F0759

E

Medication Error Rate Exceeds 5% Due to Improper Crushing and Missed Inhaler Doses

Taos, New Mexico Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a medication error rate below 5%, with surveyors identifying an 11.54% error rate based on 3 errors out of 26 observed medication administrations involving three residents. One resident received divalproex sodium (Depakote) 500 mg delayed-release tablets crushed by an RN, despite this being a delayed-release formulation. The medication package label for this resident’s divalproex sodium did not state “do not crush,” and the physician’s order for Depakote did not include any notation about crushing. A separate provider order for this resident allowed crushing oral medications “if indicated” and mixing with applesauce, but there was no specific order indicating a medical need to crush the delayed-release divalproex sodium.

Another resident did not receive ordered doses of Symbicort 160/4.5 mcg inhaler, with surveyors identifying six missed doses over several days. During medication pass observation, the RN reported the inhaler was not available, was not in the emergency medication machine, and that the facility was awaiting pharmacy delivery. A third resident received phenytoin sodium extended-release oral capsules in crushed form, administered by an RN who crushed the extended-release capsule prior to giving it. The physician’s orders for this resident allowed crushing medications and/or opening capsules “if indicated,” but there was no order documenting a medical need to crush phenytoin, and the phenytoin medication package label specifically stated “do not crush.” The DON later confirmed that facility expectations and policy are that extended/delayed-release or enteric-coated medications are not to be crushed unless there is a specific medical order to do so, and also confirmed that the process for addressing the missing Symbicort doses had not been followed.