During the Medication Administration mandatory task, surveyors (who are nurses or pharmacists whenever possible) will "make random medication observations of several staff over different shifts and units, multiple routes of administration -- oral, enteral, intravenous (IV), intramuscular (IM), subcutaneous (SQ), topical, ophthalmic, and a minimum (not maximum) of 25 medication opportunities."
This mandatory task requires diligence and attention to detail from staff members. Here is how you can prepare them.
Practice the protocol.
Staff know to wash their hands properly “prior to handling medication(s) and after administering medication(s) if resident contact was necessary,” but do they do it every time? Do they also follow the following procedures, which are just a few of those from the Medication Administration review sheet?
· Finger stick devices (both lancet and lancet-holding devices) are used for one resident.
· Staff did not crush tablets or capsules that manufacturer states “do not crush,” such as enteric coated or time-released medications.
· Staff did not crush and combine medications and then give medications all at once via feeding tube.
· Medications administered as ordered (e.g., before, after, or with food such as antacids).
· Checked pulse and/or blood pressure prior to administering medications when indicated/ordered.
· Resident was properly positioned to receive medications (e.g., head of the bed is elevated at an angle of 30–45°).
· Resident was properly informed of the medications being administered.
· Shake a drug product that is labeled "shake well," such as Dilantin Elixir.
If staff members are missing the details, do a root-cause analysis to figure out why. (Do they feel rushed?) Follow up with education that stresses the importance of all the steps in the administration of medication. For example:
· Educate on proper medication administration by route. Review proper administration of inhalers, eye drops, ear drops, and medications administered via a tube.
· Review the importance of adhering to special instructions with specific medications. For example, some steroid inhalers require rinsing of the mouth following administration.
· Some medications require that vital signs be obtained and documented before the drug is administered; stress the importance of this step.
· Provide education on high-risk medications, including but not limited to anticoagulants, antipsychotics, and insulin.
Make education as interactive as possible, such as by including return demonstrations. Be sure new staff are properly trained on your unique facility’s medication administration protocols.
Use pharmacy consultants for help with medication audits.
Review your contract with your providing pharmacy to confirm which audits are available. Request that your facility’s pharmacy consultants observe staff administering medicine. Because all citations for medication administration also fall under §483.45 Pharmacy Services, pharmacies often have an incentive to ensure that medication is administered correctly, to avoid F-Tags under that regulatory grouping.
According to the Medication Administration Observation sheet, a surveyor will “make random medication observations of several staff over different shifts and units, multiple routes of administration—oral, enteral, intravenous (IV), intramuscular (IM), subcutaneous (SQ), topical, ophthalmic, and a minimum (not maximum) of 25 medication opportunities.” Arrange for consultants to review each of these types of administration, paying special attention to any unique timing requirements between doses (e.g., inhalers, eye drops).
Schedule pharmacy audits before scheduling education so that identified facility-specific issues can be addressed during the training. Plan for the audits and education well in advance of your survey window.
Make sure meds are on time.
There is a window of two hours (up to one hour before and one hour after meds are due) during which residents technically receive their medication “on time.” It’s imperative to review med pass times to ensure that nurses keep meds on time consistently. If some medications are consistently delivered outside of the window, perhaps in the morning on the busiest med pass, consider rescheduling eligible meds for other times.
Take a look at less commonly used routes.
Take a less commonly used route and make sure that staff recall all of the administration steps. If a staff member is administering an IV, suppository, or ear drops once each month, is that individual familiar with the steps?
Often there is a disconnect between the attitude that “this is our policy and we’ve always done it this way” and manufacturer guidelines, specifically for IV flushes. Do staff know to review manufacturer guidelines and consider them along with the policy? For example, some IV ports might require a different flushing of the line with normal saline than with heparin.
Pay special attention to these meds.
According to the State Operations Manual:
If the medication is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. This is especially important with a medication that has a Narrow Therapeutic Index (NTI) (i.e., a medication in which the therapeutic dose is very close to the toxic dose). Examples of medications with NTI include: phenytoin (Dilantin), carbamazepine (Tegretol); warfarin (Coumadin); digoxin (Lanoxin); theophylline (TheoDur); lithium salts (Eskalith, Lithobid). (p. 534)
In some cases, two medications may interact (such as Coumadin and certain antioiotics) and require additional monitoring for adverse effects as well as increased lab monitoring. It is important to stress to nurses the need for additional monitoring.
The SOM also calls attention to diuretics, which if “erroneously administered to a dehydrated resident may have serious consequences . . . If the resident’s condition requires rigid control, such as with strict intake and output measurement, daily weights, or monitoring of lab values, a single missed or wrong dose can be highly significant.” Make sure that staff are aware of special-attention meds and their potentially harmful effects.
Review the checklist.
As with for any mandatory task, it’s important to familiarize yourself and your staff with the review sheet. Familiarize yourself with what surveyors will be looking for, and communicate it to staff, too. There is no reason to be surprised when the surveyors come; instead, there are many ways to prepare.
For more information about mandatory tasks, read the first article in this series, The Dreaded Mandatory Survey Task: Sufficient and Competent Nurse Staffing, and the second article, When the Surveyors Come to Dinner (or Breakfast, or Lunch).
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