Ftag of the Week – F759 Free of Medication Error Rates of 5% or More (Pt. 2)

In this week’s “Ftag of the Week” post on the CMSCG Blog, we are digging deeper into med errors. The first post for F759 provided an overview of what is considered a med error, how surveyors calculate med errors and a couple of areas where med errors can be identified during the Medication Administration task. Now we will review med errors that are due to a failure to follow the manufacturer’s specifications or accepted standards of practice.

Med Errors due to Failure to Follow Manufacturer’s Specifications

There are several important areas to be aware of where a med error could occur when staff do not follow the specifications provided by a medication manufacturer.

Shake, Rattle and Roll . . . If a medication is labeled “shake well” and staff do not follow that instruction, there is a chance that the medication could either end up diluted or overly concentrated. Likewise, if an enthusiastic staff member shakes a medication that is supposed to be “rolled,” there is an opportunity for an issue if the movement creates bubbles in the medication that could then impact measurement of the correct dose.

Another common issue highlighted in the Interpretive Guidance for F759 relates to medications where the manufacturer’s specifications state that the medication should not be crushed.

While there are exceptions to the do not crush instruction, the accepted standard of practice is that if medications are crushed, they should not be combined and given all at the same time, whether orally or via feeding tube. There are several reasons for this:

  • Crushing and then combining medications can lead to an altered therapeutic response because multiple medications may change the chemical or physical composition of the drug.
  • What about when a resident doesn’t finish the entirety of the food that the meds were crushed into? How do staff know what the resident actually consumed?
  • What about if the medications are crushed and given as a combination via feeding tube and the feeding tube is not fully patent and the “mixture” being administered back up out of the tube and onto the resident’s abdomen? Staff would not be able to tell which medications the resident received.

When you think about these scenarios, you can understand why the IG tells surveyors that if they observe medications being crushed and combined, the number of errors should be equal to the number of medications crushed. If staff combine 3 medications, then that’s 3 med errors being factored into the equation. It doesn’t matter if the meds are prepared for administration orally or via feeding tube – they are still errors before administration that have been identified.

Another note on feeding tubes – The Interpretive Guidance states that flushing the tube between each medication is considered standard of practice.

Another note on feeding tubes – The Interpretive Guidance states that flushing the tube between each medication is considered standard of practice.That means that even if staff do not crush and combine multiple meds and administer via feeding tube, that crushing medications and administering them separately but without flushing in between also creates med errors. The same goes for liquid medications when the tube is not flushed between meds – more med errors. How many, you ask? Well, the number of errors is equal to the number of medications administered without a flush between them. So again, if there are three crushed or liquid medications given, then that is three different med errors.

The IG specifically states that according to manufacturer recommendations, the administration of enteral nutrition formula and phenytoin together would constitute a med error because these must be separated to minimize interaction.


Exceptions to be aware of:

  • If a manufacturer’s guidelines state a medication is “do not crush” and a physician orders it to be crushed, the physician or the pharmacist must provide documentation in the medical record as to why crushing the medication will not create an adverse impact to the resident. Facility staff should be instructed to look for pertinent adverse side effects if such an order is in place. If a facility does not have this documentation in place with appropriate rationale, then there is a potential for a med error.
  • Another area where the “do not crush” directive may potentially be disregarded is if the provider is able to present literature from a peer-reviewed health journal or literature from the manufacturer of the medication as to why the dosage form will not create an adverse outcome.
  • As far as tube feeding flushes go, if a physician order is in place that specifies a flush schedule because a resident is on a fluid restriction, then staff would not be required to flush the tubing between each medication. In this case, the physician’s order would be expected to include the amount of water to be used for flushing between medications and for the administration of medications.

FYI – The Interpretive Guidance for F759 does state that accepted professional standards can various based on practice regulations in different states, as well as vary based on the commonly accepted health standards established by various boards and organizations, so ensure you are aware of what’s required by your state.

While there is guidance related to fluid restrictions, it’s also important to be aware of the expectations for providing adequate fluids during medication administration as well.

Administering Medications without Adequate Fluids

If the manufacturer’s specifications state that a medication needs to be provided with adequate fluids but the surveyor does not see that happen during med administration, then that is going to warrant a further look. As noted above, residents on fluid restrictions should have appropriate orders in place and documentation should show that the IDCPT considered alternative medications or administration routes for these residents. The surveyor is also expected to look for this documentation as well as the plan for residents who decline adequate fluids.

If a resident declines adequate fluid and the facility made a good faith effort to provide fluids and provide the necessary assistance for the resident to consume the fluid, then the facility would not be at fault for the lack of fluid intake. Again, it is key to show that alternatives have been considered that could potentially be better suited for a resident who does not intake the intended amount of fluid with the medications.

Administering Medications into the Eye

The last area we will look at related to ensuring manufacturer’s administration instructions are followed is when medications are going to be administered into a resident’s eye. Staff need to follow appropriate practices so the medication is appropriately absorbed. Surveyors will also be looking to see:

  • If staff verified which eye the medication is going to be administered into
  • If staff ensure the medication makes full contact with the lower conjunctival sac to help the medication wash over the resident’s eye when he/she closes his eyelid
  • If the top of the eye drop bottle actually touches any portion of the eye – which it should not
  • How long staff wait between drop administration. The IG states that the “optimal” length of time for eye drop administration is between 3-5 minutes, so if staff do not wait long enough, then this may create a med error.
CMSCG Survey Tip

Just a word on eye drop administration – there is vulnerability regarding infection control practices related to glove use, hand washing, and using a different tissue if you are administering eye drops into both eyes. One of the biggest exposures is a surveyor watching a nurse hand over the eye drop dispenser for the resident to self-administer and there is no mention of this self-administration in the care plan, no competency evaluation of the resident self-administering and no self-administration assessment complete.


In our next post, we will review some other areas where a medication error could be identified and explain what’s considered a significant med error.


About CMS Compliance Group, Inc.

CMS Compliance Group is a regulatory compliance and quality improvement consulting firm. We work with providers across the post-acute continuum, including nursing homes, assisted living providers, home health agencies and others. Our interdisciplinary consulting team provides services to clients throughout the United States to help them improve the quality of care and services being provided by their organizations. To learn more about how CMSCG can help, please call 631.692.4422 or email info@cmscg.net.


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