Monitoring Medication Storage & Administration · • Discuss proper medication storage and...
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Transcript of Monitoring Medication Storage & Administration · • Discuss proper medication storage and...
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Monitoring Medication Storage & Administration
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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
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Regulations
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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
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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
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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
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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
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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
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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
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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
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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
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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?
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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
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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
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Common Pitfalls • Lock the cart
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
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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
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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
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Medication Pass • Maintain resident privacy • Compare label to medication administration record • Then check expiration date • Check placement and comply with flushes on tube
feeders
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To Crush? • F332/333 citation
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
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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
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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
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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…
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Med Pass- Fluids • Note medications that should be given with at least 120mL of fluids
o Bulk laxatives o NSAIDS o Potassium supplementation
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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
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Reviewing Documentation • Vital signs • Blood sugars • Nursing signatures on MAR and TAR • Weekly and monthly medications • Reasons and results • Refusals
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Documentation cont. • Narcotic shift to shift count • Narcotic wasting • PRN documentation, esp. narcotics • Signing in delivery • Behaviors • Pain
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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”
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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
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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
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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)
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Pre Survey Visits
• Performed by Senior Care pharmacists to assess current survey preparedness of facility
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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
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Thank You For Attending
Clint Johnson, Pharm.D. Director of Consulting
Mobile: 417-540-0127
Email: [email protected]