Long-Term Care Survey Alert

Inject these 4 safety measures into this vital care task.

Med pass has become much harder to pass during the survey, which means you need to keep your process ready for a tough inspection at a moment's notice. Experts suggest these key strategies to keep you a step ahead of negative outcomes.

1. Give staff a dose of the new survey reality. While "surveyors used to give staff a heads-up about when they were going to observe med pass, that's no longer the case," said Lynda Mathis, RN, who presented on the subject at the Eli-sponsored MDS and Long-Term Care conference in Orlando, in July 2007.

Surveyors "may proceed directly to the med pass now just like the dietary surveyors may head straight to the kitchen," says Mathis, lead clinical consultant for LTC Systems in Conway, AR. Mathis is also seeing surveyors go on med pass with "about every nurse in the building." And surveyors are "observing more med passes on different shifts."

Surveyors are also more likely to watch nurses giving medications by different routes, including IV, IM, patches, inhalers, eye drops, enteral tubes, etc., Mathis adds. And surveyors are now counting as medication errors "things that used to count as technical errors," Mathis says. Examples include how the nurse prepared the meds or techniques for administering medications, she warns.

2. Focus not only on medication administration techniques but also on the manufacturer's recommendations for giving a medication, advises Mathis. For example, avoid scheduling too many meds at one time for a resident who can't drink the amount of water recommended by the manufacturer for each dose. Suppose the resident takes three to four meds at one time, each of which requires him to drink two ounces of water, says Joseph Gruber, RPH, CGP, director of medication therapy management programs for Omnicare Inc. in Florissant, MO.

"Some patients may not want to drink all of that" at one time, he points out.

Make sure the medication administration record has not only the name of the medication, dose, frequency and route but also "any additional information for administering it," advises Mathis.

Real-world tip: One facility devises "cheat sheets" to help nurses stay on top of additional manufacturers' instructions, such as how long to wait in between eye drops.

"You can use computerized systems that give you specific information about medications and "do's and don'ts," adds Mathis.

Timing is everything: Cheryl Dillon, RN, a quality assurance nurse, has seen surveyors cite instances where nurses didn't shake an inhaler for the required amount of time--or failed to wait long enough in between putting eye drops in one eye and the next, using the same medication. "Surveyors are actually timing that kind of thing."

3. Incorporate med pass in the multidisciplinary quality improvement process. In terms of keeping nurses doing med pass in good form, "there's no substitute for nurse managers and the consulting pharmacist actually observing nurses doing med pass on a regular basis," says former surveyor Kurt Haas, now a consultant in Lithopolis. OH. "Inspect; don't expect," he emphasizes.

Gruber suggests the consultant pharmacist "work with the dispensing pharmacy, if it's different, to review" the med pass and make recommendations for improvement. For example, the pharmacist might look at "how many drugs are passed at each med pass, which drugs, the amount of time the pass takes, recordkeeping and any problems." 

Sidestep F tags for the wrong combination of meds: The consulting pharmacist can red flag medications that can cause problems when administered together. An example would be a "a particular antibiotic with an antacid or an antacid with iron," says Gruber.

Hot survey tip: Haas is seeing an increased number of citations for outdated medications. "Discarding outdated medications requires vigilance on the part of the nurse doing med pass," he says.

4. Be prepared for tough questions from surveyors during med pass. Consultant Dee Kostolich, RN, sees surveyors during med pass ask nurses questions that can lead to F329 citations--for example, questions about dosage reductions of psychoactive medications and monitoring for side effects. Or they might ask why a resident is taking a medication or several medications, says Kostolich, with Howard Wershbale and Co. in Cleveland.

Remember: "Medications can be given off-label," says Nicole Brandt, PharmD. "So in addition to knowing the R's (right med, dose, route, time, etc.), the nurse should know if valproic acid, for example, is being given for a seizure disorder or behavioral symptom," advises Brandt, associate professor of geriatric pharmacotherapy at the University of Maryland in Baltimore.

Must-do: Put the indication for the medication on the MAR, advises Brandt. And never guess when surveyors ask: Check the MAR before answering.