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Regulatory compliance in healthcare is often one of the most dreaded responsibilities of being a leader in a facility. There are so many variables and different people involved in ensuring compliance occurs that important pieces of communication slip through the cracks and before we know it surveyors find we are out of compliance. While survey results are aimed to tell us we are out of compliance, I have to wonder are we really out of compliance or are we just inefficient?

I spend a lot of time reviewing charts, often during the restorative consulting phase, to help facilities identify their gaps in compliance. I frequently find facilities are not usually completely out of compliance. Rather, they inconsistently document the care that is and has been provided. The greatest opportunity for improvement is in care notes and medication administration records (MAR). Documentation is often just incomplete in both of these areas, let’s take a look.

Improving Medication Administration Records

Depending on the resident they may lack one or more of the following required components of a MAR despite prompting boxes on the blank MAR:

  • Medication name
  • Medication dose
  • Medication route
  • Frequency of administration
  • Indication for administration
  • Specific administration instructions i.e. give 30 minutes before breakfast

One interesting observation that I consistently see is that some residents have all of the required components of the medication order on the MAR and others in the same facility lack required components. So the question is why does inconsistency occur? Is it a lack of training for the person entering the medications on the MAR? Are there multiple staff members entering medication orders on the MAR and the verification process is not being completed correctly? Does the order from the physician for the medication lack the necessary components? I would venture a guess the cause differs from facility to facility, non the less It warrants researching.

Improving Documentation

The other frequent issue with MAR documentation is found with PRN medications. Orders entered onto the MAR nearly always lack the medical indication for use and residents often have multiple like medications without sufficient directions for administration. Both of these issues put the resident at risk for toxicity. Let’s take a look at an example. Sadie Jones is a 75-year-old who has an order for Tylenol, Percocet, and Lortab, all for unspecified levels of pain. Each order has its own time interval and lack specific parameters for when to administer or withhold the medication. Because of the lack of specific administration instruction all could be given at their prescribed intervals, ultimately overlapping with another pain medication.

Why is this a problem? Depending on how the medications are entered into the MAR, the mixed usage of generic and brand drug names may conceal the fact that all three medications have acetaminophen in them. It is not unusual to find that none of the orders have required times between administration of another acetaminophen containing medication or a maximum dose of acetaminophen in a 24-hour period of time. Both of these instructional parameters are crucial in protecting residents with multiple pain medication orders from becoming acetaminophen toxic. Excessive acetaminophen ingestion, at a minimum, causes liver failure but can unfortunately cause death.

It is unfortunate to say, this is not an unusual documentation finding. I think in the business of the day and the skill mix of community-based care, it makes it all the more important to make sure that medications are entered correctly into the MAR and that clarifications from the physician should be obtained prior to administering the medication if required components of an order are not present. Failure to do so is not only a regulatory violation, it puts the resident in danger.

Strategies to Improve Performance of Employees

I think the true question about medication assistance/administration compliance is, how can you change your facilities process to help your staff be more efficient, consistent, and thorough? Have you considered implementing “hard stops” into the MAR so that an order cannot be entered without all of the necessary information?

It is a rare day that I audit charts where care notes are complete and provide me enough information to track the care being provided. Compliance becomes an issue when a resident is on alert charting or required assessments do not contain enough information to communicate the assessment was completed. The primary issue with care notes is the lack of standardized structure and content for notes. In addition to poorly written notes, it is not uncommon to find notes that are copy and pasted from a note previously entered by another staff member. While entering an insufficient note technically meets the regulatory requirement, the lack of content will eventually provoke a regulatory citing because of the lack of clarity about whether monitoring and follow-up was really completed.

Consider legal requirements for documentation.  Cutting and pasting a note is technically falsification of documentation because it is not the authors original work. I can’t help but think that documentation issues occur because staff are unsure of what to document. When they are supposed to be following up at frequent intervals or for many days in a row, I think staff become unsure of what to enter because it seems redundant. Staff see redundancy as unimportant work and do not understand how it communicates resolution to a change of condition. Redundancy ensures that the intended progress is made. When an intervention is implemented, that the change in condition is resolved as a result of the implemented interventions, or that interventions were changed based on the need of the resident.

Consider Standardized Nursing Documentation

Standardized templates are a feasible and efficient solution to insufficient documentation. Are you aware of the components of note that will efficiently and thoroughly communicate care that is being provided? Here is what I suggest:

  • First making sure there are standardized note heading to choose from will help to communicate what the staff are documenting on. For example, RN Assessment or Alert Charting.
  • Next having a template built to integrate into new notes encourages comprehensive notes. Here is a template that works well:
  1. Situation: Resident fall
  2. Background: Resident fell 2 nights ago because of dizziness.
  3. Action: Resident encouraged to use alert button when needing to ambulate. Staff to check on Resident every 4 hours for toileting assistance while awake. Resident called 3 times for assistance. Assistance provided.
  4. Response: Resident steady on her feet and denied dizziness.

A catchy acronym for this charting template is SBAR. It is easy for staff to remember and it clearly communicates the care being provided. Standardized notes also prevent last minute scrambles and justifications of care when surveyors are questioning the care of a resident or looking at a possible violation of your policies and procedures. Out side of the regulatory arena, standardized note structures help to prevent unnecessary litigation inquiries because the right information is provided in the note.

Staff turnover tends to be very is high in community-based care, however putting documentation templates in place or hard stops on MAR entries can prevent variation in documentation, workflow and omission of important information. Creating efficiencies in your processes works towards eliminating variation in important workplace processes. It creates more time in the workday and reduces the risk of regulatory citing’s. Streamlining and building processes that prompt and assist front-line staff in being consistent ensures safe resident care and shining regulatory surveys.

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