CMS Clarifications 11/2/2012

1. CMS Clarifications11/2/2012 Medication errors Medication administration practices Medication review for short stays less than 30 days and/or changes in condition Faculty: Diane Atchinson, RN-BC, MSN, ANP, RAC-CT President, DPA Associates, Inc Kansas City, MO e mail: diane@dpaassociates.com

2. Medication errors • Administration of medications via a feeding tube F425-facility with the consultant pharmacist must provide procedures for the accurate administration of all medications • Must reflect best practices • Types of medications that may safely administered via a feeding tube • Appropriate dose forms • Techniques to ensure that the feeding tube is in the right location before administering medications • Preparing drugs for administration • Administering drugs separately • Diluting drugs appropriately • Flushing the tube before, between and after drug administration and • That drugs with know incompatibilities are not given at the same time

3. Survey implications: F 322 • Placement checked prior to medication administration • Amount of water to be used as flush noted via an MD order for medication administration • Standard of Practice (American Society for Parenteral and Enteral Nutrition) Enteral Nutrition Handbook, 2010. • Administer each medication separately followed by flushing the tube • Exception: MD order that specifies a different flush schedule • Failure to flush will constitute 1 medication error • Surveyor will review your facility policy (F425) • Surveyor will also review F 520-QA to review for monitoring for safe administration practice including TF medications

4. Enteral Nutrition Handbook (p 309-329) • Drug interactions • Compatibility • Stability • When a drug formulation is altered, by pulverizing, adding to fluid, or combining it with other substances, drug stability may be compromised • TF should be held when giving medications. IE medications should not be added to the TF. • Recommendations • Do not combine liquid medications • Do not combine crushed medications • Sustained release medications should never be crushed • Do not pucture liquid filled gel capsules • Crush each medication separately and dissolve in a small amount of water to prevent occlusion of the tube • Liquid medications can also cause problems-consult with pharmacist

5. Interdisciplinary team review • Develop • Guidelines • Nurse education • Pharmacist recommendations • This reduces tube obstruction and drug errors

6. Drug/Nutrient Interactions • Dilantin • Hold TF for 1-2 hours before and after dose is given or • Adjust the dose based on therapeutic drug levels • Diluting is recommended to avoid tube obstruction • Consistency of procedures used should be well documented • Carbamazepine • Hold TF for 1 hour before and after dose • Monitor serum levels closely • Dilute 1/1 with water • Fluoroquinolones • Separate doses from food, dietary supplements, or other drugs containing calcium, MG (antacids) or iron. • Hold TF for 1 hour before and 2 hours after dosing • Warfarin (Coumadin) • Separate the drug from the formula • Increasing the dosage via monitoring • Hold the TF 1 hour before and after dosing • Interactions with Warfarin can be life threatening

7. Medication Administration Technique • Basics-verify placement ,turn off feeding if running and do not add medications to formula • Flush the tube with at least 15cc of water • Do not mix medications together but do dilute them • Each medication administered separately • Liquid dose forms used if available and diluted • Pulverize tablets and mix with water. • Open hard capsules and dilute powder with water • Flush with at least 15cc of water between each medication administered • Restart TF as per resident specific medication needs

8. Metered Dose Inhalers • If more than 1 puff is needed (same or different medication) there should be at least 1 minute between each puff except for: • Short acting beta agonists such as albuterol-15-30 seconds is acceptable • Ensure the device is administered correctly • Examples of education sites include: • http://nhlbi.nih.gov/health/prof/lung/asthma/nurs_gde.pdf • http://aafa-md.org/thumbdrive.htm (under pharmacy file-handouts • You tube video: http://www.youtube.com/watch?v=Z_95ni8DJwU

9. Proton Pump Inhibitors (PPI) • Facility has policies related to medications and food consumption • PPI’s given on an empty stomach at least 30-60 minutes before a meal • Use greater than 1 year-higher risk of fractures, pneumonia and C diff. This should be reviewed by DRR.

10. Borrowing medications • Not consistent with best practices • Leads to medication errors • Recommendations: • Use of an E kit • Contents decided by pharmacist and DON • P and P for medication ordering and reordering of medications • Monitoring that medications are delivered as ordered • What to do if medication is not available for administration • MD aware • Use of Medical Director

11. Fentanyl patches • Polies to address: • Safe and secure storage • Limited access • Reconciliation • Safe handling, distribution and disposition • Disposal • Same manner as wasting of any controlled substance • Must be safe and secure • Where kept until destroyed • Control and accountability • Documentation if destruction for both full dose and partial doses • Timely indentification and removal lf medications from current supply

12. Medication reviews for stays less than 30 days and changes of condition • Reviews might need to occur more frequently than monthly depending on: • Resident’s condition • Risk for adverse affects related to current medications • Review applies to all residents including: • Respite • Residents at end of life or are using hospice • Residents with stays less than 30 days or • Residents who have experienced a change in condition • Complex residents in the transition from hospital to SNF • This review prevents errors due to drug/drug, omissions, duplication of therapy or miscommunication between providers and care givers • Recommendations • Facility has p and p on who needs a more frequent review (define complex resident), and risk for consequences for residents with stays of less than 30 days • How will the need for this consult be communicated • How the review will be handled if the pharmacist is off site • How the results of the report will be communicated to the provider • Expectations for the provider’s response and follow up • How and where this information will be documented