Failure to report incidents like a medication error resulting in a resident’s death may jeopardize a facility’s eligibility for Medicare reimbursement
Compliance Perspective – Medicare Reimbursement
Policies/Procedures: The Compliance and Ethics Officer with the Administrator and the Director of Nursing will review the policies and procedures outlining requirements for reporting incidents to the proper authorities.
Training: The Compliance and Ethics Officer with the Director of Nursing will ensure that staff are trained to respond and report incidents such as medication errors in a timely manner to their supervisor and to be aware that such incidents must also be reported to the proper authorities.
Audit: The Compliance and Ethics Officer with the Director of Nursing should personally and periodically conduct an audit to ensure that incidents are being reported and protocols like the five rights of medical administration are being followed—the right patient, the right drug, the right dose, the right route, and the right time.
In December 2017 a patient was admitted to the hospital due to headaches, swelling of the brain, and other related symptoms. His physician prescribed the drug Versed that is used to treat anxiety. Instead of giving the patient 2 milligrams of Versed as prescribed, the nurse administered 10 milligrams of Vecuronium, a medication used for muscle relaxation during surgery. The patient died as a result of cardiac arrest from the error, but the incident was not reported to the Tennessee Department of Health (TDH) as required.
When an onsite survey revealed the death of the patient due to the nurse’s medication error and the fact that it had not been reported to the TDH, the Centers for Medicare & Medicaid Services (CMS) issued a termination letter indicating it would end the hospital’s Medicare reimbursement on December 9, 2018, if the hospital did not respond appropriately to correct the deficiencies. The CMS letter indicated that the hospital was not in compliance with two conditions for participation—42 CFR §482.13 Patient Rights and 42 CFR §482.23 Nursing Services.
The hospital reported that at the time the incident occurred, they reviewed it and determined that the error occurred because the nurse had bypassed the hospital’s multiple safety mechanisms that were intended to prevent such errors. Although they did not notify the TDH as the law requires, they did make the family of the deceased patient aware of what had happened. The hospital contends that immediate corrective steps were taken, including what they termed “appropriate personnel actions.”
The hospital recently submitted a plan of correction to CMS that has been accepted, and Medicare reimbursement will not be interrupted. However, the hospital is undergoing a continuing review to “protect the health, safety and welfare of the patients it serves.”
