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.

Adding to the potential confusion was that the PRN medication was also prescribed as part of the person’s 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.

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 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. 
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 “rushed” transition, explains how an error or misunderstanding could occur even if a manager conducted a med review during the transition and intake process. 

Another factor that contributed to the administration of more than one dose of PRN was staff felt pressure to administer PRNs. The person’s 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’s 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.

The 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.