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?

[Daisy Joyce]

...but...I DO take my mess and supplements while eating my breakfast.

In your face surveyor!

[kbrn2002, ADN, RN]

Update on this. There's been such an incredible amount of pushback that the policy has been amended. Our pharmacist came in this week and requested a list of all residents that take meds crushed or via enteral tube. All we need is an MD order to mix crushed meds for administering. Our pharmacy is getting the orders and processing them for us

[CapeCodMermaid, RN]

CMS has backed off on this reg. They are re-writing it to say it's 'best practice'. We are taking a resident centered approach and will write orders and care plans to cover us crushing and administering all together.

[JohnKearse22]

CMS clarified its position to allow multiple medications to be crushed if its found to be the best approach for the individual patient

See "Appendix PP" issued November 22nd, 2017 on pages 505-506. Link below

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf

Page 505-506

"However, separating crushed medications may not be appropriate for all residents and is generally not counted as a medication error unless there are instructions not to crush the medication(s). Facilities should use a person- centered, individualized approach to administering all medications. If a surveyor identifies concerns related to crushing and combining oral medications, the surveyor should evaluate whether facility staff have worked with the resident/representative and appropriate clinicians (e.g., the consultant pharmacist, attending physician, medical director) to determine the most appropriate method for administering crushed medications which considers each resident's safety, needs, medication schedule, preferences, and functional ability."

[Nolanursie]

I currently work in a assisted living memory care unit. I am the only nurse for that unit. I am responsible for administering approx. 35 residents with dementia and Alzheimer's their meds.

Nearly all of them require the medications to be crushed. Several of them require coaxing, one on one, redirection, etc just to get that one spoon ful of pudding in their mouth. This new regulation could have devastating consequences for my residents.

[CapeCodMermaid, RN]

The CMS has already backed off on this regulation. They are now stating it's best practice but not a mandatory way to pass meds. ALL the new regs are ridiculous....we have to have a meeting within 48 hours of admit? We have to offer substance abuse counseling? I'm so glad I'm nearing the end of my career or I'd get out of the business now.

[Sunshine.nurse]

This is why I am getting out of sub-acute nursing. If the CMS wants to actually help residents... make a federal mandate on nurse to resident and CNA to resident ratios based on acuity NOT census!!!

[CapeCodMermaid, RN]

If they did that, they would have to mandate increased reimbursement and I don't see that happening any time ever.

[Scorchednurse]

I will carry on as usual until state is standing next to me, then I'll put on a show for them.

I swear it's like "they" are sitting around trying to find ways to make med pass as difficult as possible.

"Resident centered care." Pssh. How many people at home take their meds in such ridiculous ways?

I've had residents that take a fist-full of meds several times a day along with med pass because of weight loss. What do you suppose the extra 30 bites of applesauce/pudding/whatever is going to do to their already non-existent appetite? How about the possibility of emesis after med passes?

I'm so done with federal and state regs. They are beyond ridiculous and just when I think they've topped themselves, they prove me wrong.

I will continue until one of them is standing next to me took the words right out of my mouth...or off my keyboard anyway...

[punkdmm, BSN, RN]

What type of assessment are you all using to qualify residents to get meds crushed and cocktailed? I'm being told the IDT has to eval and make recommendations in addition to the Dr order.

[ltcnurse4u, CNA, LPN]

What type of assessment are you all using to qualify residents to get meds crushed and cocktailed? I'm being told the IDT has to eval and make recommendations in addition to the Dr order.

I believe there was a post stating the regs were updated to allow meds to be crushed and combined together if it is in the best interest of the resident. On another side note, when our facility had its survey, the state did not say anything about meds crushed together nor about giving meds in the dining room during meal time.

[GLORIAmunchkin72]

Pudding and applesauce or ice cream are not necessarily used to 'hide' meds. They help make the meds more pallatable.