N2003: Medication Follow-up

N2003: Medication Follow-up

Item Rationale

Health-related Quality of Life

Integral to the process of safe medication administration practice is timely communication with a physician when a potential or actual clinically significant medication issue has been identified.

Physician-prescribed/recommended actions in response to identified potential or actual clinically significant medication issues must be completed by the clinician in a time frame that maximizes the reduction in risk for medication errors and resident harm. Planning for Care

When a potential or actual clinically significant medication issue is identified, prompt communication with the physician and implementation of prescribed actions is necessary to protect the health and safety of the resident.

Steps for Assessment

Review the resident’s medical record to determine whether the following criteria were met for any potential or actual clinically significant medication issues that were identified upon admission:

Two-way communication between the clinician(s) and the physician was completed by midnight of the next calendar day, AND

All physician-prescribed/-recommended actions were completed by midnight of the next calendar day.

Medical record sources include medical records received from facilities where the resident received health care, the resident’s most recent history and physical, transfer documents, discharge summaries, medication lists/records, clinical progress notes, and other resources as available.

Discussions (including with the acute care hospital, other staff and clinicians responsible for completing the drug regimen review, the resident, and the resident’s family/significant other) may supplement and/or clarify the information gleaned from the resident’s medical records.

Coding Instructions

Code 0, No: if the facility did not contact the physician and complete prescribed/recommended actions in response to each identified potential or actual clinically significant medication issue by midnight of the next calendar day.

Code 1, Yes: if the facility contacted the physician AND completed the prescribed/recommended actions by midnight of the next calendar day after each potential or actual clinically significant medication issue was identified.

Coding Tips

If the physician prescribes/recommends an action that will take longer than midnight of the next calendar day to complete, then code 1, Yes, should still be entered, if by midnight of the next calendar day the

facility has taken the appropriate steps to comply with the prescribed/recommended action.

Example of a physician-recommended action that would take longer than midnight of the next calendar day to complete:

The physician writes an order instructing the clinician to monitor the medication issue over the next three days and call if the problem persists.

Examples of by midnight of the next calendar day:

A clinically significant medication issue is identified at 10:00 AM on 9/12/2017. The physician-prescribed/-recommended action is completed on or before 11:59 PM on 9/13/2017.

A clinically significant medication issue is identified at 11:00 PM on 9/12/2017. The physician-prescribed/-recommended action is completed on or before 11:59 PM on 9/13/2017.

A dash (–) value is a valid response for this item; however, CMS expects dash use to be a rare occurrence.

Examples

Resident P was admitted to the nursing facility with active diagnoses of pneumonia and atrial fibrillation. The acute care facility medication record indicated that Resident P was on a seven-day course of antibiotics and had three remaining days of this treatment plan. The nurse reviewing the discharge records from the acute care facility and the nursing facility admission medication orders noted that Resident P had an order for an anticoagulant medication that required INR monitoring, as well as the antibiotic. On the date of admission, the nurse contacted the physician responsible for Resident P and communicated a concern about a potential increase in Resident P’s INR with this combination of medications that could place them at greater risk for bleeding. The physician provided orders for laboratory testing so that Resident P’s INR levels would be monitored over the next three days, starting that day. However, the nurse did not request the first INR laboratory test until after midnight of the next calendar day.

Coding: N2003 would be coded 0, No.

Rationale: A potential clinically significant medication issue was identified during the drug regimen review; the staff did contact the physician before midnight of the next calendar day, but did not complete, to the extent possible, the physician-prescribed actions related to the INR laboratory test until after midnight of the next calendar day.

Resident S was admitted to the facility from an acute care hospital. During the admitting nurse’s review of Resident S’s hospital discharge records, it was noted that Resident S had been prescribed metformin. However, laboratory tests at admission indicated that Resident S had a serum creatinine of 2.4, consistent with renal insufficiency. The admitting nurse contacted the physician to ask whether this medication would be contraindicated with Resident S’s current serum creatinine level. Three hours after Resident S’s admission to the facility, the physician provided orders to discontinue the metformin and start Resident S on a short-acting sulfonylurea for ongoing diabetes management. These medication changes were implemented within the hour.

Coding: N2003 would be coded 1, Yes.

Rationale: A potential clinically significant medication issue was identified during the drug regimen review; the physician communication occurred, and the nurse completed the physician-prescribed actions, by midnight of the next calendar day.