Crushing and Improper Administration of Atorvastatin Against Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and physician orders for medication administration for one resident. The resident was admitted with diagnoses including cerebral infarction, epilepsy, slurred speech, and dysphagia, and had a physician’s order dated 02/07/2026 for Atorvastatin 40 mg to be administered orally once daily, with explicit instructions that the tablet was to be given whole and not crushed. The manufacturer’s prescribing information for Atorvastatin similarly stated that the tablets are to be swallowed whole and should not be crushed, chewed, or broken. The Medication Administration Record for 02/09/2026 at 9:00 PM showed that Atorvastatin 40 mg was administered and included instructions that it was not to be crushed, although it did not specify the form in which it was actually given. On the night of 02/09/2026, an agency nurse (Nurse #3), working her first shift at the facility and first time caring for this resident, crushed and administered the resident’s nighttime medications, including Atorvastatin 40 mg, without verifying the physician’s order. The resident’s POA, who stayed overnight, observed Nurse #3 crushing and administering the medications and informed her that the order specified the medication must be given whole, stating she had a copy of the order available. Nurse #3 responded that the medications had already been crushed and told the POA that if the resident refused the crushed medication, she would not receive it until the next scheduled dose. In a separate interview, the cognitively intact resident confirmed that Nurse #3 administered her nighttime medications, including Atorvastatin 40 mg, in crushed form and told her the medication would not harm her and that if she refused it, she would not receive it again until the next scheduled dose. Nurse #3 later acknowledged she crushed the medication based on her belief that it needed to be crushed due to the resident’s history of stroke and information from the previous shift nurse, and admitted she did not verify the physician’s order or contact the provider or pharmacy to clarify the order.
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