F0759

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Crushing of Do-Not-Crush Medications Leads to Elevated Medication Error Rate

Petersburg, West Virginia Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The facility failed to maintain a medication error rate below 5%, with surveyors observing 3 errors out of 29 medication administrations, resulting in a 10.34% error rate. During a medication pass, an LPN administered multiple medications to Resident #58 in crushed form mixed with pudding, including pantoprazole sodium (Protonix), potassium micro extended-release, and ferrous sulfate (iron), all of which had manufacturer or guideline instructions that they should not be crushed, chewed, or split. The National Institutes of Health DailyMed information specified that pantoprazole sodium for delayed-release oral suspension should not be split, chewed, or crushed; potassium tablets should be swallowed whole without crushing, chewing, or sucking; and iron tablets should not be crushed or chewed.

Resident #58 had a physician’s order dated 04/12/24 stating that medications may be crushed or capsules opened as needed unless they were on the facility’s Do Not Crush list, and may be mixed with food or fluids. The DON provided the Do Not Crush list, which included pantoprazole sodium, potassium, and iron salts, indicating that these medications should not have been crushed under the standing order. The DON also provided an email from the pharmacist explaining that ferrous sulfate IR tablets generally should not be crushed or chewed, potassium ER tablets like Klor-Con M should not be crushed to powder or chewed, and pantoprazole should generally not be crushed, with limited exceptions for feeding tube administration. Despite these instructions and the facility’s own Do Not Crush list, the medications were crushed and administered to Resident #58, contributing to the elevated medication error rate identified by surveyors.