{"id":24,"form_id":"23","user_id":"81","question_id":null,"organization_id":"10","tab_id":null,"question_type":null,"text_answer":"{\"Short_Answer__76\":\"201904216\",\"Date__77\":\"07\\\/15\\\/2019\",\"Multiple_Choice__78\":\"Kristie Pittman\",\"Multiple_Choice__79\":\"Jill Tilbury\",\"Short_Answer__80\":\"REM Heartland - Couger Court\",\"Short_Answer__81\":\"Devin Nelson\",\"Short_Answer__83\":\"507-223-4410\",\"Multiple_Choice__84\":\"Medication Error\",\"Multiple_Choice__85\":\"Blue Earth County\",\"Date__86\":\"06\\\/01\\\/2019\",\"Free_Text__87\":\"On 6-8-2019, it was discovered that the person had been receiving only half of the prescribed dosage of her Mycophenolate.  The missed medications were then found in the medication cabinet.  Person received half of 9am and 3pm prescribed dosage from 6-1-2019 to 6-7-2019.\",\"Multiple_Choice__96\":\"1\",\"Short_Answer__91\":\"Person received half of the prescribed dosage of medication.\",\"True_or_False__94\":\"Yes\",\"Date__97\":\"08\\\/14\\\/2019\",\"Free_Text__98\":\"\\\"Staff 1 has been working for the company for the past 4 years and her role is a direct care staff. Staff 1 typically picks up of the medication from the pharmacy.  Sometimes Staff 1\\u2019s supervisor picks up the medications.  The staff who picks up the medications is responsible for organizing and separating the medications.  This medication usually come with one pill in two separate bubble packs and sometimes it will come with two pills in one bubble pack.  The person receives this medication at 9am and 3pm.  \\r\\n\\r\\nStaff 1 picked up the medication and then organized them.  Staff 1 felt that she put the correct medication and dosage in person\\u2019s medication area in the locked medication cabinet.  Staff does not recall anything out of the norm when organizing medications.  She said she was not distracted and that it was quiet at the house.  Staff 1said all medications are kept in each person\\u2019s area in the medication cabinet. Staff 1 said it is common practice for this facility for the first person who gives medication on the first of each month to double check that the medications were set up correctly. \\r\\n\\r\\nDebriefing with Staff #2 on 8-21-2019\\r\\n\\r\\nStaff 2 has worked for the company for the past 35 years and has held various position within the company.  Staff currently works the overnight shift which is from 10pm to 9am.  She is very familiar with the person and her medications as she has been with that group home for a long time.  \\r\\n\\r\\nOn the morning of June 1st, Staff 2 went to give 9am medications and noted that something \\u201cappeared off\\u201d with the medications. The medication typically comes in two single bubble packs, but there was only one bubble pack with one pill in the 9am medication. She said however that they do occasionally come with two pills in one bubble pack.  Staff 2 checked the dosage and then checked the 3pm medication and reported that they were the same, so she concluded that the dosage must have changed.  \\r\\n\\r\\nStaff 2 was not aware of the current procedure for storing extra medications.  Staff 2 said in the past when she held a different position that she would lock extra medications in the office desk. \\\"\",\"Free_Text__100\":\"\\\"The person receiving half of the prescribed dosage of medication for six days was influenced by Staff 1 believing that they set up the medications correctly after receiving them from the pharmacy.  An additional feature that influenced staff believing that the medications were set up correctly, was the medications were not always packaged the same when they came from the pharmacy.  Therefore, staff did not question when there was only one bubble pack for the person\\u2019s 9am medications and one bubble pack for person\\u2019s 3pm medications.  Staff 2 was the first staff to give medications after staff 1 set up medications in the med drawer for the month.   Staff 2 believed medications were set up correctly was influenced by the belief that the person\\u2019s medication dosage must have changed because of the way the meds were packaged.  Contributing to the staff\\u2019s belief that medication dosage changed was further influenced by the person\\u2019s 3pm medication dosage matching the 9am medication dosage.  This was further supported by staff 2 not finding the second bubble pack in the person\\u2019s medication drawer, which was the house norm for storing all medications.  Staff 2 also believed that staff 1 set up medications correctly.  \\r\\n \\r\\nAn additional factor that had other staff following staff 2\\u2019s lead in only giving half the med, rather than following medication protocol and ensuring that the med label and the Medication Administration Record (MAR) match the dosage in the bubble pack, is that there are a lot of policies for staff to know. This provider\\u2019s medication policies had changed due to the acquisition of another company, which then had both companies revise their policies to match each other. The introduction of 245D also required this provider to revise their medication administration policies. In the absence of stable policies the staff likely followed the veteran staff\\u2019s actions and assumed if there was a med change the veteran staff would have known as well as followed policies. \\r\\n\\\"\",\"Multiple_Choice__101\":\"2\",\"Free_Text__102\":\"This was further supported by staff 2 not finding the second bubble pack in the person\\u2019s medication drawer, which was the house norm for storing all medications. Staff 2 also believed that staff 1 setup medications correctly.\",\"Multiple_Choice__103\":\"0\",\"Multiple_Choice__105\":\"0\",\"Multiple_Choice__107\":\"0\",\"Multiple_Choice__109\":\"0\",\"Multiple_Choice__111\":\"0\",\"Multiple_Choice__113\":\"3\",\"Free_Text__114\":\"The person receiving half of the prescribed dosage of medication for six days was influenced by Staff 1 believing that they set up the medications correctly after receiving them from the pharmacy. An additional feature that influenced staff believing that the medications were set up correctly, was the medications were not always packaged the same when they came from the pharmacy Therefore, staff did not question when there was only one bubble pack for the person\\u2019s 9am medications and one bubble pack for person\\u2019s 3pm medications.\",\"Multiple_Choice__115\":\"0\",\"Multiple_Choice__117\":\"0\",\"Multiple_Choice__119\":\"0\",\"Multiple_Choice__121\":\"0\",\"Multiple_Choice__123\":\"3\",\"Free_Text__124\":\"\\\"Staff 2 believed medications were set up correctly was influenced by the belief that the person\\u2019s medication dosage must have changed because of the way the meds were packaged.  Contributing to the staff\\u2019s belief that medication dosage changed was further influenced by the person\\u2019s 3pm medication dosage matching the 9am medication dosage.  \\r\\n\\r\\nAn additional factor that had other staff following staff 2\\u2019s lead in only giving half the med, rather than following medication protocol and ensuring that the med label and the Medication Administration Record (MAR) match the dosage in the bubble pack, is that there are a lot of policies for staff to know. In the absence of stable policies the staff likely followed the veteran staff\\u2019s actions and assumed if there was a med change the veteran staff would have known as well as followed policies.\",\"Multiple_Choice__125\":\"0\",\"Yes_or_No__432\":\"Yes\"}","mcq_answer":null,"other_answer":"0","status":"1","created_by":"81","updated_by":81,"created_at":"4\/28\/2021 9:32:49 pm","updated_at":"4\/28\/2021 9:36:05 pm","deleted_at":null,"report_name":"KP_REM Heartland-BEC-2019-07"}