Are you ready for the annual survey and the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review task that is part of that process? Surveyors select 5 residents to conduct this review on following the Critical Element Pathway. Consider these best practices as you assess the quality of your medication management program.
Medication Management Fundamentals
Whether using a single medication or several to treat chronic or multiple illnesses, knowing what to take, how to take it, when to take it, and the correct dosage, are all critical to successful medication therapy. There are several principles and best practices in the medication management process, focusing on ensuring prescribed medications are taken as directed. The regulations associated with medication management include consideration of:
- Indication and clinical need for medication – The resident’s medical record must show documentation of adequate indications for a medication’s use and the diagnosed condition for which a medication is prescribed. An evaluation of the resident by the IDT helps to identify his/her needs, goals, comorbid conditions, and prognosis to determine factors (including medications and new or worsening medical conditions) that are affecting signs, symptoms, and test results. This evaluation process is important when selecting initial medications and/or non-pharmacological approaches and when deciding whether to modify or discontinue a current medication.
- Dose (including duplicate therapy) – Considerations should include appropriateness of dosage based on resident’s condition, the route of administration’s influence on absorption of the medication, and review for duplicate therapy
- Duration- Periodic re-evaluation of the medication regimen is necessary to determine whether prolonged or indefinite use of a medication is indicated and that there is a clinical rationale for continued use of a medication(s).
- Adequate monitoring for efficacy and adverse consequences – The comprehensive care plan should reflect person-centered medication related goals and parameters for monitoring the resident’s condition, including the likely medication effects and potential for adverse consequences. Establish parameters for evaluating the ongoing need for the medication and to track progress and/or decline towards the therapeutic goal.
- Preventing, identifying, and responding to adverse consequences – The risk for adverse consequences increases with both the number of medications being taken regularly and with medications from specific pharmacological classes, such as anticoagulants, diuretics, psychotropic medications, anti-infectives, and anticonvulsants. Monitoring and accurate documentation of the resident’s response to any medication(s) is essential to evaluate the ongoing benefits as well as risks of various medications.
With regard to psychotropic medications, the regulations additionally require:
- Giving psychotropic medications only when necessary to treat a specific diagnosed and documented condition;
- Implementing GDR and other non-pharmacologic interventions for residents who receive psychotropic medications, unless contraindicated; and
- Limiting the timeframe for PRN psychotropic medications, which are not antipsychotic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner.
- Limiting PRN psychotropic medications, which are antipsychotic medications, to 14 days and not entering a new order without first evaluating the resident.
Medication reviews should be included as part of your routine systems for interdisciplinary team reviews, such as clinical meeting processes and care plan reviews. In addition to routine medication reviews, circumstances that should prompt an evaluation of the resident and their medication regimen include:
- Admission or re-admission;
- A clinically significant change in condition/status;
- A new, persistent, or recurrent clinically significant symptom or problem;
- A worsening of an existing problem or condition;
- An unexplained decline in function or cognition;
- A new medication order or renewal of orders; and
- An irregularity identified in the pharmacist’s medication regimen review. See F756 for guidance related to the medication regimen review.
- Orders for PRN psychotropic and/or antipsychotic medications which are not prescribed to treat a diagnosed specific condition or do not meet the PRN requirements for psychotropic and antipsychotic medications.
Opioid Abuse & Drug Diversion
Unfortunately, with the current opioid pandemic we are seeing more and more cases of narcotic diversion, especially in nursing homes as residents are often less likely to recognize or report that drugs have been diverted. Diversion can jeopardize patient care and safety, and leave healthcare organizations open to liability, including legal issues, financial loss, and reputational damage. With more than 3 million practicing nurses in the US, it’s estimated that over 300,000 of them, or more than 10%, are abusing substances, according to the National Institute on Drug Abuse. Although nurses typically don’t abuse drugs or alcohol at a higher rate than the general public, the difference lies in the types of drugs abused. Nurses tend to abuse prescription medications, such as amphetamines, opioids, sedatives, tranquilizers, and inhalants; this coincides with their workplace environment.
Healthcare and nursing leaders have a responsibility to ensure security systems are in place to prevent diversion and protect patients if nursing impairment is suspected. The American Nurses Association (ANA) has taken a stance on nursing impairment and defines professional impairment as a nurse who is unable to meet the requirements of the professional Code of Ethics established by the ANA as a result of cognitive, interpersonal, or psychomotor skill dysfunction from excessive use of alcohol or drugs.
The Joint Commission points out several safety actions to consider:
- Prevention always comes first. Health care facilities are required to have systems in place to guard against theft and diversion of controlled substances. It is important that all staff understand and comply with these protocols, and act in ways to minimize unauthorized access or opportunities for tampering and misuse.
- Even with such prevention safeguards, health care facilities must have systems to facilitate early detection. These systems can include video monitoring of high-risk areas, active monitoring of pharmacy and dispensing record data, as well as having staff who are aware of and alert for behaviors and other signs of potential diversion activity.
- Appropriate response for staff can be summarized as “see something, say something.” At the institutional level, appropriate responses include establishing a just culture in which reporting drug diversion is encouraged, assessing harm to patients, consulting with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies.
Medication Administration Competency Made Easy!
Proactive’s Basic Nursing Skills Competency Tool-Kit contains 34 individual competency forms for evaluating nursing skills in key care areas including medication administration, as well as an editable excel workbook for tracking skill assessments. Access the tool-kit in the Proactive shop
- State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities. §483.45(d) Unnecessary drugs. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/Appendix-PP-State-Operations-Manual.pdf
- Copp MB. Drug addiction among nurses: confronting a quiet epidemic. Modern Medicine. 2019.
- National Institute on Drug Abuse Nationwide Trends. Retrieved 2021. www.drugabuse.gov/publications/drugfacts/nationwide-trends
- Drug diversion detection. Perry, Jason C. MSN; Vandenhouten, Christine L. PhD, RN, APHN-BC Retrieved 2021. https://journals.lww.com/nursingmanagement/Fulltext/2019/02000/Drug_diversion_detection.5.aspx
- Nurse Drug Diversion and Nursing Leaders’ Responsibilities Legal, Regulatory, Ethical, Humanistic, and Practical Considerations. Hazel Y. Tanga, MSN, RN, CEN, MICN Retrieved 2021. https://nursing.ceconnection.com/files/NurseDrugDiversionandNursingLeadersResponsibilitiesLegalRegulatoryEthicalHumanisticandPracticalConsiderations-1382031396195.pdf
- Berge KH, et al. “Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention.” Mayo Clin Proc 87, no. 7 (2012) 674-682. doi: 10.1016/j.mayocp.2012.03.013