Crushing of Non-Crush Medications and Incorrect Dosing Resulting in Elevated Med Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 6 errors out of 25 opportunities, resulting in a 24% error rate. The deficiency centered on one resident with diagnoses including GERD, major depressive disorder, vitamin B12 deficiency anemia, hypertension, heart failure, and dysphagia. Physician orders and the MAR for this resident specified pantoprazole sodium delayed release 20 mg daily, venlafaxine HCl ER 24-hour 75 mg daily, chewable aspirin 81 mg daily, potassium chloride ER 20 mEq daily, and cyanocobalamin 1000 mcg daily, with no order to crush medications. During a medication pass observation, a CMT prepared the resident’s morning medications by removing pantoprazole DR 20 mg, venlafaxine ER 75 mg, potassium chloride ER 20 mEq from pharmacy cards, and aspirin 81 mg and cyanocobalamin 100 mcg from facility stock bottles. The aspirin provided was enteric-coated from stock, not chewable as ordered, and the cyanocobalamin dose selected was 100 mcg instead of the ordered 1000 mcg, despite a 1000 mcg stock bottle being available in the cart. The CMT then combined all of these medications into a plastic sleeve, crushed them, and mixed the crushed medications into a pudding cup before administering them to the resident. The facility’s own Medication Administration Policy required staff to verify medications against the MAR, administer medications as ordered, and not crush medications that are delayed-release, extended-release, or enteric-coated. Reference information from drugs.com cited in the report specified that pantoprazole DR, venlafaxine ER, enteric-coated aspirin, and potassium chloride ER must be swallowed whole and not crushed. In an interview, the CMT stated they were aware of which medications could and could not be crushed, claimed to have tried to position the aspirin so it would not be crushed, and indicated they believed the 1000 mcg cyanocobalamin dose was a mistake and therefore used the 100 mcg product instead. The DON and Administrator stated they expected staff to follow physician orders, verify doses with the MAR and medication containers, and avoid crushing enteric-coated, extended-release, or delayed-release medications.
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