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

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

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

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

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