Federal Nursing Home Regulation Clarifications provided by the Centers for Medicare and Medicaid Services (CMS)
Crushing of medications
Federal Nursing Home Regulation: F760 CFR 483.45(f)(2) The facility must ensure that residents are free of any significant medication errors.
The questions are not about crushing meds for feeding tubes – that is not new and is a clear standard of practice. The questions are about crushing medications for residents with dementia, who may otherwise refuse or be unable to take a pill/capsule. The questions are not regarding meds that should not be crushed or crushed meds that should not be combined, these issues remain important to verify for safety and effectiveness of the medications.
The issue is if a provider has determined that a medication can be crushed, and that there is no contraindication to combining crushed medications, can crushed medications given orally be combined into pudding, yogurt, or applesauce if the resident, resident’s representative, or resident’s prescriber prefers it that way and the risks vs benefits are explained and documented in the resident record? It seems that broad prohibitions of a practice is not very resident-centered! The Alzheimer’s Association and the National Institute on Aging recommend crushing medications, after consultation with a physician or pharmacist, for dementia patients that have difficulties swallowing pills. The concerns regarding separating crushed medications for certain residents include the increased potential for medication refusal, fluid overload, and decreased meal intake. We also have a concern about the increased amount of staff time this new guidance may cause.
Thank you for your question related to 483.45.
You asked whether a provider may give crushed medications orally and combine them into pudding, yogurt, or applesauce if the resident, resident’s representative, or resident’s prescriber prefers it that way and the risks vs benefits are explained and documented in the resident record. The accepted standard of practice for administering crushed medications orally is explained in the guidance at F759 and F760 Medication Errors:
The standard of practice is that crushed medications should not be combined and given all at once, either orally (e.g., in pudding or other similar food) or via feeding tube. Crushing and combining medications may result in physical and chemical incompatibilities leading to an altered therapeutic response, or cause feeding tube occlusions when the medications are administered via feeding tube. Additionally, a resident may not want or may be unable to finish eating the food into which combined crushed medications were added or the resident’s feeding tube could malfunction, all of which could prevent complete administration of the crushed medications. In these situations, staff would not know which medications the resident actually received because they were crushed and combined but not fully administered.
Taylor’s Handbook of Clinical Nursing Skills and Lippincott’s Photo Atlas of Medication Administration both state:
“If the patient has difficulty swallowing tablets, it may be appropriate to crush the medication to facilitate administration. However, not all medications can be crushed or altered; long-acting and slow-release drugs are examples of medications that cannot be crushed. Therefore, it is important to consult a medication reference and/or pharmacist. If the medication can be crushed, use a pill crusher or mortar and pestle to grind the tablet into a powder. Crush each pill one at a time. Dissolve the powder with water or other recommended liquid in a liquid medication cup, keeping each medication separate from the others. Keep the package label with the medication cup for future comparison of information. Combine the crushed medication with a small amount of soft food, such as applesauce or pudding…”
The research article in Science Direct, Identified Safety Risks with Splitting and Crushing Oral Medications also states “… nurses have been known to crush a variety of medications together to place into food or to prepare a “slurry” for administration of the medications through an enteral tube. This “compounding” of medications can result in unknown pharmacologic results and can place the patient at risk for harm.”
If the resident refuses or is unable to take the medication, giving only one medication at a time allows the staff to know which medication the resident is actually receiving. Safe medication administration is not only about giving the right medication and the right dose to the right resident but also in the right route and form. Staff should also consider resident rights when administering a crushed medication via food, including the right to refuse treatment. When placing a medication in food such as applesauce or pudding, consider the following:
- Does the resident want the medication in the food?
- Is the medication being added to food because the resident is refusing the medication?
- Can the medication be given with food?
CMS understands the expressed concerns regarding administering crushed medications with food. If there are multiple medications needing to be crushed, then it may help to review the resident’s medication regimen to determine if a different schedule or form of medication could be considered or if there are any unnecessary medications.