We are wrapping up our CMSCG “Ftag of the Week” series for F757 with this post. We would be remiss if we didn’t discuss the need for monitoring for adverse outcomes/ consequences related to medication use. It’s a significant section of the Interpretive Guidance (IG) which was included in the revised SOM Appendix PP effective April 25, 2025, so it’s important that you’re aware of what surveyors will be looking for.
Medication Monitoring
Per the revised IG, to evaluate the ongoing effectiveness, benefits and potential risk of medications, monitoring and accurately documenting a resident’s response to treatment is essential. This includes:
- Lab results
- Vital signs
- Progress notes
- Behavior notes
- Medication Administration Records
- Drug Regimen Review
Failure to accurately monitor and document on a resident’s condition and response to treatment can be problematic. Let’s review a recent survey citation about insufficient monitoring and documentation related to use of an antipsychotic. This is an area where CMSCG consultants commonly run into issues on mock surveys, so heads up.
2025 Recertification Survey – F757 S/S: D Citation
A facility was cited for failing to ensure that target behaviors were being monitored for a resident who was receiving psychoactive medications, including an antipsychotic medication. The resident was receiving Rexulti for treatment of dementia and Trazadone for depression. The Drug Regimen Review indicated the need to add behavioral monitoring with appropriate target behaviors for the resident, which the psychiatrist addressed as a recommendation on his next visit. The physician did not place orders for monitoring target behaviors, so staff were not instructed to monitor and document target behaviors. The resident received an antipsychotic for more than 1 month without any associated behavior documentation.
Monitoring when there’s Multiple Prescribers
The IG includes another area where it could be easy to run into problems – when there are multiple providers prescribing medications, such as when residents also see outside specialists. In Part 2 of this Ftag series, we reviewed a citation related to duplicate antibiotics, but it’s also important to consider monitoring. The resident’s physician should review medications to ensure that they are still appropriate and warranted. If a medication is started by a practitioner other than in the nursing home, there needs to be documented evidence in the medical record that it is clinically indicated. The prescribing practitioner should be documenting a rationale for continued use or that the medication should be discontinued.
Does your monitoring need more monitoring? Maybe. Here’s a recent Immediate Jeopardy citation.
2025 Complaint Survey – F757 S/S: K (Immediate Jeopardy) Citation
A facility was cited for failure to transcribe a cancer medication into the correct resident’s medical record, resulting in a resident receiving thirteen doses of an unnecessary medication. The Statement of Deficiency also indicates that two Nurse Practitioners and the Consultant Pharmacist failed to identify that the resident was being administered a drug without adequate indication for use. The cherry on top is that four licensed staff administered the medication, which was in a bottle with another resident’s name on it, to this resident. The facility was also cited under F756 and F842. Let’s look at what happened.
An RN admitted to the surveyor that she mistakenly transcribed an order to the wrong resident’s medical record after a prescription bottle bearing another resident’s name was delivered from a cancer center. The cancer center recommended restarting a medication for prostate cancer for another resident, which the NP agreed with. The order was mistakenly transcribed into another resident’s chart, and the same NP signed off on the order, failing to identify that this was not the same resident. On interview, the NP stated she did not recall being contacted by the resident’s family or the cancer center about the recommendation to change the medication and only became aware of it after the medication error was identified.
A review of documentation from 2 NPs and the Consultant Pharmacist did not identify that the resident, who lacked a diagnosis of prostate cancer, was receiving medication ordered for treatment of prostate cancer. The surveyor interviewed all staff who administered the medication to the resident, and all validated that they did not check the name on the bottle prior to administering the medication.
As you can see, a lot of things went wrong in this scenario. Even with the NP validating the order change due to an outside oncologist recommendation, there was still an error. This was coupled with the additional failure- to recognize that this medication was not ordered for the right resident. If even one staff member had checked the prescription per policy and appropriate practice, the resident may not have received any doses of the incorrect med, much less 2 weeks’ worth.
Something to thing about regarding this citation: you need to consider what happened to checking this new order by at least one other licensed nurse – some facilities do double and triple checks of orders to make sure everything is correct including that the orders are for the right resident. It is also apparent that the licensed nurses who administered the medication forgot what they learned in “med pass 101.” Hopefully, your facility has sound systems in place related to medication management and administration.
Adverse Consequences
Appendix PP provides the following guidance related to monitoring for adverse consequences:
- Surveyors are instructed to review documentation to confirm that residents are being adequately monitored for adverse consequences and re-evaluated for tapering, if appropriate.
- FDA requires manufacturers to include statements on medical labeling regarding serious problems or contraindications.
- The CMS Adverse Drug Event Trigger Tool is available for providers to use to minimize risk factors and mitigate harm to residents.
- Facilities can track certain medication classes as part of their QAPI Programs to assist with identification of trends and reduce adverse events.
The IG includes a table which has information on signs, symptoms and conditions which could be associated with a medication. It also provides guidance to surveyors on reviewing the medical record for insight on how the IDT managed a resident’s medications. Note that the revised Interpretive Guidance states that surveyors do not need to directly correlate an adverse consequence to medication use, but to cite F757, they would need to prove that there was a failure in the care process related to the facility not considered or acting upon the potential for an adverse outcome.
