Meds on the mind: what we've learned about medication management in the last few months.

As you're probably aware by now, the updates to the unnecessary drugs and pharmacy services F-tags #329, #425, #428, #431 present a number of operational challenges to any nursing home. Although the regulations related to unnecessary medications did not change, the background information in the tags and the survey protocols are vastly different and have many new, specific issues on which surveyors will focus.

Your facility team needs to look at the protocols for the F-tags to prepare for pointed observations and questions about residents' drug regimens. Nurses have to be focused when taking new orders for medications and must question any unusual dosages or combinations of medications that could be problematic. Based on how facilities have reacted to the new survey guidelines thus far, we will probably see many situations in which nurses will need order clarification from physicians.

Good tip: Purchase laminated reference cards showing drug interactions and reactions so that nurses have a handy reference source at the desk and on the medication cart.

How the team interacts

The medication regimen review F-tag contains significant information about how the pharmacist, the nurse, the physician, and the interdisciplinary team should all interact. Here are some tips on how to comply with the unnecessary drugs regulations:

* A system for monitoring drug effectiveness should be in place, and staff should document efficacy clearly in the record and after the pharmacist's review.

* Both professional and direct care frontline staff should monitor and report changes in the resident's condition that could be related to medication use.

* Most facilities will need to increase the time they dedicate to train staff in this area, as well as improve the documentation systems to track and report changes in a resident's condition. The integration of all these observations and assessments with the completion of the MDS is also essential.

* Discontinuation of medications is also an important part of the regimen review process. Staff should know options other than medications they can take, when they are feasible, and when they should be attempted.

This is much larger than the nursing responsibility and should be discussed by the entire interdisciplinary team, which includes the pharmacist.

The timeliness issue

The new regulatory material includes not only medication administration, but also guidance on the timely delivery of routine and nonroutine medications. The nursing home staff must regularly evaluate the composition of the drugs available in the emergency supply box. Facilities should also consider how they acquire non-routine medications late at night or on the weekends.

If this system is to work, it requires active communication between the pharmacist, administrator, clinical leadership, and attending physician. Administrators and directors of nursing need to have specific pharmacy policies and procedures updated to match their pharmacies' policies.

Medication regimen review

F-tag #248, the Medication Regimen Review (MRR), has a new protocol, which focuses on the details of the review, report, and outcome of the reporting. It requires that the pharmacist work with the care team to be sure all aspects of safe medication use are addressed and documented and that the team considers nonpharmacologic approaches when appropriate.

Facilities should review their forms for reporting MRR and be sure the forms comply with the requirements for review in the F-tag. When the pharmacist makes a recommendation during the MRR, staff must document it and follow up on the results.

The F-tag states that irregularities or adverse consequences related to medication use must be reported to the director of nursing and the attending physician. The medical record must contain documentation of evidence of action.

Operational managers and clinical directors need to take a good look at the new regulations and check that their lines of communication with their consultant pharmacists and managing pharmacists are open.

From what we've seen so far, all parties need to review the new regulations and then discuss each person's role in compliance. MRR processes must follow the basic requirements of the regulations; communication of MRR results must be specific and action-focused.

The implications for building managers are significant and require detailed knowledge of the regulations. Facilities need to show strong leadership to achieve compliance with internal staff, consultants, and vendors.

Leah Klusch, RN is the executive director of Alliance (OH) Training Center and a nurse educator and operational consultant who brings more than 40 years of experience to her work. She can be reached at the Alliance Training Center at 330/821-7616.