Crushing Oral Medications...New Regulation

[ltcnurse4u]

Our pharmacy sent out newsletter on Monday that states:

As of November 28, 2017, phase 2 of the new federal regulations will take effect. Part of the changes relates to crushing oral (PO) medications. The new regulation states:

"Crushed medications should NOT be combined and given all at once either orally (e.g in pudding or similar food) or via feeding tube."

We have known medications given via feeding tube cannot be cocktailed unless there is an order from the MD with a clinical indication to do so. However, the separation of crushed ORAL meds is new and there is no wording in the regulations allowing for any exceptions.

Additionally, if a surveyor observes medications being crushed and combined, then the number of errors would be equal to the number of medications crushed. For example, if five medications are crushed and combined, then this would count as 5 med errors. If the med error rate is greater than 5%, then the facility is sited under F759.

We do have concerns regarding separating crushed medications. It could result in resident medication refusal, fluid overload, and decreased meal intake for certain residents. This is in addition to increase nursing medication administration time. The updated regulations focus on person centered care. Hopefully this applies to med crushing as well. Can crushed medications given orally be combined if the resident prefers and the risks vs benefits are explained to the responsible party? If there is a contradiction to separate the medications and the prescriber documents the rational with risks vs benefits, will this suffice?

I work at a small facility and I have about 15 residents who requires crush meds. 5 of them have more than 10 different meds and take their meds like little baby birds.

How will the new regs affect your med pass??

What are the risks vs benefits of giving crushed meds separately?

[CapeCodMermaid, RN]

Get an MD order stating all meds may be crushed together. Do people not realize that all these new regulations are only chasing more and more nurses out of the LTC world? Show me some evidence surveyors.

[caliotter3]

Get an MD order stating all meds may be crushed together. Do people not realize that all these new regulations are only chasing more and more nurses out of the LTC world? Show me some evidence surveyors.

If the doctors play along with this nonsense and don't write the orders, we're in for a hard time of it.

[LadysSolo]

People who write regulations should first have to work in the real world of a nurse on the floor. This is pure insanity, probably written so the surveyors can find yet another nit-picky reason to cite a facility and justify their job.

[kbrn2002, ADN, RN]

Good heavens, that's absolutely nuts! I'm just picturing passing meds to some of my residents that take 20 or so pills. Even crushed together it takes a few bites to get them all down, no way are they taking them one at a time. I have enough residents that take meds crushed that I can see this easily doubling my need pass time. Not to mention the added cost. A separate med cup and spoon for each pill might not sound like much, but it'll add up in a hurry. Plus way to add all those plastic med cups and spoons to the landfills. That's a real good idea. Sheesh, idiots!

[Penelope_Pitstop, BSN, RN]

It was suggested that we try giving each med one by one, document the negative outcome, discuss the negative outcome with the resident/responsible party

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[djh123]

1. The rule is crazy and proof it's written by someone who has really never done a med pass.

Key point. :^) And many rules are written by Those Who Are Not Doing The Work.

[CapeCodMermaid, RN]

Speak to your medical director. He or she should speak to the other MDs if they are not willing to be reasonable. It's far better for the residents.

[brillohead, ADN, RN]

When I was in nursing school, I had a patient with a PEG tube who had 8-10 meds that needed to be crushed and administered via PEG. My clinical instructor made me crush each one individually and administer it individually, complete with flushes between each med.

Crush Med 1 and put in water.

Draw up plain water flush in syringe.

Connect flush syringe to PEG.

Unclamp PEG, flush, reclamp PEG, disconnect syringe.

Put Med 1 in syringe.

Connect syringe to PEG.

Unclamp PEG, admin Med 1, reclamp PEG, disconnect syringe.

Draw up flush in syringe.

Unclamp PEG, flush, reclamp PEG, disconnect syringe.

Now on to Med 2.

Crush Med 2 and put in water.

Put Med 2 in syringe.

Connect syringe to PEG.

Unclamp PEG, admin Med 2, reclamp PEG, disconnect syringe.

Draw up flush in syringe.

Unclamp PEG, flush, reclamp PEG, disconnect syringe.

Now on to Med 3. Etc., etc., etc.

I think that med pass took me about an hour and a half, crushing each med individually, administering each one individually, and flushing between each one. My next clinical, I was doing an observation in the critical care unit, and I observed the nurse crush up ten meds together and give them all at once through a feeding tube, and the entire process took minutes instead of hours, and I was SO glad to see that happen In Real Life!

My C.I.'s rationale for dividing up the meds to be administered individually was that "only a pharmacist can compound medications" and crushing and mixing them would be considered "compounding". Stupidest thing ever, since they're all going to end up mixed together in the stomach anyway, but she had to follow the Official Policy when teaching students.

[LadysSolo]

Problem with giving each med individually with liquids becomes apparent with a resident with a fluid restriction, and you use up the entire day's allowed fluids in one med pass. Stupidity never ceases to amaze me.

[CapeCodMermaid, RN]

I'll give you an example of stupidity: woman with PEG tube. Had at least 2000ml daily between the free water and the flushes. Was on a PO fluid restriction because the NP didn't want her to go into overload. Fluid is fluid whether you drink it or have it via g-tube.

[Irish_Mist, BSN, RN]

What moron thought of this? I swear, these non clinical suits need to stop thinking of more ways to torture everyone with their "innovation".

[ComeTogether, LPN]

WHO comes up with this crap?!?!? We ALREADY have WAY MORE patients than we can handle, (I do, anyways) I spend my shift with cotton mouth and aching feet just trying to get everyone medicated and treated while trying to manage random things that come up and make sure my CNAs are doing what they should be doing....how in GODS GREEN EARTH do they actually think we would have the time to do this?

Someone HAS to realize that these expectations are NOT realistic and they just include them anyway because no one can be that dumb!

Sometimes I am still so utterly shocked at what we do to our sweet lil' old people. Good GRIEF!

anyways, I guess what you do when state comes is hide in a bathroom and pray to god they choose to watch someone with two meds.