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.
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 http://www.factsandcomparisons.com/assets/hospitalpharm/
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
- did the consultant pharmacist evaluate the appropriateness of crushing
- is there a facility protocol that allows the particular medication to be
- does the facility have information to support the crushing of the
- 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:
- if the medication was administered without any food the observation will
be considered an error,
- in cases where a meal has just been consumed or is about to be consumed
the medication is considered given with food,
- 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
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
If there are further questions please contact Doug Englebert,
BQA Pharmacist at 608-266-5388.
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