How would you tell your boss this?

[RNOTODAY]

Here is the situation. I work in a residential facility for kids with psych/behavioral disorders. They currently give all kinds of OTC's with no standing order, just a consent upon admission from parent/guardian. I brought this up with the director twice--- both times she assured me we were covered just with the consent. I know better.....

And another thing that bothers me.... the med "system".

The kids are on lots of psych meds, with lots of changes, naturally. They come on bubble pak cards, from an outside pharmacy. When a kid is d/c, or a med is changed, they keep that med, and we use it to start another kid on it if we get an order or a new admission. They just cross the name out and write the new kids name. There is a closet FULL of meds. So when something new is started, we go to the cabinet, get it out and put that card in the kids binder. Now I know this isnt kosher, but I need something to go to her with, since she is obviously clueless that this cant happen.

How would you approach this with her without sounding confrontational?

Where can I get proof of this to show her?

[EMSnut45, BSN, RN, EMT-P]

Also... I was told that it is illegal to write on the rx label unless you are a doctor or pharmacist. This includes who the med is prescribed to. Hey, maybe I like seroquel... could I just cross out your name and write in mine? Is it really dispensed to me now?

If you want a resource, try contacting your state nursing board. I found them to be really helpful when I had a question about the "correctness" of a situation. They advised me that the situation was not correct, and they launched an investigation. In the mean time, they were able to help me cover my butt so that I didn't become a bulls-eye myself.

[Susan9608]

I thought every agency that cares for patients has to have licensing and credentialing of some kind? It would really scare me if that's not the case. There *has* to be someone the agency reports to, even if it's just the state board of health or even a business bureau. If there is no regulatory agency, then I'm seriously question whether or not I wanted to work there.

Also, I thought that institutions that accept things like Medicare and Medicaid had to be JACHO inspected? I'd seriously, seriously question both this medication practice AND who your institution reports to.

[roxxy3773, RN, APRN]

Not that this is helpful in answering your question, but I used to work in a residential home and give meds and the situation you are dealing with would never happen where I worked. If there was ANYTHING mislabeled on the bubble pack (name, how to take the medication, etc., even a misprint) it had to go back to the pharmacy to be fixed, we were never to make any changes. We would have gotten in so much trouble otherwise. We were never to give someone else's medication to another individual, no matter what the situation. They were also very strict about discontinuing a medication. I just can't imagine how this can be justified by the people in charge.

[txspadequeenRN, BSN, RN]

i think there is a chance to get this place in order, but your boss must listen and agree to have some (actually a total revamp of your policies/procedures) policy's put into place. i don't really know where to go for info ;i just know whats going on there is wrong!!! i also know that whoever is there with a valid nursing license is standing in a line up, cig in mouth ready to be taken down by the firing squad. if something happened to one of these kids whether it was your fault or not ,someone will be into investigate and then your gonna need to start explaining. is your boss a nurse and who is her boss? cause they need to know how this is being handled and your concerns. this is sad cause in the end it will be the kids that suffer...

[vampiregirl, BSN, RN]

At one time I worked as the manager of residential facility for individuals with developmental disabilities- probably a different type of residential facility than yours. The facility I worked for had one nurse for every 4-5 group homes and was available by phone. The staff, who passed the meds, were all certified by the state through a course called "medication administration in the community". We had some pretty heavy duty psych meds that we were responsible for passing. Now as a nursing student, this arrangement really scares me, but at the time I was ok with it. I had a written copy of all state regs for our type of facility, we always were in full compliance with all of the regs, and were regularly inspected by the state (and passed with no deficencies). There were also a lot of other requirements- med reviews/ reductions every so many months, pharmacist inspecting meds monthly, nurse visiting all residents weekly, etc. For the type of facility we were, everything was by the book. However, there are so many different types of facilities, I wonder if your manager is fully aware of the regs that apply to your facility or that some of her practices aren't medically appropriate. Maybe she is unaware that it is not appropriate to relabel meds or give them to someone else. She may be looking at from the perspective that the meds are "just going to be thrown away" ($$$) and not seeing the other (nursing) side of things. I was always so grateful when our nurse let me know when anything was a concern to her or when anything in my group home wasn't fully meeting the regulartory requirements. I just wanted to run a facility that best served the residents.

From your post, you can tell that this is really bothering you and you want to do things the correct way. I hope you have success in resolving this, residential facilities so need caring people.

[vampiregirl, BSN, RN]

A thought on the OTC's- I know one place I worked at years ago had a general consent signed by the guardian that just gave general approval for OTC's. Then each resident's physician was given a printout with a list of OTC's (tylenol, tums, neosporin etc), each with the reasons for use and the dosage/ frequency. The doctor had to sign for all these meds (and make any changes they wanted) then these things were added to the MAR. The pharmancy sent out bubble packs with only a few doses in each so they weren't wasted, the rest of script was entered in refills, so more could be ordered if needed. Even then though, the bubble packs could only be used for the specified resident and for like the neosporin, each resident had to have their own tube. But, that way we were able to administer basic OTCs.

[realkreativ]

All medical facilities in each state are subject to their state's 'state board of nursing.' Best you contact your state's 'state board of nursing (https://www.ncsbn.org/515.htm),' let them know the situation, and step back. Who knows, there may be some legality to what she is doing and your state board will tell you (though prob not legal to do what you described). They will consult with you on how best to handle the situation, for your ethical safety, as well as your boss's.

It's better to have sound medical ethics than to get caught up in something that could affect your entire career as well as future nurses who may work at the facility; pleasant job or not.

[HM2VikingRN, RN]

Check out your state Department of Human Services to find out who handles licensing of the home.

Call child protective services for help in locating the licensors.....

I agree with calling the BON for advice.

[catlynLPN]

Relabeling of meds prescribed for one person to another person is "practicing dispensing". And that's illegal unless done by a licensed pharmacist.

[twinmommy+2, ADN, BSN, MSN]

Check out your state Department of Human Services to find out who handles licensing of the home.

Call child protective services for help in locating the licensors.....

I agree with calling the BON for advice.

Thats exactly what I was going to say, but wouldn't also JACHO have something to do with this?

[jill48, ASN, RN]

You are right to question such procedures. About the OTC meds, I wouldn't give ANYTHING unless a physician ok'd it. No way. About the bubble packs, let me tell you little story. I had a patient on an antipsychotic, non narcotic. For three days in a row her medication was not there. After calling pharmacy repeated times and charting every time I called, I made a huge mistake. I felt at the time I was doing the right thing for my patient. Her roommate was on the same med, same dose, same doc, and had a bubble pack. I was afraid of what would happen to my patient after three days without her antipsychotic. I borrowed one dose from the roommates bubble pack and gave it to my patient. I circled it on the bubble pack and initialed it, writing next to it that "borrowed for Mr. XX, dated, initials". This is something that is done everyday in many facilities and is accepted practice. I should have known better. Someone called the BON. There was an investigation and my license was publically censured. I'm very embarassed about this and I have never admitted it on this site before, so please don't any of you ream me a new one. I know what I did was wrong, so leave me be. I'm just trying to show the OP how dangerous it is to mess with bubble packs. OP, please learn from my mistake. Check these things out with your BON before you perform any of these actions that are widely accepted, but make you question the action. The fact that you are questioning it shows you that deep down inside you know it may be illegal, so check on it. Good luck.

[miko014]

I agree with what several others have said. You know what's going on isn't right. You have to do something about it. I think you should set up a meeting with your boss and maybe even her boss. Check out your BON website for guidelines on standards of practice. Tell them that you will have to go to the BON if you guys can't figure uot a way to get compliant. If you're worried about the facility/nurses "getting in trouble", then there has to be SOMEBODY watching over you guys (though it sounds like they are doing a terrible job!). Definitely start with the BON website, and contact them if you have to. Does your facility have any policies as far as med admin goes? You'll want to have those handy too, so you can correct any flaws that you might find. Are you in a position to suggest improvements? That will probably go over a lot better than if you were to say, "yeah this situation sucks and is dangerous for the residents, the nurses, and the facility. It's only a matter of time before something happens and we get busted or sued. We need to make some big changes, but I have no idea how."

Good Luck!! It takes a lot of guts to make changes like this, but think how much safer your facility will be once all this gets straightened out! Volunteer to work on a committee to bring about the change - just think how that will look on your resume (if you ever decide to leave this job)!