Up next on the CMSCG Blog, we will be reviewing two additional regulations that are part of the Pharmacy Services regulatory group, F759 and the associated tag F760. First, we will review F759 Free of Medication Error Rates of 5% or More, and then will review F760 Residents Are Free of Significant Med Errors. SOM Appendix PP ties the two regulatory requirements together, and the associated Interpretive Guidance co-mingles the two requirements, however, we will review them separately.
Before you dive into the next few posts in the CMSCG Blog “Ftag of the Week” series, you may wish to review our prior Ftag of the Week posts for Pharmacy Services, especially F755 Pharmacy Svcs/ Procedures/ Pharmacist/ Records.
F759 – The Regulatory Requirement
F759 requires a nursing home to ensure that its medication error rates are not 5% or greater. It’s a short regulation, but there is a lot of guidance, and surveyors also have LTCSP tools to help them with this determination (more on that later). Let’s start with understanding what constitutes a med error and how the error rate will be calculated by the survey team.
“Medication Error” – The SOM defines a med error as either the observed or identified preparation or administration of a medication or biological that is not prepared or administered in accordance with the prescriber’s order, manufacturer specifications or accepted professional standards of practice and principles.
“Medication Error Rate” – The SOM provides the following equation for med error rate:
Medication Error Rate = Number of Errors Observed / Opportunities for Errors (Doses given + Doses ordered by not given) x 100
This calculation is used to determine the percentage of med errors that are observed during a medication administration observation. In order for the surveyor to cite F759, the error rate identified must be 5% or greater. The survey team is not allowed to “round up” to 5% if the rate is slightly less than 5%.
- The numerator is the total number of errors that the survey team observes (both non-significant and significant)
- The denominator is the total number of observations or opportunities for errors. It includes all of the doses that the survey team observed being administered plus any doses that were ordered but not administered.
Medication Observation
During survey, the surveyors will observe med pass several times so that they can observe multiple staff members administering medications, as well as multiple routes and times of administration. The multiple observations are also reflected in the potential error rate, as noted in the equation provided above. The more med passes, staff members and routes of administration, the more potential there is for an error – or more.
Even though multiple med passes will be observed, the surveyor observing is expected to watch the med pass for one resident at a time, with an observation of all prescribed medications to be given at that time for that individual resident.
The surveyor will document what he/she observed, and then will reconcile that information with the resident’s medication orders to determine if a med error has occurred. If the surveyor were to only complete a partial observation, then the observation would be incomplete, thus reducing the information available to see if something went awry.
The Interpretive Guidance states that observation is the preferred method for a surveyor to identify and cite a med error. Surveyors also have the opportunity to identify med errors based on sources such when documentation related to a resident’s change in condition shows that the change is due to one or more medication errors. However, just because a surveyor identifies something on paper (such as a blank space on the MAR) does not make it a med error. The surveyor would be expected to investigate any potential concerns through interviews and additional record reviews.
What Do We Need to Be Looking At?
Remember, surveyors are looking to determine if the medication was administered:
- According to a valid physician’s order
- To the correct resident
- At the correct time
- In the correct dose
- By the correct route
- According to accepted standards of practice
- According to manufacturer’s recommendations
Let’s review how a couple of these issues can be identified.
Prescriber’s Orders
It goes without saying that medications need orders, but surveyors will review the latest recapitulation of med orders to determine if there is a valid order in place for a medication – and it’s been signed by the physician.
Correct Resident
Again, this one doesn’t require a lot of explanation, but creates a risk if your facility doesn’t have a strong system in place to ensure that the correct medication is provided to the correct resident. Does your staff actually check the resident’s ID band if that’s your practice? Are they checking the resident’s photo to ensure it’s the right person? Lots of issues could occur when staff don’t follow your policy.
Correct Time
Does your medication administration policy include dosing schedules? We hope so, because in order to determine scheduled medication times, surveyors are directed to review your facility’s policy for these schedules. That’s when surveyors will know to be ready to observe administration – will your staff be prepared?
Here are a couple key timing-related administration errors to be aware of:
- If a medication is prescribed to be given before a meal, but is administered after a meal, this is a med error. The reverse creates a med error as well – if a medication is prescribed for a resident after meals, but is given before meals, then that’s a problem.
- If a medication is administered 60 minutes or more before or later than its scheduled time of administration, this can be a problem if the timing could cause the resident discomfort or jeopardize the resident’s health and safety.
- While residents have the right to choose their schedules, providers still need to consider the physician’s orders, manufacturer’s guidelines, types of medications being administered and other factors to ensure that medication administration times can be safely adjusted. Time-critical medications should be administered in a manner that ensures resident safety and ensures a therapeutic effect is achieved.
A final word on timing – do your nurses know what to do it they are “running late” with their medication administration pass or a medication is not available until after the med pass?
A final word on timing – do your nurses know what to do it they are “running late” with their medication administration pass or a medication is not available until after the med pass? Their individual decision to administer the medication outside of the defined time parameters could have a negative effect on a resident depending on the classification of medication being administered. How often do your nurses actually pick up the phone and obtain a directive from the physician regarding administering the medication late or holding a single dose? You should know what they are doing as a surveyor is certainly going to follow-up on such an observed practice.
In Part 2 of our Ftag of the Week for F759, we will review med errors that are due to a failure to either follow accepted standards of practice or manufacturer’s specifications, as well as some other important areas that surveyors will be looking.
