Up next on the CMSCG Blog “Ftag of the Week” series is F757 Drug Regimen is Free from Unnecessary Drugs, which is part of the Pharmacy Services regulatory group. F757 includes only a set of regulatory requirements, with no Interpretive Guidance, however, deficient practices are widely cited under this regulation, and issues identified can be in IJ in the making. This regulation states that each nursing home resident’s drug regimen must be free from unnecessary drugs.
What’s “Unnecessary?”
Per F757, an “unnecessary drug” is considered any of these:
- Any drug used in excessive dose, including duplicate drug therapy
- Any drug used for excessive duration
- Any drug used without adequate monitoring
- Any drug used in the presence of adverse consequences which indicate the dose should be reduced or discontinued
- Any combination of the above mentioned considerations
That’s it. The whole regulation is summed up in a few bullet points, but each of these requirements can result in a potential negative outcome, so it is important to ensure that your facility’s medication ordering, administration and monitoring systems are sound. There are many opportunities for things to go wrong if procedures are not being followed.
Monitoring
Many of the issues identified related to unnecessary drugs are due to a lack of monitoring the resident’s medications, labs, blood sugar levels, and anything else the physician has prescribed. The failure to monitor can result in a harm level citation or higher given some of the outcomes related to poor practices by the physician, nursing staff and/or the consultant pharmacist (an issue gets missed during the monthly MMR), so facilities without strong systems to monitor residents’ health status as it relates to medications may find themselves in a jam.
Here are two actual Immediate Jeopardy-level citations related to lack of monitoring and follow-up:
Complaint Survey – F757 S/S: J
A facility was placed in Immediate Jeopardy for failure to provide adequate monitoring of a resident taking antidiabetic medications, resulting in the resident being re-hospitalized with diabetic ketoacidosis. The resident was found in his room by a CNA with warm, clammy skin and unresponsive and a blood sugar check result read “high.” The resident was transferred to the ER and arrived at the emergency department with a blood sugar level of 700. A review of the resident’s record identified multiple BS omissions prior to this incident.
Complaint Survey – F757 S/S: K
A facility was placed in Immediate Jeopardy when it failed to obtain a follow-up lab for 1 resident. The lab had been ordered due to high PT/INR results on labs drawn more than two weeks prior. The resident had a nosebleed that bled for more than two hours overnight and did not alert any of the staff. The staff member who initially found out about the nosebleed did not document it and did not tell the resident’s physician. There was no care plan in place for the use of anticoagulants, and there was no monitoring in place related to the anticoagulant therapy that had been ordered.
The facility was cited for failure to develop and implement care plans for monitoring multiple residents receiving anticoagulant therapy, failure to follow physicians’ orders to obtain repeat labs after receiving elevated PT/INR levels, and failure to notify the physician of the PT/INR results to obtain further orders for monitoring.
Jumping the Gun on Antibiotic Prescribing
An area that is frequently cited (especially in certain states) relates to unnecessary antibiotic drugs prescribed prior to receiving the results of lab orders for tests such as urine culture or urinalysis when an infection is suspected. Many issues have been identified when one antibiotic is prescribed and administered, only to have lab results come back and the prescribed antibiotic turns out to be the wrong one.
Other Citations at F757
Here are some other issues that have been identified on surveys in 2021 – could similar issues be occurring in your building?
- Standard Survey – F757 S/S: E – Facility failed to discontinue an anticoagulant per the hospital discharge summary, resulting in one resident receiving the medications for 11 days beyond the intended stop date (missing on hospital order). The nurse responsible for transcribing the orders acknowledged to the surveyor that she had not read the hospital discharge summary and did not ask for a stop date from the hospital physician.
- Standard Survey – F757 S/S: D – Facility failed to ensure that narcotic pain meds were administered with adequate indications for use for one resident who was provided PRN Oxycodone for a pain scale of 0. The physician’s orders included a pain scale and stated that this pain medication should be provided for moderate pain (pain scale of 4-6).
- Standard Survey – F757 S/S: D – Facility failed to ensure physician’s orders were followed related to obtaining O2 sat readings for, obtaining blood sugar readings and reconciling duplicate medication orders for one resident. Review of the resident’s medical record showed MAR omissions for checking 02 sat twice a day per orders, and only one blood sugar reading a day versus the ordered frequency of twice a day. The resident had duplicate orders for one medication and the MARs reflected that the medication was being given twice.
- Complaint Survey – F757 S/S: D – Facility failed to ensure one resident remained free from unnecessary medications related to a failure to hold laxatives when the resident was experiencing loose stools.