{"Short_Answer__76":"201902151","Date__77":"06\/18\/2019","Multiple_Choice__78":"Scott Schifsky","Multiple_Choice__79":"Sara Beauchene","Short_Answer__80":"Taylor SLS","Short_Answer__81":"Michael Taylor","Short_Answer__82":"miket.sls@charter.net","Multiple_Choice__84":"Medication Error","Multiple_Choice__85":"St. Louis County","Date__86":"03\/22\/2019","Free_Text__87":"Staff 1 administered the person another roommates\u2019 medication at 8:15pm on 3\/22\/19. Immediately following, Staff 1 notified the facility's RN Consultant, the person's primary physician, poison control, and the home's Associate Director. Poison Control suggested that the person be transported to a local emergency room for treatment. The Staff 1 immediately dialed 9-1-1and activated EMS. EMS arrived and brought the person to St. Mary's Medical Center ER in Duluth via Gold Cross Ambulance. VA was brought into an ER room and assessment began. The Associate Director met the person at the hospital. The person was given IV fluids as a precaution. Blood was drawn and x-rays were taken. ER MD planned on transferring person from the ER to a regular room for overnight observation. In the interim, the person had a seizure in the ER and the ER MD's plan was changed to have him transferred to an ICU bed for monitoring. The person was moved from the ICU to a regular hospital room on 4 East the next day. The person was discharged from the hospital on 3\/24 at 1:30pm as he returned to baseline without any adverse effects per Hospitalist.","Multiple_Choice__96":"1","Short_Answer__91":"Agency staff administered incorrect medication to a person living in the home.","True_or_False__94":"Yes","Date__97":"08\/01\/2019","Free_Text__98":"Staff 1 arrived at work at 2:00pm and described it as a normal day.  The person 1 who received the incorrect medication was picked up by his Mother around 3:00pm and staff was told they would be back at 6:00pm.   Staff 1 stated that the person receives seizure medications and it is important to administer at specific times per doctors\u2019 orders.   Missing medications or being untimely can trigger seizures.   Evening medication pass is at 7:00pm and as of 7:30pm the person 1 did not arrive home.  Staff 1 stated they felt anxious about not being able to pass medications, however, there is a one hour window on each side of medication passes.   Therefore, medications could be passed between 6:00pm and 8:00pm.   As of 8:30pm, the person 1 did not arrive and staff 2\u2019s shift ended. Staff 2 asked staff 1 if he could administer all medications to the people who lived there.  Staff 1 agreed and continued to feel anxious given the person was not home and was not able to administer medications.     \r\n\r\nStaff 1 began the process of a blood check that is routine for person 2 who lives in the home.   Person 2 receives sleep medication (Trazadone 300mg).   Staff 1 described that person 2 needed a lot of time to prepare for his blood check and taking his medications which required significant attention.  Person 2 was watching TV and required a lot of reminders to eventually transition to the kitchen area to take medications.  Staff 1 was eventually at the kitchen table with person 2 and began the blood check. At about 9pm, person 1 arrived home and staff 1 went to lock the medication cabinet that he had left open.  Staff 1 had already prepared person 1 and 2\u2019s medications.  Staff 1 put both sets of medications on the table in apple sauce and then quickly passed medications to person 1.   Person 1 proceeded to eat a snack while staff 1 was finishing the blood check with person 2.   \r\n\r\nShortly after the medication was passed, staff 1 realized he gave person 1 the incorrect medication and proceeded to contact the house LPN and director.","Free_Text__100":"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differientiate between the medications in apple sauce.   An additional factor influencing giving the incorrect medication to the person was that the provider had one less staff working than they typically did during medication administration. The provider typically had a 2 staff to 4 person ratio until 8pm, so that two staff would be on during the 6p-8p med administration window. On this day, the person\u2019s mother kept him out past the medication window, so that when he returned the second staff had left, leaving one staff on to administer the person\u2019s meds when he arrived. The provider's staff ratio and schedule is influenced by the county\u2019s service agreement with the provider to deliver services. MNCHOICES also influences how the county determines how many staffing hours to include in their service agreement and what medication administration responsibility they assign to the provider.    \r\n\r\nStaff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.  \r\n\r\nThe DWRS, MNCHOICES assessment, and county service agreement also impacted the staff schedule and further complicated the medication protocol.","Multiple_Choice__101":"0","Multiple_Choice__103":"0","Multiple_Choice__105":"0","Multiple_Choice__107":"0","Multiple_Choice__109":"0","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"0","Multiple_Choice__117":"2","Free_Text__118":"Staff had further constraints on their attention while assisting another person in the home with a blood check. This was further supported by staff worrying about the adverse effects of not passing seizure medications within the window of the medication protocol.  The pressure to pass timely seizure medications is based on the provider\u2019s medication protocol. 245D licensing and nursing protocols further complicated the medication protocol which connects to the person\u2019s physician who established specific times and dosages. Medications for both people were in apple sauce and when the person arrived staff felt pressure to pass medications and did pass the incorrect nighttime medications to the person.","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"Agency staff administering the incorrect medication was influenced by passing medications in apple sauce to two people at the same time. Staff punched out medications for two people from pre-packaged bubble packs at the same time, placed them both in apple sauce but then could not differentiate between the medications in apple sauce.","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}