{"report_id":24,"form_id":"23","user_id":81,"organization_id":10,"question_id":"100","question_type":"Free_Text","text_answer":"\"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\"","created_by":81,"updated_by":81,"updated_at":"4\/28\/2021 9:36:06 pm","created_at":"4\/28\/2021 9:36:06 pm","id":2135}