CNA's passing meds

ShannonRN2010, BSN, RN · Oct 11, 2002

I can only say that as a LPN I would NEVER delegate to ancillary members of the team to pass meds...first I wouldn't feel comfortable with it, and second I took a 6 month pharm. course to know what I am passing so I feel like that is my "job" to know what I am passing. I would rather trust MY judgment when it comes to something that deals with someones LIFE and in the end that is what matters...I wouldn't risk anyones life to make mine easier. Case in point at work yesterday the FNP-C wrote a script for Augmentin and the man was allergic to PCN...I went to her and asked if she really wanted to give him that since he is allergic to PCN and she thanked me for catching that...what if I had turned that over to someone else and the man had a reaction? I would have felt like crap!

jdomep · Oct 11, 2002

They don't pass meds here but...

I was in the hospital doing my clinical last weekend and was surprised the CNA's do Foley's :eek: I asked the CNA if I could watch (never seeing one) she said sure... (she was 18 and she said "we had a class on this but I have only done 1 which was said in front of the man she was doing" ) This procedure was far from sterile in my eyes... tips were layed down on table tops, touched with hands she didn't even clean the area before trying to insert it. This poor guy screamed as she put it in

Once we learn to do them I sure hope that her "technique" is wrong ...

Youda · Oct 11, 2002

I've moved a little on my feelings on this since the thread began, based on my own research, mostly from position statements from my BON and articles written about UAPs in some of the various professional journals. I am reading where nurses have been legally shown to have "vicarious liability" when using CMTs, and some real dangers to this practice. There are also some isolated criminal negligence convictions to the nurse. So, I would encourage anyone working in an environment where CMTs are used, to really get informed on the legal and ethical ramifications to delegating any task. Delegating is an appropriate nursing function, but you need to know what you're doing, and what your CMT is doing! In LTC, it is NOT appropriate to leave the monitoring of the CMT up to the LPN, the LPN requiring supervision by the RN, also.

mboyce · Oct 11, 2002

There are many tasks now being done by nurses that keep nurses from taking care of patients. By refusing to let go of them we make the problem worse. There are not enough nurses to do the work that needs to be done now and there are going to be fewer of us in the years to come. We are not talking about a topic as narrow as individual nurse liability for the practice of small subordinate group (you are already responsible for the work of others, please stop thinking that the CMA represents a new issue) we are talking about the survival of the profession.

The discussion around refusal to delegate and refusal to participate and refusal to acknowledge how anyone could allow such a thing to happen is dust in the wind. You will soon find yourself in a position where you are unable to exercise any control because you are refusing to see what has already passed you by . . . a position you are in right now for the failure of others to act in the past.

The issues that are being addressed here as problems: delegation, competency, responsiblity, accountability and others are influencing factors that will determine the form of nursing as it changes. The environmental forces, e.g., patient need, economics, profitability, organizational viability, patient/staff/community well-being, cultural perspectives who should get what kind of health care andothers, can only be ignored or resisted to the peril of the profession. If we don't step up to the plate and solve the problems ourselves others will . . . I would ask you to remember the struggle around the RCT (Registered Care Technician) proposed by the AMA and nearly created about twenty years ago. The RCT would have been a nurse surrogate directly responsible to the MD but supervised by the nurse. It was only narrowly defeated by a general mobilization of resources headed up by the ANA. People who want to create these kinds of alternatives learn from their mistakes.

Why is it that we don't?

NrseK · Oct 11, 2002

In the long term care facility where I work, we apparently have a much higher staffing level than some other facilities. Although, my state does not have a mandatory number or ratio of patient to caregiver listed, we have our own set standard. We have for years used CMA's, with absolutely NO ill effects. Our CMA's do not pass narcotics, give meds via Peg-tube or administer SVN's or inhalers. They are required to ask the nurse for an assesment of any symptoms that they believe needs a med to be given prn, with the nurse being responsilbe for the pre and post assesment and charting, thereof. We have 3 LVN's, on 6-2 and 2-10 and 2 nurse's on 10-6. In addition, we have 2 R.N.s on duty for at least 8 hours a day, 7 days a week, along with 15 CNA's on 6-2, 12 on 2-10 and 6 on 10-6. This does not include the 2 CMA's, the in-house therapy personnel or the administrative staff, on 6-2. We also have 2 CMA's on 2-10. Our Social Worker is here 3 days a week and our Pharmacy consultant comes in bi-monthly to review all of the residents meds,etc., as does our dietician, to check on the residents current diets and possible needs; she does this in response to the weekly weights that are taken by our Restorative aides, who are our CNA supervisors. One R.N. is always on call, and all carry beepers, as do all of our department heads, inclusive of our Administrator, who also carries a cell phone, who's number is posted in house. Perhaps our staffing habits are one reason that the CMA's work so well for us. There are ALWAYS resources for them or any other staff member to go to and asking questions BEFORE doing something is encouraged. The nursing door is always open... Perhaps it is not this way at other facilities. Our CMA's are long term employees that have been promoted from within, are very well versed in our residents behaviors, i.e., what is normal what is not normal. They know the meds that each resident is taking far better than any of us nurses, facility wide, simply because the medication administration is their ONLY job, whereas, our jobs are so varied and widespread, that even without emergencies that occur, doing medications would be a virtual impossibility, at least if any of the other care issues were to be adressed. This does not include hours of charting, calling and dealing with MD's and family members. Our's is a 91 bed facility, by the way, with a waiting list that nerver becomes empty. :) :) :) :saint:

Youda · Oct 11, 2002

NrseK, any openings for a nurse at your place? Sounds wonderful.

LIZZIE57 · Oct 12, 2002

Interesting are all the different opinions generated by the cma "contraversy". I feel for the nursing student who is trying to practice evetry principle as taught....setting a standard that will remain throughout the career. From a legal standpoint, the nurse who encounters a med tech does not have much say in the hiring process and cannot change the staffing ratios on a day to day basis. One can choose not to work in any facility in states that allow med techs; one can stand firm and refuse to work under these certian "conditions". One will find themselves without a job, or having to travel miles to another state. Mabye an answer is to have the ADON, DON be responsible on a day to day basis for the supervision of the CMA????? RI is a small state, but has @ least 211 facilities (that I know of), most of whom utilize med techs. RI is also one of the states that does NOT require ceu's for re-licensure. Any suggestions for the Nurse manager/charge nurse working 40+ hours who is surrounded by these situations???????????

LIZ, R.N.

NrseK · Oct 12, 2002

Youda,

Actually, no, we don't. I can honestly say that we have a very low percentage of turnovers here. With the exception of two of our 16 nurses, who were added when we increased staff, we've all been here for at least 3-4 years, with our longest term nurse having been here for 12 years. Our lead CMA has been here for 21 years... Not as a med-aide the whole time, though. But thank you for asking!!

Youda · Oct 12, 2002

NrseK, this is what I see over and over in nursing. When staffing is appropriate to the acuity, and employees are treated with respect, there is a low turn-over. I'd have no problem with a CMT working in your facility, because they can be supervised and tenure is high. In my state, CMTs are typically thrown to the wolves after passing the class with little or no further training or supervision, simply because the nurses are drowning and really have no time to monitor a med pass. That's dangerous for everyone. In my state, that's why I'm so strongly against CMTs. But, to repeat, I'd have no problems with a CMT if I were working at your place!

Scavenger'sWife, RN · Oct 12, 2002

This topic really interested me and I have had experience in this in my state of Ohio. I will try to be brief.

I was the Health Care Coordinator for an Assisted Living Facility in my city. Title sound good? Haha. What it translated to was this: In an ALF of 32 full occupancy, I was the ONLY nurse. I am an RN and worked here with only walked-in-off-the-street, unlicensed "helpers" who were called "PCA's" (Personal Service Assistants). I was expected to train these new people in: First Aide, Basic CPR, safe lifting techniques, basic ADL, feeds, etc., etc., as well as MED ASSISTING. (I also was to care for the residents, do new admit assessments, help with assessing new applicants for residence as to appropriateness for placement, be the diet tech, and so on....)

The med company where the residents obtained all the meds used a supposed "fool-proof" method: The meds were in little packets printed with the residents' name, the date the med was to be given, the time of day to be given, and the names w doses of the meds included in the packet. BUT MISTAKES WERE STILL MADE. Even tho we used a MAR, which I taught the PSA to use, and a Drug Book, MISTAKES still happened. Ex: even thos she knew better, and was a PSA who "Loved" all the res and who truly DOES have "a heart of gold" (see a previous post by another member who defends this practice), she tried to save herself steps...she took two packets in her pocket to give meds to two different residents. - You guessed it...she gave the wrong packet to the res.

I got so upset at the lack of competency, the lack of caring that this facility had .... We were admitting res who should NEVER live in an ALF but were admitted over my objections...well, the family had the money to pay the cost, and admin wanted the beds filled, and my Director did not get her bonus unless she filled beds, etc...

I began researching the legalities of med "assisting" in the state of Ohio. I came to the conclusion that what my PSA's were doing was indeed MED ADMINISTRATION d/t the LOC of many of the pts., and there IS a difference. "Assisting"? Means (basically) the pt has the ability to recognize and understand what meds he/she is taking. No way this was being done.

Also, the level of people who were hired to do the job ... despite my INTENSE training, retraining, checking daily, looking at the MAR for errors, etc., I never got a good feeling about what I was seeing done here.

I called the State BON, State Board of Pharm, etc....and got contrasting answers. NO HELP FOR ME THERE!!! I just wanted to know MY legal stance if there was a med error that resulted in an severe uoutcome or, God help us all, a death.

I decided, no matter WHAT the BON said, or my administrator, or the Association who owned and operated the organization I worked for (Owns over 180 ALF in 36 states)...*I* would end up responsible for the errors. I will never work like this again.

NON-LICENSED persons should NEVER be allowed to handel, assist, or "pass" meds. This is, and should be, a NURSING SKILL. The physical assessment reasons already discussed in this thread are ones I also encountered and totally agree with. NURSES need to be the ones passing meds.

ALF are in a gray area in Ohio as far as laws are concerned. The regulations are way too irregular and allow too many differences in the way the facilities are run. As I said, I was the ONLY nurse in the ALF, and I was on-call 24/7. I was expected to work only 1/2 hour per resident per week and yet get ALL this work done, plus the massive paperwork. Other ALF 's in my city operate entirely differently and have LPNs pass all meds.

How I lasted a year at the place I was, I'll never know.

Anyway, thank you for reading this post. I MUCH prefer working at the hospital where I currently am being driven crazy........:chuckle

Agnus · Oct 12, 2002

ADONDONNA, it is true there is more than one side to a coin. And Yonda has a very valid point with which I agree. As well trained as your people may be, they do not necessairly know what they do not know. It takes nursing judgement in many instances to give or hold a med. As extensive as the training may be it is not as extensive as an nurse's education. It is her entire education that she draws on in making judgements and decisions and realizing when she needs to consult a collegue. You are fortunate and I hope your situation remains so.

A CMA hear mentioned that, CMA's "pick up thinks" from nurses. You do not know what it is you do not know.

Pebbles, you have a good point. Supervision is the key. However, a nurse cannot be in all places at all times. Most likely the nurse discovered the blood in the foley after the aide gave the cumadin. By the way cumadin, and potasium are classified high risk drugs for a reason.

Both of you make the point that this frees up the nurse to do nursing. I am sorry this is just a poor excuse for not properly staffing, period. Medication administration is nursing. Granted it is not the only thing nursing is but it does require the judgement of a nurse. Unless the nurse follows the aide around continually and makes these judgements you are at risk. If you are following her in this way how does that free you?

What professional duties take presidence over medications in your facility. What things are there that require more expert nursing judgement and skill than this? If you can train some one to do a task like pass meds in a short period and pay them less why not do this with all nursing tasks. Lets face it if we reduce our profession to a series of tasks like this we should not need nurses at all. (No I am not scared we will be phased out) My point is nursing, thought it may appear this way to the uneducated, is not just a bunch of tasks.

Nursing tasks require expert judgement and understanding to carry them out, in a safe and effective manor. PRN meds are not the only ones requiring judgement. I evaluate every med I give in relation to the patien's condition every time I give it. And I do hold routine meds when appropriate. I do resehedule meds when appropriate. And I use my judgement when an order is given as a range. Most likely Aides are given a specific dose but they are not qualified to judge if it is appropriate does every time in every instance. They do not recognize all symptoms. Bottom line you are stepping over dollars to pick up penneys and the patient is the unwitting pray.

Liz, what a shame the aide knows the patient's meds better than the RN. What is it that keeps you too bussy to be on top of this most important aspect of patient care? I also repeat the education to make good clinical judgement about medications requires more than just being able to recite what is in a drug book. I am not impressed by your staffing.

I am sure those of you who educate these folks are proud of your own standards. I am sure those of you in administration are doing the best you know how to balance the bottom line, and your staffing issues. This does not justify this practice.

I also find it interesting that this practice is most prevelant in LTC facilities that house throw away populations such as the elderly, those who have chonic physical or mental disabilities, psychiatric patients, and VA facilities which services a huge indigent/homeless population. (perhaps you are not aware few VA patients are in a financial position to utilize only, medical services that are exclusively outside the VA system) Hmmmm :stone

I am not suggesting that LTC, VA, PSYC etc suggest that those who work there are necessairly bad care givers or that a particular facility is necessairly bad. I am suggesting that society does indeed see the above mentioned populations as throw away.

NrseK · Oct 12, 2002

Just so that the issue dosen't get confused... Let's be clear about who listed the staffing at their facility... It was I..NrseK... Not Liz. Fortunantely, I wasn't asking anyone to be impressed by our staffing:rolleyes: I was simply supplying information as to why I felt the CMA's had worked so well for us in years past, up through present. However, Liz was correct in her summation of hiring practices. There isn't a lot of us can do because it is a job description, not a "delegation", per say. I can only speak for my facility, and our population is most definintely, NOT a "throw- away" population. I apologize if that is the impression that anyone has gotten from an experience with a LTC. :eek: I hope that everyone's weekend is wonderful!!:roll