MDS Alert

Find out what surveyors are searching for during these pilot surveys.

An emerging hot topic in the quality-of-care realm is medication-related adverse events in nursing facilities. Here’s what you need to know to prepare for new pilot surveys to become the norm.

Background: The Centers for Medicare & Medicaid Services (CMS) began pilot testing a focused survey on medication safety systems to examine nursing homes’ systems regarding high-risk and problem-prone medications using an Adverse Drug Event (ADE) Trigger Tool. In July 2015, CMS made the draft tool available to assist surveyors in investigating medication-related adverse events and to nursing homes as a risk management tool.

Stemming from a February 2014 HHS Office of Inspector General (OIG) report on adverse events in skilled nursing facilities (SNFs), the pilot focused survey focuses on medications found to have actual or potential adverse events. The OIG report found that one in three SNF residents were harmed by an adverse event or temporary harm event within the first 35 days of their stay, and 37 percent of these events were medication related.

Expect Scrutiny of 15 Medications

The pilot focused surveys are concentrating on specific medications that CMS considers “high risk,” according to a November presentation by Colleen Kayden, RPh, of Medication Information Services in Lancaster, Penn., for the Pennsylvania Association of Nurse Assessment Coordinators. These medications include:

• Opioids (ADE: change in mental status/delirium related to opioid medication use, or prolonged constipation, ileus or impaction related to opioid use);
• Psychotropic medications (ADE: change in mental status/delirium related to psychotropic medication use, including antipsychotics, antidepressants, anxiolytics, and hypnotics);
• Antidiabetics (ADE: hypoglycemia related to use of antidiabetic medication or ketoacidosis related to insulin therapy);
• Antithrombotic medications (ADE: bleeding related to antithrombotic medication use);
• Anticoagulants (ADE: thromboembolism related to anticoagulant medication use);
• Diuretics (ADE: electrolyte imbalance, including dehydration and acute kidney injury, related to diuretic use);
• Acetaminophen (ADE: drug toxicity related to acetaminophen);
• Digoxin (ADE: drug toxicity related to digoxin);
• Levothyroxine (ADE: drug toxicity related to levothyroxine);
• Angiotensin-converting enzyme (ACE) Inhibitors (ADE: drug toxicity related to ACE inhibitors);
• Phenytoin (ADE: drug toxicity related to phenytoin);
• Lithium (ADE: drug toxicity related to lithium);
• Valproic Acid (ADE: drug toxicity related to valproic acid);
• Antibiotics (ADE: drug toxicity related to antibiotics); and
• Cardiac medications (ADE: altered cardiac output related to cardiac medications, such as blood pressure medications and beta blockers).

Ask Yourself 4 Crucial Questions

In addition to focusing on specific types of drugs, the ADE Trigger Tool guides surveyors in spotting certain risk factors, signs and symptoms, and clinical interventions that may indicate an ADE has occurred. The Trigger Tool also provides surveyors with questions to ask in determining whether an ADE occurred.

But what surveyors are ultimately trying to determine is whether your facility is able to effectively identify, monitor, prevent, and respond to ADEs and potential ADEs. According to Kayden, you should ask the following questions and consider taking the following action points to prepare for the expansion of the ADE focused surveys:

1. Has your facility identified preventable ADEs? Action points:

o Create a risk audit committee.
o Perform a baseline risk assessment on current residents so that you can benchmark and assess any risk reduction strategies for positive outcomes.
o Utilize the pharmacist consultant, as well as facility staff.
o Track medications identified on the Trigger Tool.

2. Has your facility identified residents’ risk factors? Do you have individualized interventions? Action points:

o Use the Trigger Tool to create a list of residents with diagnoses-related risk factors.
o Integrate the pharmacist’s monthly review of individual residents into the process.
o Engage your medical director in prioritizing high-risk residents for review.
o Create a process to ensure ongoing identification of preventable ADEs as residents’ conditions and medications change.

3. Has your facility implemented effective systems to prevent, recognize, and respond to ADEs? Action points:

o Make your risk audit committee responsible for creating policies and procedures.
o Implement facility-wide education to help ALL staff recognize potential ADEs.
o Ensure that ALL staff know the process for either alerting clinical staff and/or responding to ADEs.

4. What monitoring are you doing for high-risk medications? Action points:

o Create specific policies and procedures for anticoagulant monitoring.
o Create specific policies and procedures for antidiabetic medication monitoring.
o Identify a process that ensures appropriate lab follow-up, reporting, and length of treatment (e.g., anticoagulation S/P surgery or DVT).

Bottom line: “The ADE Trigger Tool is just that — a tool to help us help our residents,” Kayden said. “Our real objective should be creating a culture of critical thinking and situational awareness for our licensed staff and all those who prescribe medications for our residents.”

Resources: The ADE Trigger Tool is part of a July 17 Survey & Certification memo (S&C: 15-47-NH), which you can access at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-15-47.pdf. The Tool is also available in a stand-alone PDF document at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/Downloads/Adverse-Drug-Event-Trigger-Tool.pdf. To read the OIG report, “Adverse Events in SNFs: National Incidence Among Medicare Beneficiaries,” go to http://oig.hhs.gov/oei/reports/oei-06-11-00370.pdf.