1. Supervising Consumer Self Administration of Medication (SAM) Information, Rules, and Laws Prepared by Scooter Brown, RN, Director of Nursing Annual Refresher Training For MR Staff, Foster Care Providers, and Villa Del Sol Staff

2. Class Objectives Understand: Role of Unlicensed (non-nursing) Staff Classifications of Medications Purpose/Intended Effects of Medications Common Side Effects of Medications Medication Rules & Laws

3. Medication Rules and Laws

4. Who Makes the Rules? Federal Drug Enforcement Agency (DEA) Texas Legislature per Texas Administrative Code Texas Board of Pharmacy Texas Medical Board Texas Board of Nurse Examiners Texas Department of Public Safety (DPS) Other

5. Why are the rules for prescription medications so strict? “dangerous drug” “controlled substances” Many medications require a prescription because they are too dangerous without a doctor’s supervision. Most prescriptions fall into this “dangerous drug” category. Other prescription medications have potential to become habit forming, easily abused, be sedating, or may interfere with breathing. These are called “controlled substances” and are monitored even more strictly.

6. History of the Psychiatric Patient and Person With Mental Retardation Years ago persons with Mental Retardation or Mental Illness had very limited treatment options. Their care required 24 hour nursing staff. Years ago persons with Mental Retardation or Mental Illness had very limited treatment options. Their care required 24 hour nursing staff. Medications and treatments have developed that allow persons with Mental Retardation or Mental Illness to function more independently and nursing tasks (such as medication issues and other health care functions) can be delegated to non-nursing staff. Medications and treatments have developed that allow persons with Mental Retardation or Mental Illness to function more independently and nursing tasks (such as medication issues and other health care functions) can be delegated to non-nursing staff. Community Mental Health settings and Group Homes allow consumers to Self Administer their own medications with trained staff supervising and an appropriate level of assistance. These staff may supervise medications, but are not allowed to administer medications. Community Mental Health settings and Group Homes allow consumers to Self Administer their own medications with trained staff supervising and an appropriate level of assistance. These staff may supervise medications, but are not allowed to administer medications.

7. Criteria for Delegation to Unlicensed Assistive Staff Per Texas Board of Nurse Examiners CRITERIA Consumer or guardian is willing to participate in consumer’s care. Consumer has a stable predictable condition (chronic not recuperative). Consumer is in an independent living environment. PROCESS An RN assessment (or) An LVN evaluation with a physician signature of the consumer to determine if delegation of the nursing task is appropriate and the level of assistance required. A medication class must be taught by a Registered Nurse. A Nurse must verify the competency of the unlicensed staff to perform the nursing task. A Nurse should be available for consultation and questions.

8. Staff’s Role Definitions

9. Definitions: Self Administer Medications (SAM) Self Administer Medications (SAM) A consumer taking his own medication out of the container and taking or applying it. A consumer taking his own medication out of the container and taking or applying it. Supervising/Assisting with SAM Supervising/Assisting with SAM Staff gesturing, prompting, instructing consumer, or offering hand-over-hand help and making sure the “five rights” are correct. Staff gesturing, prompting, instructing consumer, or offering hand-over-hand help and making sure the “five rights” are correct. Administer Medication Administer Medication Taking a medication out of a container, placing a medication in the mouth, or applying a medication. (Only nurses may do this.) Taking a medication out of a container, placing a medication in the mouth, or applying a medication. (Only nurses may do this.) Dispense Medication Dispense Medication To place medication in a container or label a medication container. (Staff or nurses may not label or fill bottles.) To place medication in a container or label a medication container. (Staff or nurses may not label or fill bottles.)

10. Who May Do These Tasks? Self Administer Consumer Self Administer Consumer Administer Licensed Nurse Administer Licensed Nurse Supervise Consumers Who Self Administer Trained Staff Supervise Consumers Who Self Administer Trained Staff Dispense Pharmacist or Doctor Dispense Pharmacist or Doctor

11. What is Staff’s Role With Medications? Help the Consumer Be Independent Help Keep the Consumer Safe Follow Federal and State Laws

12. Teaching Consumers About Their Medications We offer our consumers the opportunity to learn about their medication, but consumers are not required to know or recite medication information.

13. Expected Action of the Medication Sometimes different for MR population than general population. Example: Antidepressants may be prescribed for obsessive compulsive disorder, Antipsychotics may be prescribed for racing thoughts or impulsivity, There may be an opposite reaction (paradoxical response) to some medications

14. Possible Side Effects to the Medication May be temporary Help the consumer track the frequency and severity so the doctor or nurse will know if the medication should be continued or is mild enough to tolerate. The consumer may not necessarily have to discontinue the medication.

15. What are the rules for consumer’s medications? There must be a doctor’s order or prescription for the medication. There must be a doctor’s order or prescription for the medication. In a group home or foster care provider home there must be a Medication Administration Record (MAR) that matches doctors’ orders or prescriptions. In a group home or foster care provider home there must be a Medication Administration Record (MAR) that matches doctors’ orders or prescriptions. The medication container must be labeled by a pharmacist or doctor/practitioner. The medication container must be labeled by a pharmacist or doctor/practitioner. Only a doctor, pharmacist, or consumer may place the medications in the prescription bottle. A nurse may fill a consumer’s “pill minder”, “pill planner”, or similar container specifically designed for medication storage (or an RN may specifically delegate this function in accordance with the Nurse Practice Act guidelines.) Only a doctor, pharmacist, or consumer may place the medications in the prescription bottle. A nurse may fill a consumer’s “pill minder”, “pill planner”, or similar container specifically designed for medication storage (or an RN may specifically delegate this function in accordance with the Nurse Practice Act guidelines.) Only the person on the prescription may use the medication. Only the person on the prescription may use the medication. Only a nurse or doctor may call in new medications or changes in medication doses or instructions to a pharmacy. Only a nurse or doctor may call in new medications or changes in medication doses or instructions to a pharmacy. In our MR setting the consumer must self administer his own medication with supervision of staff. In our MR setting the consumer must self administer his own medication with supervision of staff. Only a licensed nurse can administer medication. Only a licensed nurse can administer medication. If there is a medication error the nurse or doctor must be notified for instructions. If there is a medication error the nurse or doctor must be notified for instructions.

16. The Medication Label Every medication label should have the following information: Consumer Name Medication Name Medication Dose Time to Take It Way (route) to Take It This should be verified with the MAR.

17. Items to Check When Supervising SAM The “Five Rights” of Medication Right Person ( Correct Consumer Name on the Med Bottle) Right Medication (Correct Name of Medication on the Med Bottle) Right Dose (Correct Amount or Size of Pill) Right Time (Correct Time of Day) Right Route (Correct Way)

18. Supervising Consumer’s Self Administration of Medication 1. Notify consumer it is time for medication. 2. Have consumer clean area and wash hands. 3. Have consumer gather equipment and meds (glass of water, pill cup). 4. First check: verify “five rights” and pill count before consumer removes pill from container. 5. Second check: as consumer places pill in pill cup verify “five rights” again. 6. Third check: as consumer places medication back in med container verify “five rights” again. 7. Documentation: staff initial, number of pills remaining.

19. Medication Administration Record It is a Legal Document 1. Use correct documentation procedures. 2. Use black ink only. 3. No White Out. 4. Sign at the time you supervise the medication being taken.

20. PRN Medications 1. “PRN” means “as needed” and there has to be a doctor’s order (Standing Orders) and the same SAM procedure must be followed as for prescription medications, except that it is not necessary for the staff to enter a pill count for prn medications. 2. Staff documents consumer’s symptoms or reason for prn medication and time prn is taken. 3. Staff monitors consumer for desired effect and documents results. 4. If symptoms persist call the nurse.

21. Medication Storage Medications must be stored separately from other items. Topicals (creams or ointments) and drops must be kept separate from oral meds. Medications must be in a locked cabinet. Controlled substances must be in a locked box inside a locked cabinet. A pill count must be maintained for prescription medications. Medications must remain in their original containers.

22. Transporting Medications Never leave medications in a vehicle -theft risk -heat or cold can damage or alter medications

23. Medication Errors Can Be Dangerous! Medication Errors Are Strictly Monitored By Local, State, and Federal Oversight TYPES OF MEDICATION ERRORS Documentation Errors Administration and Dosage Errors Omission Errors Missing Pills or Incorrect Pill Counts MOST MEDICATION ERRORS OCCUR WHEN STAFF IS IN A HURRY OR DISTRACTED BY OTHER TASKS

24. Poison Control 1-800-222-1222

25. Do not throw away medication! Several agencies regulate how expired and contaminated medication must be disposed of. These medications must be given to the nurse who will follow the appropriate disposal process. NEVER throw away a pill, a liquid, or a container of medication.

26. Questions? Questions about the content of this refresher training, medications, or the SAM process should be directed to Scooter Brown, RN, Director of Nursing 830-792-3300 ext 2068 (or) sbrown@hillcountry.org Test After completing the test, please send it to: Suzanne Lindell Director, Staff Development By e-mail: slindell@hillcountry.org slindell@hillcountry.org (Fax) 830-896-4448