{"Short_Answer__76":"201905922","Date__77":"09\/16\/2019","Multiple_Choice__78":"Kelly Sather","Multiple_Choice__79":"David Vukelich","Short_Answer__80":"Bluewater Residential Services","Short_Answer__81":"Toni Martindale","Short_Answer__82":"toni.martindale@brsduluth.com","Multiple_Choice__84":"Medication Error","Multiple_Choice__85":"St. Louis County","Date__86":"08\/13\/2019","Free_Text__87":"Alix passed medications for the night to Rodney and the other residents. She had passed the meds to JT\r\n(resident) and she had to bring Rodney's upstairs to him because he says he has difficulty coming down the stairs. After giving Rodney\r\nhis medications JT came to her and told her that what she gave her was not her medications (250 mg of Clozapine). By the time Alix got to\r\nRodney he had already ingested the incorrect medications. She immediately called poison control and was referred to bring him to the\r\nER. The overnight staff arrived as the ambulance was getting there. Rodney was admitted for observation and intubated due to trouble\r\nbreathing and was released on 8\/15\/19 and is doing fine.","Multiple_Choice__96":"1","Short_Answer__91":"Staff administered the wrong medications to two individuals.","True_or_False__94":"Yes","Date__97":"10\/22\/2019","Free_Text__98":"The staff member has worked at the agency since February 2019 and is experienced working in similar settings. \r\n\r\nThe night of the incident, the staff member was working with the house manager earlier in the day, but believed it was around 4:30-5:00 p.m. when she started working alone, which is not uncommon for the house. She prepared dinner and typically waits until approximately 6:30 to begin clean up as one individual living in the home takes longer to finish eating. This evening, she recalled being behind in the cleaning and at 7:30, individuals requested their medications.\r\n\r\nThere is a medication procedure in the home, which the staff member explained that they are to use hand sanitizer, check medications and MARS, she places a dot next to the medication signifying that it was given, removes medications from med box and places in cup. Once given to the individual, the staff returns to the MARS and signs where the dot was left previously. When further asked about this, the staff member explained that the MARS shouldn\u2019t be signed until after you ensure that the individual took their medication in case of refusals. When asked about whether or not this is done all at once for everyone or individually, she stated it should be done with each person; however, she has done this combined. She explained that she felt this was okay because she has seen other people do it and normally she is very attentive. \r\n\r\nThe staff member explained that this night she was in a rush because she was behind in cleaning and knew she was due to be done soon. She did the medications as she normally does, reviewing them, dotting the medications, and putting them into the cups. She stacks the cups based on the order she distributes them. She brings Individual 1\u2019s first since she is on the first floor. She brought the cup to individual 1 who was relaxing in her room. The staff member then went upstairs to bring Individual 2 his medications. She had to wake him up to give him his medications so she did recall that he did not look in the cup that she handed him and just took his medications. It was at this time that Individual 1 came up to the staff member and told her that these were the wrong medications. The staff member realized then that she switched up the two medication cups having given Individual 2, Individual 1\u2019s medications.","Free_Text__100":"The staff administering the wrong medications to two individuals was impacted by the staff member feeling rushed. It was towards the end of the shift and staff was behind in cleanup. The way the staff member manages the time and tasks such as when to begin cleaning and the time to dispense medications of the shift contributed to her being behind and feeling rushed as she waited until the end of the shift to complete many of her duties.  Another factor contributing to feeling rushed was when an individual approached the staff asking for his\/her medications. The staff prioritized the medication administration over her other duties to which she was attending to accommodate the request. When the individual asked for their medications this impacted how staff chose to manage their time and tasks. The staff's being rushed influenced their decision not to follow the medication protocol having observed other staff members distribute all medications at one time for the residents. The staff member distributed all four medications at once and did not ask the individuals to verify the medications given. Both of these areas influenced the staff administering the wrong medications to the two individuals. The managing of time and tasks is influenced by the medication protocol and the houses having different schedules. The different schedules are impacted by the staff ratio, which is derived from the 6790 and the CSSP, as well as the expectation that there is person centered choice within the home. This choice allows for the schedule of the home to be more fluid adapting for the individuals that live in the home. Person Centered Choice is impacted by 245D licensing and the Home and Community Based Services (HCBS). \r\nAn additional factor in administering the wrong medication was that the staff feeling pressured to complete all her duties before the end of the shift, which contributed to the staff feeling rushed. Staff felt pressure because they were previously written up due to not meeting shift responsibilities\/tasks. The provider\u2019s expectations of staff impacted both the house responsibilities that each staff member must complete and writing up staff who don't follow through on their responsibilities. These house responsibilities influenced the staff feeling rushed. The provider's house responsibilities and staff expectations were influenced by the Community Services and Support Plan (CSSP). The CSSP is impacted by 245D licensing and the 6790 that identifies how staffing should be conducted.\r\n\r\n\r\nThe medication protocol was another influence of how the staff chose to manage the time and tasks. The protocol outlines the time frame that medications can be given and the procedure in distributing the medications. The medication protocol has a reciprocal impact with the medication protocol training. It is also impacted by the pharmacy consultation and sign off, 245D licensing and liability that exists for the provider. Medication administration errors can result in licensing violations, maltreatment investigations and even civil lawsuits. This Liability results in the provider creating medication protocols implementing a number of safeguards to reduce the likelihood of committing a med error, but those safeguards also increase the complexity of administering medications. This complexity can increase the amount of time it takes to administer medications, so when staff are rushed they are likely to weight efficiency over thoroughness.","Multiple_Choice__101":"1","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":"2","Free_Text__116":"This Liability results in the provider creating medication protocols implementing a number of safeguards to reduce the likelihood of committing a med error, but those safeguards also increase the complexity of administering medications. This complexity can increase the amount of time it takes to administer medications, so when staff are rushed they are likely to weight efficiency over thoroughness. The different schedules are impacted by the staff ratio, which is derived from the 6790 and the CSSP, as well as the expectation that there is person centered choice within the home.","Multiple_Choice__117":"3","Free_Text__118":"The staff administering the wrong medications to two individuals was impacted by the staff member feeling rushed. It was towards the end of the shift and staff was behind in cleanup. The way the staff member manages the time and tasks such as when to begin cleaning and the time to dispense medications of the shift contributed to her being behind and feeling rushed as she waited until the end of the shift to complete many of her duties.  Another factor contributing to feeling rushed was when an individual approached the staff asking for his\/her medications. The staff prioritized the medication administration over her other duties to which she was attending to accommodate the request. When the individual asked for their medications this impacted how staff chose to manage their time and tasks.","Multiple_Choice__119":"0","Multiple_Choice__121":"0","Multiple_Choice__123":"2","Free_Text__124":"This choice allows for the schedule of the home to be more fluid adapting for the individuals that live in the home. Person Centered Choice is impacted by 245D licensing and the Home and Community Based Services (HCBS).","Multiple_Choice__125":"0","Yes_or_No__432":"Yes"}