On Oct. 1, 2018 updates to Section N of the MDS were implemented by CMS. Two questions were added to Section N (N2001 and N2003) if the assessment type is coded as PPS 5-day, and one question was added to Section N (N2005) if the assessment type is coded as a SNF Part A PPS Discharge Assessment. These questions are related to reviewing the drug regimen for residents. Per the RAI Manual, the intent of the updated questions is to “document whether a drug regimen review was conducted upon the resident’s admission (start of Skilled Nursing Facility (SNF) Prospective Payment System [PPS] stay) and throughout the resident’s stay (through Part A PPS discharge) and whether any clinically significant medication issues identified were addressed in a timely manner.”
Question N2001 encodes the MDS with data related to the drug regimen review and clinically significant issues identified during the review. The initial drug regimen review should be completed upon admission or as close to the actual time of admission as possible. Adverse consequences and errors related to the drug regimen can cause “serious harm or death, emergency department visits and rehospitalizations, and affect the resident’s health safety and quality of life” and the risk for error escalates during transitions of care. A drug regimen review includes reviewing prescribed medications, over-the-counter medications, nutritional supplements, vitamins, homeopathic products, herbal products, total parental nutrition, and oxygen for clinically significant medication issues.
Clinically significant medication issues include, but are not limited to:
- Medication prescribed despite documented allergy or prior adverse reaction
- Excessive or inadequate dose
- Adverse reaction to medication
- Ineffective drug therapy
- Drug interactions (serious drug-drug, drug-food, and drug-disease interactions)
- Duplicate therapy
- Wrong resident, drug, dose, route, and time errors
- Medication dose, frequency, route, duration not consistent with resident’s condition, manufacturer’s instruction or applicable standards of practice
- Use of medication without evidence of adequate indication for use
- Presence of medical condition that may warrant medication therapy
- Nonadherence (purposeful or accidental)
Question N2003 encodes the MDS to indicate if the physician or physician designee was contacted and the prescribed/recommended actions were implemented prior to midnight of the next calendar day. This question is only activated if clinically significant medication issues were identified.
Question N2005 is only completed if the assessment type is SNF Part A PPS Discharge Assessment and reviews the entire stay for clinically significant medication issues identified since the admission and if the physician or physician designee was contacted the prescribed/recommended actions were implemented prior to midnight of the next calendar day.
It is important to review and update the systems utilized to evaluate medication usage. Many facilities have the pharmacy review medication orders, but it is important to review the time frame in which the pharmacy completes the medication review. Some EHRs offer assistance with completing the drug regimen review, such as allergy check and drug-to-drug interactions check at the time of order entry. These additional safeguards can assist with the drug regimen review, but clinicians need to communicate those issues to the physicians and physician’s designee timely. Pharmacy reviews and EHR checks performed at the time of the order do not constitute a full drug regimen review. Educating the nursing staff on the proper medication administration and adverse effects of medications is imperative. Frequent reviews of administration records should be completed to identify issues with omissions and nonadherence. Medication errors such as wrong resident, drug, dose route and time errors should be tracked and fully investigated to determine the root cause.