Form Cms-20056 - Medicare Adminstration Observation
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3DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Medication Administration Observation
Facility Name:
Facility ID:
Surveyor Name:
Observation Instructions: Make random medication observations of:
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Several staff over different shifts and units,
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Multiple routes of administration (oral, enteral, intravenous, intramuscular, subcutaneous, topical, optical, etc.),and
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A minimum (not maximum) of 25 medication opportunities.
Note: Do NOT preselect residents for observation. Watch and document all of the resident’s medications for each observed medication
administration (this does not mean all of the medications for that resident on different shifts or times).
Coordination Instructions: At team meetings, discuss the number of residents and opportunities observed.
During observation of medication administration, determine whether any of the following situations occur:
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Incorrect medication administered to resident;
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Incorrect medication dose administered to resident;
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Medication administered without a physician’s order;
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Medication not administered as ordered before, after, or with food/antacids;
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The administration of medications without adequate fluid as manufacturer specifies such as bulk laxatives, NSAIDs, and potassium supplements;
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Failure to check pulse and/or blood pressure prior to administering medications when indicated/ordered;
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Crushing tablets or capsules that manufacturer states “do not crush,” such as enteric coated or time released medications;
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Medication administered after date of expiration on label;
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Medication administered to resident via wrong route;
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Prior to medication administration, nasogastric or gastrostomy tube placement not checked (NOTE: If the placement of the tube is not checked,
this is not a medication error; it is a failure to follow accepted professional practice and should be evaluated under Tag F281 requiring the facility
to meet professional standards of quality and Tag F322 requiring appropriate treatment and services for tube feedings);
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Nasogastric or gastrostomy tube not flushed with the required amount of water before and after medication administration based on the resident’s
clinical condition;
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Improper technique used for IV/IM/SQ injection;
Insulin Suspensions − the failure to "mix" the suspension without creating air bubbles;
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The failure to "shake" a drug product that is labeled "shake well," such as Dilantin Elixir;
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IM/SQ injection sites not rotated;
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Transdermal patch sites not rotated;
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Inhaler medication not administered according to physician’s orders and/or manufacturer’s guidelines;
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Multiple eye drops administered without adequate time sequence between drops;
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Did not observe the complete medication administration process, such as leaving the medication at bedside;
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Medication administered in presence of adverse effects, such as signs of bleeding with anticoagulants.
FORM CMS–20056 (5/2013)
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Parent category: Medical