In March, we dedicated a few “Ftag of the Week” posts on the CMSCG Blog to F759 Free of Medication Error Rates of 5% or More. Now we are circling back to an associated Ftag, F760 Residents Are Free of Significant Med Errors. These two tags share the same set of Interpretive Guidance (IG) from State Operations Manual Appendix PP, but we’ve dug through the requirements so you can understand what criteria the Centers for Medicare and Medicaid Services (CMS) is using to categorize significant medication errors from “other” med errors.
Significant Med Errors – Definition & Criteria
Per the IG, a med error is significant when it causes a resident discomfort or jeopardizes his/her health and safety. Significance can be defined as subjective or relative and depends on the actual situation that has occurred and its duration. The IG provides three guidelines for determining that significance – resident condition, drug category and frequency of error.
A med error could be deemed “significant” if the resident’s condition requires “rigid” control as it pertains to things like monitoring lab values, taking daily weights, or I/O measurements. This means if a resident’s medications are not administered appropriately and result in a resident having something like abnormal lab values due to inappropriate administration of an anticoagulant, which may be more significant than another error.
Actual Harm Citation (Complaint) – F760 S/S: G
A nurse failed to accurately transcribe a resident’s medications from his hospital discharge summary upon readmission, resulting in the resident not receiving an anticoagulant medication, the correct doses of a cardiac med and a med ordered for muscle weakness for more than two weeks. The resident was transferred to the hospital and admitted with high BP, rapid heart rate, anxiety and weakness.
The category of a drug can also impact whether the error is considered significant or not. The IG states that if the medication is from a category of drug that would usually require an individual to be titrated to a specific blood level or has a Narrow Therapeutic Index (NTI) then even one med error could alter that level and result in a negative outcome.
Immediate Jeopardy Survey Citation (Complaint) – F760 S/S: J
A Unit Manager discontinued a resident’s anticoagulant without valid/signed physician’s orders, which resulted in the resident exhibiting signs and symptoms of a stroke, including slurred speech and left-sided facial weakness when smiling, as well as being unable to hold up his/her left upper extremity. The resident was transferred to the ER and diagnosed with an acute pulmonary embolism. The resident’s condition continued to decline, and he/she expired.
The Unit Manager stated she had received an NPO order from the hospital prior to a scheduled CT scan. She discontinued the resident’s meds without documenting the resident’s condition and did not check with the physician as to whether the meds should have been restarted prior to the CT scan. The hospital started that its directions were to have the resident be fasting from food, but no orders were given to stop any medications.
Frequency of Error
The IG notes that if a resident’s medication is omitted multiple times, then it may or may not be a significant med error but depends on the two above criteria. Surveyors are instructed to use the dose reconciliation technique as a supplement to the observation technique when an omission has been detected via observation. After the error has been identified, the surveyor can then potentially understand how frequently an error has occurred, which can assist with determining whether an error is significant or not.
Actual Harm Survey Citation (Standard/Complaint) – F760 S/S: H
A facility failed to administer a medication per physician’s orders for a resident with behavioral symptoms and who received an antipsychotic medication. The resident stabbed a staff member with a fork and was hitting/scratching staff. After evaluation, one of the resident’s medications was increased, but review of the resident’s medical record showed that he continued to exhibit the same behaviors, including taking food and clothing from other residents, causing other residents to be agitated. The resident then began to exhibit new behavioral symptoms, including eating out of trash cans and exposing himself to others.
When the MAR was reviewed, it was determined that the medication had been unavailable for administration on multiple occasions. The consulting psychiatric APRN had attempted to contact the facility multiple times regarding her concern that the med was not being administered. On interview, the DON stated that 4 licensed staff had documented that the med was administered even though it was not available.
The number of doses in the remaining supply is compared to the number of days that the medication has been in use and the directions for use. This technique can only be used when the number of medications received, the date and the specific pass when a medication was started has been documented in the medical records. If this documentation is not available, surveyors cannot use this technique, because, per the IG, there is no Federal authority under which a surveyor can request this information if it is not available, with the exception of controlled medications. If the surveyor does have the information needed to conduct a dose reconciliation, then he/she is expected to conduct interviews and record review to determine if actual med errors occurred. With all of that information, then the determination could be made as to whether a significant med error occurred.
Thoughts from CMSCG President Linda Elizaitis
Just a few things to think about:
There are multiple errors that occur related to both the nurse and medical practitioner not carefully reviewing the hospital discharge summary and ensuring that all medications are ordered. The physician plays a part in ensuring that all required medications are ordered – he/she has a responsibility to also review hospital discharge records especially the medications on the discharge summary.
Over the years nurses have been known to write an order without contacting the medical practitioner to obtain the order/directive. This is an unacceptable practice and, I wonder, if all nurses who take it upon him/herself to write that order understands the full consequences to them as well as the resident if a negative outcome occurs for the resident. Who really wants to be reported to the licensing board?
I am closing this out with the recommendation that medication administration competencies should be a routine practice in your facility as well as routine monitoring of medication associated documentation to identify omissions, medications not being available for administration, medications not being effective and necessary follow-up not. Let’s also not forget – doing random reconciliations of the medication supply against MAR documentation is a great way to help identify medication concerns.
In the second part of CMSCG’s “Ftag of the Week” for F760 Residents Are Free of Significant Medication Errors, we will review examples of what makes an error significant or not, as well as review the list of medications that, if an error occurred, would be considered significant errors regardless of the resident’s status.