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F-Tag 760: Avoiding a Citation When Crushing Medication

By Lynn A. Milligan, MSN/ED, RN, DNS-CT, RAC-CT 

Some residents require or request that their medication be crushed for oral administration. But not following CMS guidelines for crushing medications could result in a citation under §483.45(f)(2) (Residents Are Free of Any Significant Medication Error). This citation could also occur in administering crushed medications via feeding tube. Facility leaders and the nurse administering the medications must first be sure that the particular medication can be crushed per manufacturer instructions. The Institute for Safe Medication Practices website can be a helpful resource in determining which medications should not be crushed.

If the manufacturer’s instructions for a medication state that it should not be crushed and there is not a suitable replacement for this medication, there are two exceptions that the facility staff may follow to avoid being cited under §483.45(f)(2):

· The prescriber of the medication or a pharmacist must explain in the resident’s clinical record why the crushing of the medication will not adversely affect the resident. There should also be good documentation that the pharmacist informed the facility staff which pertinent adverse effects should be carefully observed for in the resident.

· The facility staff can also provide literature from the medication manufacturer or from a peer-reviewed health journal to justify why crushing it or modifying the original dosage form will not compromise resident care. The literature should be readily available, and good documentation in the resident’s clinical record should reference the literature.

A best practice for administering crushed medication is to crush and administer each medication separately. Crushing and combining medication may result in physical and chemical incompatibilities, leading to an altered therapeutic response; it can also cause a feeding tube occlusion. 

Another best practice for oral administration is to give with food. When administering via feeding tube, the tube should be flushed with water after each crushed medication. In the case of a resident with fluid restriction, a physician order must be obtained stating that the resident does not require flushing of the tube after each medication and that a different flush schedule should be used. The amount of water to be used for administering and flushing the crushed medications should be included in the physician order.

There may be times when crushing and administering each medication separately is not appropriate for a resident. When this is the case, facility staff should actively involve the resident, the resident’s representative, the attending physician, the consultant pharmacist, and the medical director, as needed, to ensure that there is a person-centered, individualized approach to administering each medication. The resident’s safety, preferences, functional ability, medication schedule, and needs should be assessed and care-planned. To avoid a citation under §483.45(f)(2), It is also imperative that there not be a Do Not Crush Medication physician order in place.

Residents’ diagnoses and preferences should always be considered when creating a plan of care. When the crushing of medication is required, it is important that considerations of diagnosis, preference, and manufacturer’s instructions for each medication be part of the plan of care.

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