Monitoring Medication Storage & Administration

Monitoring Medication Storage & Administration

Objectives Review F-Tags pertaining to medication management Discuss proper medication storage and administration Understand medication cart and medication room audits Highlight the most common medication errors and discuss prevention strategies for your facility Examine areas of medication pass that commonly result in survey citation

Regulations

CMS F-Tags F-176 Self administration of drugs F 281 Service provided or arranged by facility must meet professional standards of quality F-329 Unnecessary drugs F-332/333 Medication errors/ Med pass F-425 Pharmacy services F-428 Drug regimen review F-431 Labeling of drugs and biologicals F-441 Infection control

F-176 Self Administration May administer if interdisciplinary team determines practice to be safe Determine who will be responsible (nurse or resident) o Storage of medication and location o Documentation of doses administered o Location of administration Careplan should specify determinations Have an order specifying self administration Ability to self administer should be reassessed quarterly or as resident s condition changes

F - 281 Service provided or arranged by facility must meet professional standards of quality According to accepted standards of clinical practice Current guidelines Negative resident outcome is determined to be related to facilities failure to meet standards o Examples: Failure to order and obtain INR o Not waiting proper time between eye drops o NG Tube not being checked for placement prior to admin o Failure to rotate patch sites o Non-compliance with CHEST guidelines

F- 329 Unnecessary Drugs Pertains to any drug o Duplicate therapy o Excessive dose or duration Stop dates (ABX/ Anticoagulants) Short term meds (PPI/Allergy/Pain/Wound care) o Without adequate monitoring Appropriate labs, pain scales, AIMS testing o Without adequate indication Diagnosis alone is not sufficient. Supportive documentation required o In the presence of adverse reactions Failure to identify or document side effects o Beer s List medications Optimal dosage and appropriateness o Gradual dosage reductions

F-425/426 Pharmacy Services Facility must provide: o Pharmaceutical services to meet needs of each resident o Routine and emergency drugs to its residents or obtain them under agreement Timeliness of the services E-kits Our goal is to assist you in providing quality care for your residents

F-428 Drug Regimen Review Drug regimen must be reviewed monthly by a licensed pharmacist o Order review, diagnosis, dose, indication, duration, labs F- 429 o Pharmacist must report any irregularities to attending physician and director of nursing o Drug specific guidance found here/beer s list

F431 Labeling and Storage of Drugs and Biologicals All drugs and biologicals must be stored: o In a locked location o At the proper temperature o So that only authorized personnel have keys to access medication o Controlled drugs must be in a separately affixed location using different locks than the rest of the medications There must be a system in place to account for all medications periodically to prevent diversion

F431 Labeling and Storage of Drugs and Biologicals Minimum labeling requirements o Name of the medication o Strength o Expiration date o Resident s name o Route of administration o Instructions/precautions

Med Room Audit Review handout Is medication room clean and organized? Are house stock meds organized and in date? Are internals separate from externals? Are syringes and needles disposed of properly? Are expired and discontinued drugs stored separately, written up properly, and ready for disposal?

Med Room Fridge Med fridge between 36-46 degrees Is temperature recorded daily? Is the fridge clean? NO FOOD in med fridge o Separate food fridge should be kept 35-40 degrees Narcotic lock box should be kept locked Separate internals and externals Expired products should be removed ALL opened products MUST be dated o #1 missed opportunity: TB vials

Med Cart Date your products o Insulin/Inhalers/Eye drops/nasal Sprays/Fluids Compartmentalize your life. Organization: o Internals separate from externals (orals not kept with suppositories or creams) o Injections should be separate from patches which should be separate from inhalers. Replenish your carts o OTC s, reorder resident medications before empty o Never think oh, I will get it later Forget and get a tag o Check house stock for expiration dates weekly. Highlight those that will expire within 90 days to keep you looking at them

Lock the cart Common Pitfalls o Even when not using or when you step away from the cart Have a lock on the narc drawer/box Clean out loose pills- never leave them lay Sticky bottles wipe them off Dispose of meds/patches immediately o i.e. Exelon patch removed from resident placed back into cart Date water pitchers and med pass items

F-335/333- Med Error & Pass See Med Pass handout Must have med error rate not 5% or greater Medication Error Rate = Number of errors observed/opportunities for errors Free of significant medication errors o Causing discomfort or jeopardizing health/safety o Drug category narrow therapeutic index (digoxin/phenytoin) o Frequency of error Not following manufacturer guidelines o Not mixing/not shaking/improperly crushing medications

Medication Pass Have all supplies on cart Wash hands o When in doubt wash and glove Observe parameters (BP, pulse, blood sugar) Be mindful of crush status of meds Clean your glucometer per policy

Medication Pass Maintain resident privacy Compare label to medication administration record Then check expiration date Check placement and comply with flushes on tube feeders

F332/333 citation To Crush? o if manufacturer states do not crush Except o Prescriber orders to crush o Reason must be explained in clinical record why this will not adversely affect resident o Pharmacist to review o OR Facility can provide literature supporting Best to specify per order crush or do not crush

Passing via Tubes (NG, etc.) Check for placement prior to admin Must flush before and after meds with 30 ml of H20 o Failure is a med error Ensure meds are ordered/specified to be given via tube Do not crush extended release products unless specifically instructed by pharmacist Need to separate certain medications from other medications and nutrition o Dilantin Medications flow by gravity Remember clean barrier

Med Pass- Eye Drops Wash Hands Eye Contact o Only the drop not the dropper can make contact with the eye Sufficient Contact Time o Must wait at least 3-5 minutes between drops Restasis manufacturer specify 15 minutes between o Encouraged to press tear duct for ~1 minute to prevent systemic absorption of drug

Med Pass - Timing Before meals (AC) or after meals (PC) o If ordered AC but given PC = error Wrong time error >60 min earlier/later o But ONLY if time error causes discomfort or jeopardizes health/safety i.e. digoxin has long half life so 15 min = no jeopardy Playing with fire when you push the envelope here

Med Pass- Fluids Note medications that should be given with at least 120mL of fluids o Bulk laxatives o NSAIDS o Potassium supplementation

Matchback A successful med pass is often contingent upon regular match- back audits o Consider scheduling per cart and cleaning cart Nurse compares label on medication to medication listed on the medication administration record and checks expiration date If there is a discrepancy the chart is pulled for clarification

Reviewing Documentation Vital signs Blood sugars Nursing signatures on MAR and TAR Weekly and monthly medications Reasons and results Refusals

Documentation cont. Narcotic shift to shift count Narcotic wasting PRN documentation, esp. narcotics Signing in delivery Behaviors Pain

Recent Survey Citations 332 and 333 Free of Med Errors/Medication Pass Observation o Timing of insulin o Failure to follow up on ordering medication (ordering procedures) o Order not matching the MAR (especially an issue with emar) o Medication outside of time frame o Eye drop directly to the eye o Not waiting one minute between puffs o Resident privacy o Proper flushing of tube; pushing meds down tube o Crushing potassium o Holding lisinopril without a hold parameter

Recent Survey Citations F tag 329 Unnecessary Drug o Failure to DC Lortab once an ulcer was healed. Order specified for ulcer pain o Failure to do a dose reduction (also failure to answer pharmacy report) o INR not ordered or obtained F tag 425 Pharmacy Services o Locking the cart (security) o Refrigerator too cold

Recent Survey Citations F tag 428 Drug Regimen Review o Failure to make sure a facility followed up on AIMS testing o Not writing a recommendation that a surveyor felt should be written F tag 441 Infection Control o Touching inside of souffle cup. Touching inside Silent Knight Pouch. o Improper IV procedures o Proper handwashing (glucometer, eye drops especially) o Improper Glucometer use o Methadone dropper use

Recent Survey Citations F 281 Service provided or arranged by facility must meet professional standards of quality o Failure to order and obtain INR o Not waiting proper time between eye drops o Out of time frame o Failure to rotate Exelon patches Medication Error (425 and 329) o Administering duplicate anticoagulants F 514 Clinical Records o Failure to Document (on MAR)

Pre Survey Visits Performed by Senior Care pharmacists to assess current survey preparedness of facility

Main Focus Taking CARE of the RESIDENT All of these items help insure that the resident gets proper treatment and does not subject them to unnecessary illness or side effects

Thank You For Attending Clint Johnson, Pharm.D. Director of Consulting Mobile: 417-540-0127 Email: Clint.Johnson@scp-rx.com