An Iowa nursing home was cited by the Iowa Department of Inspections and Appeals with failing to respond to an internal, electronic warning that pertained to two drugs administered to one of the residents. One week after the resident was admitted to the nursing home, the facility’s electronic health record (EHR) issued a warning pertaining to the resident, indicating a possible adverse drug interaction between her blood thinning medication and an antibiotic that she was receiving.
The EHR identified the interaction as a moderate severity. The use of the medications together had the potential to increase the risk of bleeding complications. According to the state inspection report, the resident’s progress notes lacked documentation of the nursing staff acknowledging the warning, of notification to the resident’s primary care physician (PCP) of the warning, and lacked documentation of the PCP’s decision and rationale for using the medications together despite the risk of interaction.
Six days after the system issued the warning, an employee at the facility turned the woman on her side and discovered a large amount of foul-smelling, red and black substance that appeared to be blood draining from a pressure wound. There was new bruising on the resident’s left shin, left upper back, and on her ribs on the left side. The bruises were purple in color.
The next day, the resident was admitted to the hospital emergency room. According to the attending physician, the resident had a gastrointestinal bleed (GI Bleed) and had lost about 4 units of blood, presumably through her stools. The hospital was in the process of setting up a unit of blood to give to the resident, but she died before it was ready.
Staff at the facility told inspectors that there was a medication book that might have information relevant to the woman’s death. However, no one on the staff could find the medication book. A corporate clinical nurse consultant said the relevant information could be found in an EHR, but was unable to locate it or show staff where to find it. The director of nursing told inspectors the facility maintained one desktop computer at the nurses’ station that had full access to the internet, and the staff could use that computer or their personal cell phones to Google medications if they had any questions or concerns about medication dosages or interactions.
As a result of the state inspectors’ findings, the facility was cited for failing to ensure that each resident’s drug regimen was free from unnecessary drugs.
Compliance Perspective
Issue
Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate drug therapy), for excessive duration, without adequate monitoring, without adequate indications for its use, in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination of the above. Each resident’s entire drug/medication regimen should be managed and monitored to promote or maintain the resident’s highest practicable mental, physical, and psychosocial well-being. Concomitant use of certain medications warrants careful consideration of potential alternatives, possible need to modify doses, and diligent monitoring.
Discussion Points
- Review your policies and procedures on medication use and monitoring. Update as needed.
- Train all clinical staff on your medication policies, including the risks of drug interactions and the importance of immediately addressing any medication-related warnings or notices. Document that the trainings occurred and file the signed document in each employee’s education file.
- Audit to ensure medications prescribed to residents list indication for use, are the correct dosage and duration, will not interact adversely with other medications, are adequately monitored by the attending physician or other designated practitioner, and that a licensed pharmacist has provided consultation. Also audit to ensure staff know how to access current medication references and pertinent clinical protocols to help promote safe administration and monitoring of medications.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
