The nurse at Mayfair Village Nursing Care Center crushed extended-release Metoprolol, a heart medication, and potassium supplements for a resident with severe dementia who had lived at the facility since April 2019.
Both medications carried "do not crush" labels in the upper left corner of their medication cards. The resident's medical record shows diagnoses including dementia, heart conditions requiring a pacemaker, chronic kidney disease, and long-term anticoagulant use.
Inspectors observed the medication error during the 8:25 a.m. medication round on December 1. Licensed Practical Nurse #74 crushed three tablets — the Metoprolol Succinate ER 100mg, Potassium CL ER 20 mEq, and Eliquis 2.5mg — then mixed them into pudding before giving them to the resident.
The resident's cognitive assessment could not be completed because staff reported the person is "rarely/never understood." The assessment confirmed the resident's decision-making ability is severely impaired.
When questioned 45 minutes later, the nurse confirmed crushing and administering the three medications to the resident.
A second nurse called the facility's pharmacist on speakerphone while inspectors watched. Pharmacist #20 confirmed that both the Metoprolol Succinate ER 100mg tablet and Potassium CL ER 20 mEq tablet should not be crushed.
Extended-release formulations are designed to deliver medication slowly over time. Crushing them can release the entire dose at once, potentially causing dangerous blood pressure drops or other complications.
The facility's own medication policy requires staff to follow the "10 rights" of medication administration, including verifying the right drug by comparing labels three times and confirming the correct dose. The policy instructs staff to "stop and verify all information before administering" if there are any questions about a medication.
Another facility policy addresses medication errors, requiring staff to notify the pharmacy and physician when mistakes occur and monitor residents according to doctor's instructions.
The resident had been taking the heart medication since December 23, 2024, with orders to hold the dose if blood pressure dropped below 110 systolic. The potassium supplement had been prescribed since December 2019 for low potassium levels.
The medication error occurred despite the facility having 86 residents and multiple licensed nurses on duty. The violation affected one of five residents inspectors observed during medication administration rounds.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The investigation stemmed from a complaint filed against the facility.
Mayfair Village's medication policies acknowledge that crushing certain medications can alter their effectiveness and safety profile. The facility requires notification of physicians and pharmacists when medication errors reach residents, along with monitoring for adverse effects.
The resident's complex medical history includes conditions that make medication precision critical. Beyond the heart and kidney problems, the person has swallowing difficulties, muscle weakness, and takes blood thinners that require careful monitoring.
The December inspection found the medication administration error during routine complaint investigation procedures. Inspectors documented the violation under federal regulations requiring nursing homes to ensure residents are free from significant medication errors.
The crushing of extended-release medications represents a fundamental medication safety failure that could compromise treatment effectiveness for vulnerable residents who depend on precise dosing schedules.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mayfair Village Nursing Care C from 2025-12-01 including all violations, facility responses, and corrective action plans.