Based on clinical record review, facility documentation review, and staff interview, it was determined that the facility failed to ensure an accurate assessment for one of five resident records reviewed for unnecessary medications (Resident 16).
Review of Resident 16's clinical record on September 17, 2019, at approximately 11:00 AM revealed diagnoses including hypertension (elevated/high blood pressure), and major depressive disorder (mental health disorder characterized by chronic low mood, loss of interest in pleasurable activities, sleep pattern disturbances, and other symptoms).
Review of Resident 16's physician orders on September 17, 2019, at approximately 11:00 AM, revealed a physician order for phenobarbital (nonselective central nervous system (CNS) depressants that are primarily used as sedative-hypnotics) 15 milligrams (mg - metric unit of measure) by mouth in the afternoon and 32.4 mg by mouth two times a day; both doses for seizures (neurological disorder of the brain).
Review of Resident 16's quarterly Minimum Data Set (MDS - assessment tool utilized to identify a residents' physical, emotional and psychosocial needs), dated July 15, 2019, revealed that section N: Medications; Subsection: N0410D Medications received: Hypnotics was coded to reflect Resident 16 did not receive a hypnotic medication.
Review of Resident 16's Medication Administration Record (MAR - documentation tool used to record when a resident is administered a medication), and prior physician orders, revealed that Resident 16 had a scheduled daily dose of phenobarbital medication since June 23, 2017.
During a staff interview on September 18, 2019, at approximately 2:00 PM, the Director of Nursing provided guidance from the facility's contracted pharmacy. Review of the facility document titled, "MDS 3.0 Section N: Medications," last revised April 2013, identified phenobarbital as, "should only be coded as a hypnotic if is being used for sleep (not if being used for seizures, etc)."
Review of Centers for Medicare & Medicaid Services' "Long-Term Care Facility Resident Assessment Instrument 3.0," (instructions and directions for the assessment and completion of the MDS form), dated October 2018, revealed that the instructions for section N0410A-H:; of N: Medications Received, stated, "Code [record/document] medications according to the pharmacological classification, not how they [the medications] are being used."
During a staff interview on September 19, 2019, at approximately 10:45 AM, Director of Nursing revealed that the facility was following guidance from the consultant pharmacy and was unaware of a change in the MDS coding instructions to code a medication per the classification and not use of the medication.
28 Pa Code 211.12(d)(3)(5) Nursing services
| ||Plan of Correction - To be completed: 10/23/2019|
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulations the center has taken, or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance. All alleged deficiencies cited have been or will be corrected by the dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. This plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being.
1 .Resident 16's MDS has been modified on section N0410D to reflect accurate coding for hypnotic medications. Resident suffered no ill effects from MDS coding.
2. Any resident who receives hypnotic medications have the potential to be affected. All residents currently receiving hypnotic medications their MDS will be audited to ensure accuracy of section N0410D.
3. The MDS Coordinators have been educated on accurately coding section N0410D on the MDS.
4. MDS Coordinators or designee will conduct an audit of 5 completed MDS assessments weekly to ensure accuracy of section N0410D for hypnotics. Audit will be weekly for 4 weeks then monthly for 2 months. QAA committee will track and trend audits and determine the need for further audits.