{"report_id":225,"form_id":"23","user_id":81,"organization_id":10,"question_id":"98","question_type":"Free_Text","text_answer":"Several workers administered the medication in the same way resulting in the error. Their decision to administer the medication in the way they did was driven by the instructions on the MAR which they all interpreted the same way, and which was also the incorrect interpretation. The staff interpreted the instruction of \u201cdaily\u201d to mean he could have it daily instead it meant a maximum daily (meant once a day and must be 4-6 hours after the last medication and only once a day, not every 4-6 hours daily), thus the over administration. The instructions were on the MAR and not on the med label, which was common practice. The staff followed the policy to check the label and MAR 3x any time there\u2019s a med pass. All staff had received the required training and followed the signature and other MAR review requirements.\r\nThere were four people who signed off as over-administering the PRN. Two were DSPs, one area manager and one program director. The area manager and program director were covering for DSP hours due to a staffing shortage. The DSPs there were new to the agency, as was the program supervisor and the person. It was also noted the person subjected to the overmedication was a new client to the provider. It was conveyed that in a perfect world the provider wouldn\u2019t take new service recipients until all staff were trained specific to a person. He came into a house that was already short-staffed. \r\n\r\nThe person had a high level of care, high needs, compared to others served at the home and was a newer resident of the home, moved there in September and incidents occurred in October. He began receiving services from this home after being in a hospital long after he required a hospital level of care. The transition from the hospital was described as hard: hospital social worker and care team communications were strained and confusing, and the med orders were also described as confusing. When a person with controlled meds transfers from a hospital to a provider, that time was described as being filled with angst. The sense of urgency leads to added stress. He was at the hospital for almost a year and there was extreme pressure to move him out of the hospital. The transition and care planning for this person were complicated by the fact that his guardian and contracted case manager were from Ramsey County. \r\n\r\nHe had multiple controlled meds and overlapping PRNs. For example, one PRN can only be taken X# of hours after another PRN, and there were several of these time lines and instructions to monitor. There was also one other man at the home who had a high contingent of medications. \r\n\r\nThe decision to administer the PRNs was also driven by the prescriber\u2019s instruction to \u201cgive him the PRN if he asks for it.\u201d Person had been asking for many PRNs frequently. It was common for him to have more than one agitation a day. He had a diagnosis that included schizophrenia, delusional behavior. He had a long history of chemical abuse. Some of his PRNs included an inhaler, med to reduce nausea, ointment for gums. Staff describe his as having high seeking behavior and describe him as liking to be in control of his medications. He was seen by the staff as being very anxious and demanding. He occasionally raised his voice, swore, used power moves, his thoughts could get \u201cout of control\u201d and turn delusional. It was difficult for staff who had no experience with that. \r\nStaff attribute staffing of the house as a challenge. The house was very short staffed. The provider was not receiving exception rates for the people at this home. They attempted to increase the wage. The location of the home may have been a barrier to keeping it staffed. \r\nThe incident on 11\/20\/2018, the omission of a medication on the MAR, was influenced by a staffing shortage. The medication was not added to the MAR and it would have been a supervisor\u2019s role to ensure the MAR was correct. The supervisor in charge of the MAR at that time is no longer with the company and was not debriefed. The person who attended the appointment, which was likely the same supervisor, also had a duty to ensure the correct instructions were passed along but that did not happen.","created_by":81,"updated_by":81,"updated_at":"5\/26\/2021 5:21:09 pm","created_at":"5\/26\/2021 5:21:09 pm","id":38326}