Revised Ftag of the Week – F757 Drug Regimen is Free from Unnecessary Drugs (Pt. 2)

Last week in Part 1 of our Ftag of the Week post, we reviewed some of the key definitions and intent associated with F757 Free from Unnecessary Drugs, an Ftag which was revised earlier this year. In this post, we’ll review the newly added guidance related to the comprehensive assessment and determining the need to use a medication.

Medications and the Comprehensive Assessment

Much like anything else related to care and services provided to a resident in a SNF/NF, the comprehensive assessment drives decision-making. Assessing the resident’s physical, behavioral, mental and psychosocial signs and symptoms allows the IDT to ensure that initiation, continuation or discontinuation of a medication is the appropriate course of action. Part of that assessment includes assessing relative risks and benefits, preferences and goals for treatment. Important guidance that has been added includes the following:

• Potential underlying medical conditions can be identified as part of the assessment, including the need to rule out these conditions as contributing to the signs/ symptoms the resident is exhibiting. The facility is responsible for ensuring that medication initiation or changes are not due to a medical condition or problem which is expected to resolve.
• The IDT should not initiate or change a medication when it has been determined that signs/ symptoms are due to environmental stressors or psychological changes alone which will resolve once addressed.

The Interpretive Guidance (IG) also provides a list of circumstances where a resident’s underlying medical condition(s) and medication(s) should be evaluated. These include:

• On admission
• Readmission
• New or worsening change in condition or status
• The Medication Regimen Review (MRR) has identified an irregularity
• When a new medication has been ordered as an emergency measure

The practitioner and IDT should determine the continued need for use of a medication. This includes if a resident has been admitted with orders for medication but there is not a clear indication for why it is being used, or there is an expectation that the resident’s condition may improve after an acute illness has stabilized.

Ensuring Medication is Necessary

Another section of the IG which has been added to this Ftag is about proper medication selection and prescribing. The guidance states that a resident’s outcome, quality of life and/ or functional capacity may be improved (or stabilized) with the appropriate use of medications. However, a medication or combination of medications may result in a serious side effect:

• Without adequate indications
• In excessive dose
• For excessive duration
• Without adequate monitoring

A link to the AGS Beers Criteria for information on safely prescribing meds for older adults has been included in the IG and it’s a highly-recommended resource for providers.

As indicated above, medications need to be prescribed in the appropriate dose and for the appropriate duration. The revised F757 includes additional information on dose and duration.

“Duplicate Therapy” is when two or more medications of the same pharmacological class/ category are ordered without a clear distinction between when one medication should be administered versus another. Duplicate therapy can also be linked to excessive dose.

Here’s a recent survey citation where an issue was identified with duplicate therapy – and it’s a good reminder to ensure that the whole team is aware of the plan of care.

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Recertification Survey F757 S/S: D

The facility failed to ensure a resident was not treated with two different antibiotics by two different clinicians concurrently without adequate indications for their use. The resident received  doses of Augmentin prior to the facility receiving lab results related to a suspected UTI, without a clinical rationale for use. Per the clinical documentation, the resident was started on antibiotics, spiked a temperature, and acetaminophen was given with good effect.

The physician who received this report ordered a STAT chest x-ray and Bactrim DS twice daily for three days.  The resident received six doses of Bactrim without clinical indication for use while concurrently receiving Augmentin. The chest x-ray came back without findings. The second prescribing physician indicated he thought the resident may have aspiration pneumonia because he/she had vomited a few days earlier (dx of gastroparesis) and was not made aware of the x-ray results until several days later. He indicated that he was not aware the resident was already receiving another antibiotic. Meanwhile, the IP reviewed the resident’s record and stated that the resident would not have met the McGeer criteria for a UTI, and that vomiting would not have been a factor for UTI given that this is a common symptom for the resident’s diagnosis of gastroparesis.

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Dose and duration should be based on factors such as:

• Diagnoses
• Signs and symptoms exhibited
• Current condition
• Coexisting medication regimen
• Lab and other test results
• Age
• IDT input about the resident
• Resident’s preferences and goals
• Type of medication
• Therapeutic goals

Here’s another recent survey citation which looks at some of the factors above. This is the type of citation we may be seeing more of with the revised guidance to surveyors, so this is a good area to review.

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Recertification Survey F757 S/S: D

A resident with a diagnosis of neurocognitive disorder with Lewy bodies was admitted to the nursing facility from an assisted living. He was admitted on an antipsychotic and an antidepressant. The resident was evaluated as being pleasant and without any behaviors on multiple occasions. The antipsychotic was discontinued, and there were no behaviors documented as occurring. A few weeks later, the resident went to a neurology appointment and returned with an order to restart the antipsychotic, which the facility did. The facility documented that the resident was having increased morning sleepiness, was difficult to awaken, showing more signs of confusion and wandering and that the neurologist had been notified.

The order for the antipsychotic had a directive associated with it which indicated that the medication should not be discontinued unless directed by the neurologist. However, the document did not include any evidence of an indication for use of the antipsychotic. On interview, the Director of Nursing confirmed that the facility did not address stopping the antipsychotic when it was restarted despite the resident not exhibiting any behaviors or meeting the requirement for the prescribed medication.

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Important Reminders:

Don’t forget:

• The medical record must include documentation of the comprehensive assessment, including the rationale for chosen treatment options. Ensure you have an appropriate rationale for use.
• Medications, including dose, should be evaluated if a resident’s condition has declined despite treatment or has not responded to the treatment.
• The clinical rationale for the continued use of medication needs to be documented in the medical record.
• “Polypharmacy,” the use of give or more medications, can increase the risk of adverse outcomes, especially for nursing home residents.

Also, don’t forget about the need to monitor for adverse outcomes/ consequences. We’ll discuss that more in Part 3.

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