushing of Non-Crush Medications During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to manufacturer specifications, specifically by improperly crushing medications that should not be altered. During a morning medication pass in the main dining room, a QMA crushed and spoon-fed memantine tablets mixed in applesauce to a resident with vascular dementia, severe cognitive impairment, and documented swallowing difficulties. The physician’s orders allowed crushing of appropriate medications, but memantine was listed by the contracted pharmacy on a “do not crush” list, and a medication reference from the Mayo Clinic indicated memantine tablets should not be crushed, chewed, or divided because crushing can cause the drug to release too quickly into the body. In a separate observation, the same QMA crushed and spoon-fed aspirin EC (enteric coated), Jardiance (empagliflozin), and potassium chloride ER (extended release) mixed together in applesauce to another resident with a history of stroke and vascular dementia, who had severe cognitive impairment but no signs or symptoms of a swallowing disorder. The physician’s orders also allowed crushing of appropriate medications, but aspirin EC and potassium ER were on the pharmacy’s “do not crush” list. ISMP guidance indicated enteric-coated and ER medications should not be crushed or dissolved, and FDA information described potassium chloride ER as a formulation intended to slow potassium release. The QMA stated she always crushed all medications for these residents and administered them mixed together in applesauce, doing so for one resident due to swallowing problems and for the other because she took them better that way. The Regional Nurse Consultant indicated there was no formal facility policy for crushing medications, although a pharmacy-provided list of medications that should not be crushed was available, and the facility’s General Dose Preparation and Medication policy required staff to crush oral medications only in accordance with pharmacy guidelines and/or facility policy.
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