Long-Term Care Survey Alert

Published on Sun Nov 18, 2007 PDF

Don't miss this important survey guidance about herbals and vitamins.

Does your facility record administration of dietary and nutritional supplements on the medication administration record? Even if it does, surveyors shouldn't count nurses' mistakes in administering the supplements as med errors, according to a recent Centers for Medicare & Medicaid Services survey & certification memo (S&C-07-39) to state survey agency directors. But CMS expects the nursing home staff, along with the prescriber and consulting pharmacist, to be aware of, review for -- and document -- any potential adverse consequences between a resident's medications, nutritional supplements and dietary supplements.

Nutritional supplements are medical foods used to complement a resident's dietary needs. Examples include total parenteral products, enteral products and meal replacement products (e.g., Ensure, Glucerna and Promote), according to the memo. Herbal and alternative products are considered to be dietary supplements, which the Food and Drug Administration does not regulate for safety and effectiveness, states the memo.

If a dietary supplement administered to a resident between meals has a vitamin as one or more of its ingredients, it should be documented and evaluated as a dietary supplement rather than a medication, instructs the memo. It's important to document in the clinical record that a resident is taking these substances, and monitor their potential effects, which can include interactions with medications.

Vitamins and minerals another story: Medication errors involving vitamins and/or minerals should be documented at F332 and counted toward the 5 percent error rate. The errors would only be considered a significant medication error if they met the criteria for F333. A significant med error is defined at F333 as one causing a resident discomfort or jeopardizing his health and safety (see S&C 06-30).

Example of a significant med error related to vitamin administration: Failure to administer physician-prescribed vitamin K for a resident with complications related to warfarin (Coumadin). The RAI user's manual says to code medications administered in the past seven days -- which includes the administration of vitamins.

Most consultant pharmacists do review herbals, dietary supplements and vitamins as part of their medication regimen review if the supplements and vitamins are listed on the resident's chart/record, Carla Saxton McSpadden, a pharmacist with the American Society of Consultant Pharmacists, tells Eli.

A good rule of thumb, McSpadden says, is to "carefully evaluate any medication, herbal, dietary supplement, nutritional supplement, vitamin, etc., added or discontinued when someone is taking warfarin (Coumadin)." The same goes for antibiotics, McSpadden advises. Before a resident starts an antibiotic, "always check for interactions" with any herbals and dietary supplements the person is taking.

A potential stumbling block: Some residents might be secretive about the fact that they are taking the products because they don't consider herbals and vitamins to be medicines -- or they don't want their physicians to know about it, cautions McSpadden. So ask residents/families about the residents' use of such products at admission and periodically.

Editor's note: For more information, read "Master Medication Reconciliation -- Or Reconcile Yourself To Survey Citations," in the April 2006 Long-Term Care Survey Alert, which you can access through the free Online Subscription Service.