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Guidelines for Crushing Medications and Placing Medications in Food

PDF Version of BQA 04-023 (PDF, 29 KB)

DATE: August 31, 2004 DSL-BQA-04-023

TO: Nursing Homes NH 12

FROM: Michael J. Steinhauer, Resident Care Review Section, Bureau of Quality Assurance

via: Criselda Ros-Dukler, Director, Bureau of Quality Assurance

In January 1993 the Bureau of Quality Compliance (now Bureau of Quality Assurance (BQA)) issued Memorandum BQC 93-003-03 that included a group of nurse practice guidelines. Two of the guidelines addressed procedures for the following questions: Can medications be crushed and can medications be placed in food prior to administering the medications to residents?

There are many possible practice guidelines that facilities can adopt in these two areas. In lieu of providing further practice guidelines, this memo highlights issues facilities should consider when developing policies and procedures, provides some resources to utilize and shares an overview of the guidance surveyors receive when evaluating potential deficient practices.

Crushing Medications

Surveyors evaluate the crushing of medications when they complete the Medication Pass Survey Task as part of the federal survey protocol. Surveyors are required to count as a medication error when a facility staff person crushes a medication that should not be crushed. Exceptions to this requirement would include the consultant pharmacist providing information that the crushing of the medication will not compromise the care of the resident and physician orders the medication to be crushed. Facilities can also provide literature from the manufacturer or other published sources that support the crushing of the medication. Much of this information can be obtained from the facilityís consultant pharmacist.

Surveyors will use multiple resources to determine if a medication that was crushed is one that should not have been. Information about crushing is available from the drug manufacturer and is routinely used by surveyors. An additional resource that is commonly adopted by many providers is "Oral Dosage Forms That Should Not Be Crushed" published in Hospital Pharmacy. It can be accessed at Crush-2000.pdf [file no longer operable]

If surveyors observe a medication administered that is crushed and they believe it should not have been, they will attempt to obtain the following information:

  1. did the consultant pharmacist evaluate the appropriateness of crushing the medication,
  2. is there a facility protocol that allows the particular medication to be crushed,
  3. does the facility have information to support the crushing of the medication, or
  4. is there a physician order to crush?

If no support for crushing the medication is provided to the surveyors the crushing of the medication will be counted as a medication error.

It is recommended that facilities ask their consultant pharmacists assist in developing procedures for crushing medications. Facility procedures may include one or all of the following:

  • pharmacist reviews
  • physician orders
  • maintenance of a select list of medications that may be crushed without a physician order or pharmacist review.

Placing Medication in Food

From a survey perspective, placing medications in food is a concern in the following circumstances: 1) the resident does not want medication in food, 2) the resident refused medication so the facility places the medication in food, and 3) medication cannot be given with food.

Resident choice usually becomes apparent in resident, family and staff interviews. If a resident does not want his/her medications given to him/her in food or a put into a particular food, that request should be honored so long as it does not interfere with the medication.

If a resident is refusing medication, informed consent and court orders may need to be pursued. Surveyors will request information supporting the facilityís decision to place medication in food against residentís wishes. Therefore, facility policies should address what information is required when giving medications in food against a residentís wishes. Often residents may have dementia or swallowing troubles. In these cases placing the medication in applesauce or pudding eases the administration process.

The last concern surveyors may investigate is when medication is given with food inappropriately. Some medications need to be given on an empty stomach. Surveyors routinely rely on the drug manufacturer requirements. If the facility is not following the requirements, surveyors will look for information supporting the facilityís practice. Therefore, facility procedures should include consultant pharmacist evaluation, physician orders, or literature to support the practice.

Other Medication and Food Issues

In some cases physicians will order or manufacturers require medications to be given with food. The question that usually arises during surveys is what quantity of food is adequate? Often medications are required to be given with food to impact the effect of the medication and/or impact the side effects, like GI distress. When medications that were ordered or required to be given with food, surveyors will apply the following:

  1. if the medication was administered without any food the observation will be considered an error,
  2. in cases where a meal has just been consumed or is about to be consumed the medication is considered given with food,
  3. if the medication was administered with food, but there is a question about the quantity, the surveyor will interview the staff, the resident and review records if necessary to determine if the amount of food was adequate.

In some cases, adverse effects of the medication may be avoided by giving a single cracker or small sandwich. In other cases, residents may require more food to avoid the side effect. The amount of food should be resident specific as some residents eat very little food and yet the medication response is appropriate. Facilities should ask their consultant pharmacists to assist in providing information about administering medications with food to optimize resident response to medications.

Medication administration is a complex, invasive healthcare intervention. The results of the intervention often lead to changes in residentís care. It is important for all those involved in making recommendations about medications to be fully informed about the processes that are being implemented.

If there are further questions please contact Doug Englebert, BQA Pharmacist at 608-266-5388.

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