Medication Administration – Survey Alert

Karen Morris and Nancy Leveille in Clinical & Quality

Medication administration issues on survey have been skyrocketing across the state. A number of the high level citations given have been related to non-compliance of standards of practice for medication administration. Please use the list below to review your policies and procedures for some of the more common areas that have been cited:

  1. Are controlled drugs counts being conducted at the beginning of every shift on every unit?  Suggest administrative nurses conduct spot checks during count times. Nurse coming on duty should count the medications and nurse going off duty should check the documentation. Any discrepancy should be reported to nursing administration/designee for immediate review. 

  2. Are Medication lists being reconciled when residents are readmitted from the hospital?  Suggest using the INTERACT Medication Reconciliation work sheet (see attached.)  Does transfer paperwork include the last dose resident was given of the medications, particularly cardiac meds, anticoagulants, insulin, antibiotics etc. 

  3.  Are medications being administered timely on every unit, every shift?  Regulatory definition of timely is within one hour before the designated administration time or one hour after.  Suggest spot checks during medication passes and regular meetings with medication nurses to discuss their issues.

  4. Are medications for new admissions/readmissions available to be administered as ordered?  Do policies address notifying the physician any time a medication is not available at the time it is to be administered? Suggest record reviews related to medication availability, review of the  policies related to the use of emergency box and the types of medications available in the emergency box and if they meet the needs of the current resident population, review of pharmacy delivery times and any issues related to delivery and/or availability with nurses (particularly on off shifts/weekends.)

  5. Are issues related to electronic medical records related to medication administration records addressed?  Can nurse override if administration times are arbitrarily assigned by the computer program?    

If you have problems associated with any of these processes, we suggest initiating a root cause analysis and development of process improvement strategies, with the specific team members who do this work, to be able to stay in compliance with standards of practice for medication administration and management.