{"Short_Answer__76":"201900095","Date__77":"05\/15\/2019","Multiple_Choice__78":"Sara Beauchene","Multiple_Choice__79":"Charles Young","Short_Answer__80":"REM Arrowhead","Short_Answer__81":"Corey Labissoniere","Short_Answer__82":"Corey.LaBissoniere@thementornetwork.com","Multiple_Choice__84":"Medication Error","Multiple_Choice__85":"St. Louis County","Date__86":"10\/02\/2019","Free_Text__87":"Several staff administered more than one dose of PRN on several occasions to a person who had been prescribed several PRNs.","Multiple_Choice__96":"1","Short_Answer__91":"Staff administered more than one dose of PRN on several days in October 2018.","True_or_False__94":"Yes","Date__97":"06\/25\/2019","Free_Text__98":"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.","Free_Text__100":"Several staff were involved in administering more than one dose of PRN to a person on several dates. This was influenced by a misinterpretation of instructions on the Medication Administration Report (MAR) which is created by the pharmacy. The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.\r\n\r\nAdding to the potential confusion was that the PRN medication was also prescribed as part of the person\u2019s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.\r\n\r\nWhile the MAR and other medical instructions are typically reviewed and clarified at intake and then communicated with staff, this transition and intake was perceived as rushed, even urgent. The med instructions were reviewed, but the confusing nature of the instructions along with the rushed intake explain the eventual misinterpretation by staff.There are circumstances that can make a typical intake feel rushed and urgent, which is what happened here. In this case, prior to moving into the home, this person had been in the hospital for a year beyond when he was assessed to no longer require hospital level of care. Hospital administrators feel a high level of pressure to release people. Case managers, in turn, feel that high level of pressure from the hospital. Logically, the provider feels that urgency with which the transition is needed to occur. Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. The federal rate structure does not allow for hospitals to bill for services to people who do not require hospital level of care. The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs. \r\nEven under the very best of circumstances, working under an urgent timeline to transition a person with a complex medication schedule, and the fact the residential program was very understaffed, increases the likelihood an incident can occur. The confusing nature of the medication instructions, along with an expedited or \u201crushed\u201d transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process. \r\n\r\nAnother factor that contributed to the administration of more than one dose of PRN was staff felt pressure to administer PRNs. The person\u2019s history and diagnosis along with staff wanting to avoid a behavior incident added to the pressure to administer. The person asked for PRNs frequently and it was also the prescriber\u2019s instruction to give the person the PRN when he asked for it. Additional dynamics contributing to the staff feeling a pressure to administer are that the person was new to the home; there were new staff recently hired, not necessarily fully trained for the exact unique needs of the person; and, the management staff covering for a staff shortage were just newly acquainted with the person.\r\n\r\nThe provider desired to make the placement successful, which also added to a perceived pressure to administer. There was a belief that administering PRNs as prescribed and when asked for would be one way to assist in a successful placement. Adding to the desire to facilitate a successful placement was the provider who has incentive to fill open beds which is directly impacted by the Disability Waiver Rates System, whose payment structure is determined by the number of people in a home.","Multiple_Choice__101":"2","Free_Text__102":"The person\u2019s history and diagnosis along with staff wanting to avoid a behavior incident added to the pressure to administer. The person asked for PRNs frequently and it was also the prescriber\u2019s instruction to give the person the PRN when he asked for it.","Multiple_Choice__103":"2","Free_Text__104":"Additional dynamics contributing to the staff feeling a pressure to administer are that the person was new to the home; there were new staff recently hired, not necessarily fully trained for the exact unique needs of the person; and, the management staff covering for a staff shortage were just newly acquainted with the person.","Multiple_Choice__109":"3","Free_Text__110":"Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. Even under the very best of circumstances, working under an urgent timeline to transition a person with a complex medication schedule, and the fact the residential program was very understaffed, increases the likelihood an incident can occur. The confusing nature of the medication instructions, along with an expedited or \u201crushed\u201d transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process.","Multiple_Choice__113":"3","Free_Text__114":"The instructions on the MAR, on the medication bottle and on the referral form for this person were all different. Although the instructions were different enough in wording and readability to create misinterpretation, they were not directly conflicting. For example, the dosage and timing in relation to other PRNs and possible interactions were not fully outlined on each in the same way.  This explains why the confusion may not have been caught despite staff triple checking the instructions each time they administered medications.\r\n\r\nAdding to the potential confusion was that the PRN medication was also prescribed as part of the person\u2019s daily regimen, meaning that in addition to the instructions that it was a daily medication, the PRN was also instructed to be given as needed, but instructions did not specify a timeframe for administering after the daily dose was administered.","Multiple_Choice__115":"1","Multiple_Choice__117":"2","Free_Text__118":"While the MAR and other medical instructions are typically reviewed and clarified at intake and then communicated with staff, this transition and intake was perceived as rushed, even urgent. The med instructions were reviewed, but the confusing nature of the instructions along with the rushed intake explain the eventual misinterpretation by staff. There are circumstances that can make a typical intake feel more urgent or even rushed, which is what happened here. In this case, prior to moving into the home, this person had been in the hospital for a year beyond when he was assessed to no longer require hospital level of care. Hospital administrators feel a high level of pressure to release people. Case managers, in turn, feel that high level of pressure from the hospital. Logically, the provider feels that urgency with which the transition is needed to occur. Since the hospital had been providing services for a year after the person no longer required hospital level of care, staff sensed urgency around the release. Once a provider is found, the timeline for release is nearly immediate. The federal rate structure does not allow for hospitals to bill for services to people who do not require hospital level of care. The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs. \r\n\r\nThe provider desired to make the placement successful, which also added to a perceived pressure to administer. There was a belief that administering PRNs as prescribed and when asked for would be one way to assist in a successful placement. Adding to the desire to facilitate a successful placement was the provider who has incentive to fill open beds which is directly impacted by the Disability Waiver Rates System, whose payment structure is determined by the number of people in a home.","Multiple_Choice__119":"3","Free_Text__120":"The length of time the person remained at the hospital was impacted, likely directly caused, by a statewide shortage of community placement options for people with complex needs.","Multiple_Choice__121":"0","Multiple_Choice__123":"1","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}