Crushing Oral Medications...New Regulation

[ltcnurse4u, CNA, LPN]

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?

[Nascar nurse, ASN, RN]

I just attended a seminar on the upcoming rules of participation and this was discussed there as well.

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

2. 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 - discuss risks/benefits, get physician order for ok to combine the meds and careplan all of this. BUT, she also said - who knows what will happen, they might still tag you for it!

[bluegeegoo2, LPN]

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.

[VivaLasViejas, ASN, RN]

As a former state surveyor, I say this is ridiculous. No one who has ever done a med pass in LTC would agree with such a regulation, and that includes many surveyors. I feel sorry for the ones who have to enforce it at the local level, to say nothing of the nurses and med aides who have to follow the rule. Shame on the authorities for coming up with this one.

[NurseCard, ADN]

Welp, my idea of getting a PRN position at a local LTC may have just gone

flying out the window.

[dream'n, BSN, RN]

I found the new regulations; Federal Register

::

Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities

They are from the federal Medicare and Medicaid Program and apply only to LTC facilities.

Ridiculous!

[CoffeeRTC, BSN, RN]

Yikes. I would be working with the MDs and pharmacists to get the list of meds whittled down....especially all the extra MVIs etc.

[NurseSpeedy, ADN, LPN, RN]

This is insane. Anyone who has ever done a med pass in LTC knows that it takes forever without separating all the PO meds into different cups. Now mixing each separately and trying to get the resident to open up their mouth for each one is complete madness...hell, some it's like pulling teeth to just get them to take ONE. Many meds will be refused and then the resident is the one who suffers from not getting the medications that they need for their heart, BP, breathing, etc. Just the amount of apple sauce/pudding required is going to decrease nutritional PO intake at mealtimes.

[bluegeegoo2, LPN]

This is insane. Anyone who has ever done a med pass in LTC knows that it takes forever without separating all the PO meds into different cups. Now mixing each separately and trying to get the resident to open up their mouth for each one is complete madness...hell, some it's like pulling teeth to just get them to take ONE. Many meds will be refused and then the resident is the one who suffers from not getting the medications that they need for their heart, BP, breathing, etc. Just the amount of apple sauce/pudding required is going to decrease nutritional PO intake at mealtimes.

Exactly. We will have to decide which meds are "most" important and attempt to give them in some sort of order. Good luck getting that calcium down.

[caliotter3]

Welp, my idea of getting a PRN position at a local LTC may have just gone

flying out the window.

Same here. And for the record, I take my meds by the fistful, although not crushed. If I had to do this for myself, I would never get to work.

[Ddestiny, BSN, RN]

I'm really curious about why they're starting to do this. Noticeably absent is any kind of rationale or examples of harm being caused by crushing and combining these PO medications. How is it any different from someone taking a fist full of pills with a few sips of water? I'm all for changing procedures for the benefit of the patient/resident but they're giving us no reason for why this has been changed other than "here's your new regulation," and all I can see is the additional time and resident frustration ("I can't eat all that pudding/applesauce") and potential noncompliance with prescribed meds that will occur.

[ltcnurse4u, CNA, LPN]

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 .