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?

[ComeTogether, LPN]

So I spoke with DON and our pharmacy rep about this issue today. ( I am so happy I picked up this shift!!) So here is the skinny:

MDs will NOT be able to writer an order to crush meds and combine. If you are crushing meds...for PO or PEG..you need to get into the habit now of doing each med separately. If you crush meds and combine, then its a med error for EACH med that is crushed and combined. There is no wording for meds taken whole mixed in pudding our applesauce, but we were advised to give meds separately. My suggestion...get in the habit now !!

Now..in my facility..we are for the most part a small facility with 65 beds and our med pass has a 4am-6am, 7-10am, 11-1400 pm, 1500-1800 and 1900-2100 med pass time. My DON is going to sit down with our medical director to discuss this very issue, see about what meds we can dc and if the med pass times are working. We are looking at changing some daily meds to the evening shift to lighten up the AM med pass.

The pharmacy rep today could not tell us why the changes other than what we already know..and she agreed none of this makes any sense.

I did my med pass this morning...I had 3 residents that take their meds crushed...and two who take whole in applesauce. I still finished about the same time I always do..around 945am...I did make a point of waiting to give their meds at the breakfast table. They did not have any issues with breakfast and they tolerated taking multiple bites. My co-worker on the other unit did the same..but she had more trouble and she finished her med pass late. She said stated it wasnt actually that bad..just time consuming.

Good luck guys!! Any suggestions ..let me know!

I will do no such thing, this is pure absurdity. This will only lead to residents refusing their meds all together and nurses taking 5x longer to finish their med passes, leading to late meds for everyone.

I'm not doing it, period. I have 30 patients, at least 15 of them get their meds crushed and they consist of meds like lipitor, cardizem, lisinopril, remeron, pravastatin, metformin, etc. etc. Can't afford for them to refuse after the first batch and can't afford to be late for everyone else. I will just have to hide when state comes or I will do what everyone else does during survey week and pretend we actually do things the right way all the time. Or maybe I'll end up leaving LTC which isn't going to help any of these sweet lil old people, given the kind of nurses I've seen hired lately.

I just don't understand what the people are thinking. They make all these regulations without mandating nurse patient ratios or making it even remotely possible to follow them.

I mean, they quite literally have to be stupid to think all of these regs can get followed WITHOUT med errors happening including wrong time. Pure insanity.

[kbrn2002, ADN, RN]

I will do no such thing, this is pure absurdity. This will only lead to residents refusing their meds all together and nurses taking 5x longer to finish their med passes, leading to late meds for everyone.

I'm not doing it, period. I have 30 patients, at least 15 of them get their meds crushed and they consist of meds like lipitor, cardizem, lisinopril, remeron, pravastatin, metformin, etc. etc. Can't afford for them to refuse after the first batch and can't afford to be late for everyone else. I will just have to hide when state comes or I will do what everyone else does during survey week and pretend we actually do things the right way all the time. Or maybe I'll end up leaving LTC which isn't going to help any of these sweet lil old people, given the kind of nurses I've seen hired lately.

I just don't understand what the people are thinking. They make all these regulations without mandating nurse patient ratios or making it even remotely possible to follow them.

I mean, they quite literally have to be stupid to think all of these regs can get followed WITHOUT med errors happening including wrong time. Pure insanity.

I'm with you on this one. Nobody at work has mentioned this new regulation yet and I'm sure not going to be the one that brings it to their attention. The longer it is before management forces this craziness on us the better. When it does inevitably start, I too will be one that absolutely doesn't comply unless a state surveyor is hovering right over me.

[bluegeegoo2, LPN]

I am thinking of a lady that I take care of that has dementia with behaviors. These behaviors consist of beating the hell out of anyone who comes near, scratching (some staff have scars) biting (no teeth, thank God) spitting directly in your face and cussing you like a dog. You are lucky to get one bite of crushed meds into her. You've hit the lottery if you can manage two. I get her meds into her by making her a delicious "shake" that she drinks right up. Meds administered. Moving along.

She takes seroquel, risperdal, and depakote among other things. I would have to decide which meds to give first. The seroquel? Risperdal? No chance to get them all in her.

Besides the obvious need to keep behaviors at a minimum, imagine the horrific withdrawal she would suffer if she were suddenly not getting these meds. She would likely end up in a short-stay psych facility to get stabilized only to come back and withdrawal again and again.

I guess "they" didn't consider scenarios like that when conjuring up this rule. Smh.

[CapeCodMermaid, RN]

It's not your management forcing this on you. It's CMS. The state surveyors don't have any input...they do what they're told from their bosses. This is one of the stupidest regs I've seen and I've been in the business for more than 25 years.

[ComeTogether, LPN]

I am thinking of a lady that I take care of that has dementia with behaviors. These behaviors consist of beating the hell out of anyone who comes near, scratching (some staff have scars) biting (no teeth, thank God) spitting directly in your face and cussing you like a dog. You are lucky to get one bite of crushed meds into her. You've hit the lottery if you can manage two. I get her meds into her by making her a delicious "shake" that she drinks right up. Meds administered. Moving along.

She takes seroquel, risperdal, and depakote among other things. I would have to decide which meds to give first. The seroquel? Risperdal? No chance to get them all in her.

Besides the obvious need to keep behaviors at a minimum, imagine the horrific withdrawal she would suffer if she were suddenly not getting these meds. She would likely end up in a short-stay psych facility to get stabilized only to come back and withdrawal again and again.

I guess "they" didn't consider scenarios like that when conjuring up this rule. Smh.

My point exactly. I understand what they are getting at, in theory, but this is only going to harm the patients, not help them. It seems like they are hoping that docs will D/C meds that aren't "necessary" in order to make folks more likely to comply, but what I've gathered based on the time's i've tried to do just that, is the random supplements, statins, protonix, etc. are not D/C'd for some type of CYA.

They go on to say "does the resident want their meds in food"? - Um, No. They don't want them at all!

"are the meds being hidden in food (I'm assuming applesauce counts as "food} because the resident is refusing the meds - Um, yeah! They are.... so we should just let them all refuse, right? CHF can just rear it's ugly head, bowel obstructions will happen left and right and folks will start to stroke out when they don't take their HTN meds. Hey - they have that right!

It's so maddening. You would let a two year old refuse their seizure meds, these folks are no different.

I would NEVER sneak meds into an alert and oriented patient, but folks with dementia really can't be allowed to refuse if there is any possible way of getting them to take their meds. I'm not going to hold them down and pinch their noses until they open up, but I sure will slip them some chocolate pudding laced with lisinopril if that's what it takes.

[CapeCodMermaid, RN]

It is against every regulation to hide medications in food--applesauce, pudding. You're forcing someone to take meds when they clearly don't want them. Even someone with dementia has the right to refuse anything. Do you force them into the shower? It will have to be the FAMILIES putting pressure on CMS to change this. Caregivers have no clout.

[Orion81RN]

Someone at work had stated it was because when a resident spits out a medication that is crushed, you do not what medication it is because the meds have been crushed together. This is ridiculous and will cause more harm than good to the residents. I have yet to see the risks vs benefits .

I was thinking this was the reason. However, once already crushed and mixed individually, we no longer know which med they spit out just the same. Absurd. And we're not suppossed to write it with a sharpie on the med cups.

So after giving 1 patient 6 med cups of crushed meds mixed, and they refuse or spit out, or don't finish even ONE, we are suppossed to know without a single doubt WHICH med they missed HOW exactly. Ridiculous and nauseating to think about.

[Orion81RN]

It is against every regulation to hide medications in food--applesauce, pudding. You're forcing someone to take meds when they clearly don't want them. Even someone with dementia has the right to refuse anything. Do you force them into the shower? It will have to be the FAMILIES putting pressure on CMS to change this. Caregivers have no clout.

Meanwhile, in the real world....

[jenean]

I work in a long term care facility and have several residents with swallowing issues. Please reconsider this mandate. These people will either not get all their meds or they will aspirate. I don't see how separating them will be beneficial. Thank you.

[adm8185]

I do not think this new regulation is a good idea because nurses already do not have enough time to administer medications in a timely manner. I do not see any benefit for the patient with this new way of administering medications, it only makes it more difficult for the patients that already have a hard time taking medications. We all know that with some patients you only have one opportunity to give these meds and with this new way many medications will NOT be administered. The next time rules and regulations are presented for change or approval put yourself in the shoes of these geriatric patients!!!!!!!

[LadysSolo]

They are trying to accomplish the nurses being sure what meds the resident is refusing, which I get. But they are going to accomplish the residents refusing all the meds, or if they take their meds, refusing their meals (which are more nutritious) because they are full of applesauce or pudding. Then you will have a weight loss, which will require more supplements, which will further reduce the amount of meals taken, etc, etc. I think any regulations should come from someone who has actually had to work in LTC.

[packisnumber1]

We just got this memo from Pharmacy today. I can't believe this is even going to go into effect!! I work in a memory care unit and take care of 23 dementia residents. I also have another hallway with general population. I might as well pass medications all day and forget doing anything else! Some of my patients take 10+ meds in the mornings!! If I use more than the bare minimum of pudding, there's no getting those meds in! Sigh, this world is messed up!! I need a different profession!!!