{"Short_Answer__76":"201906882","Date__77":"10\/15\/2019","Multiple_Choice__78":"Jill Tilbury","Multiple_Choice__79":"Marilee Bengtson","Short_Answer__80":"Wingspan Life Resources","Short_Answer__81":"Therese Davis","Short_Answer__82":"tdavis@wingspanlife.org","Short_Answer__83":"651-242-5840","Multiple_Choice__84":"Medication Error","Multiple_Choice__85":"Hennepin County","Date__86":"08\/30\/2019","Free_Text__87":"VA was taken to the doctor and AP received a written script to increase one of the insulin medications (Tuejeo) by 2 units.\r\nOrder was given on 08\/29\/2019.\r\n\r\nAP is suppose to transcribe the right medication on the med sheet but instead he documented a referral for the appointment and\r\ndocumented the increase on the to visit note and informed staff. The med sheet was never updated and Staff are suppose to follow the\r\nmed sheet.\r\n\r\nThere was a couple days where VA did give the right dosage because AP gave it to her himself. Nurse discovered this on Thursday Morning 09\/19\/2019 and informed Reporter of the mistake.","Multiple_Choice__96":"1","Short_Answer__91":"Medication Error over an Extended Period of Time","True_or_False__94":"Yes","Free_Text__98":"The VA has had Type 1 diabetes since they were 6 years old and now is 44 years old.  The VA lives in an adult foster care setting for the past seven years with three other individuals.  The VA enjoys walking the dog, going to work 5 days a week, and being active in the community.  \r\n\r\nThe VA has a protocol that all staff are trained on and due to this regimen it is difficult to have any fill in staff cover shifts at the adult foster care home.  The VA completes the blood sugar checks without assistance from staff with an Accuchek machine.  The machine then tells the staff how much insulin is required at that time depending on how many carbs the VA is going to eat at that meal time for both medications.  The VA gets novolox 4x\/day and the tuojeo 1x\/day at dinner.   The protocol goes onto say if the numbers are within this range give this much insulin and if they are within this much give this amount.  The VA takes two different types of insulin along with several other medications. This protocol is listed on the computer within the MAR system that the provider utilizes to document medications and communications amongst the staff.   \r\n\r\nThe staff will then \u201cdial up\u201d the insulin for the VA and they will give themselves the insulin injections.  The insulin medications are not labeled with the amount of units that are to be given due to the variances based off of the blood sugar numbers and the amount of carbs that are about to be eaten by the VA.  The VA is aware of the regimen and understands the necessity to take her insulin each day. \r\n\r\nThe VA is unable to feel the effects of having blood sugar numbers out of the normal range (80-120) and their numbers will reach as high as 300-400 without any signs (dizzy, light headed, sweaty, etc.).  The VA understands when their numbers are high if they exercise they can reduce the numbers.  The VA had a checkup with their doctor regarding the blood sugar being high, although the staff will educate the VA on proper eating choices and the VA exercises frequently.  The doctor stated the Tuojeo needed to go from 15 units to 17 units at dinner time.  The supervisor of the house had taken the VA to the appointment and came home and documented this in the MAR and in the staff notes of the change and had given the VA the change in medications when giving the medication that evening.  The supervisor gave the other staff the information to follow.  \r\n\r\nThe nurse found the error in the medications after different staff had worked and not just the supervisor and the staff that was informed on 8\/29\/19 after the VA went to the doctor appointment.  The supervisor had been doing compliance checks once a week of the medications, however did not see it because the medications and the MAR don\u2019t match because they never have matched because of the variances in the medication that is given based off what the numbers are and how many carbs are being eaten.  There are many moving parts to giving the insulin medications while the staff also must follow the protocol.  The staff typically give the medication after the supervisor has left for the day as well due to the supervisor working from 9a-5pm and the VA gets this medication at dinner time.","Free_Text__100":"Staff not providing the correct medication dosage to an individual was influenced by the staff being unware of the increase in the medication dosage. A contributing factor to the unawareness of the increase was that information was not communicated to the staff in the transition time because there is not enough time available to read the health progress notes.  The short amount of staff transition time is impacted by the provider not building transition time into the staff schedules due to contributing factors of the weather, the staff\u2019s second job, and the labor laws.  The other influencer is the CSSP and the 6790 does not allow the ability of the rate system to pay the provider more to have staff overlap on the shift change.  Another contributor of the staff not being able to communicate during the transition is there are several documentation points for communication for each individual living in the home thus requirements set for by licensing 245D.  \r\n\r\nStaff giving the incorrect dosage was also influenced by the documentation was not completed in the Medical Administration Record (MAR). At this home, it was the supervisor\u2019s role to update medication changes in the MAR.  The individual\u2019s medication administration had complexities to giving the medications that were not relayed in the MAR as the individual was to receive two different types of insulin and staff relied on the previous MAR to provide the medication.  The influence of the MAR not being updated is the provider experiencing frequent lapses in internet connectivity (which occurred frequently at the residence) and the MAR is an electronic document, thus the documentation is in two places and not reviewed by all staff.  The supervisor had relied on the protocol for the med changes that is given by the physician, which has an outside influence of the pharmaceutical laws that informs the physician on how to write the protocols.  \r\n\r\nA final influence to staff giving the incorrect dosage was that they were using an \u201cold\u201d prescription because the physician did not change the prescription with the pharmacy.","Multiple_Choice__105":"2","Free_Text__106":"A contributing factor to the unawareness of the increase was that information was not communicated to the staff in the transition time because there is not enough time available to read the health progress notes.","Multiple_Choice__107":"0","Multiple_Choice__109":"0","Multiple_Choice__111":"0","Multiple_Choice__113":"0","Multiple_Choice__115":"0","Multiple_Choice__117":"0","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"At this home, it was the supervisor\u2019s role to update medication changes in the MAR.  The individual\u2019s medication administration had complexities to giving the medications that were not relayed in the MAR as the individual was to receive two different types of insulin and staff relied on the previous MAR to provide the medication.  The influence of the MAR not being updated is the provider experiencing frequent lapses in internet connectivity (which occurred frequently at the residence) and the MAR is an electronic document, thus the documentation is in two places and not reviewed by all staff.","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}