Giving meds in a group home setting

[SoftballNurse49]

Hi all, had a question that I feel I know the answer to but need some reassurance. I'm a LVN in the state of California. I recently started working in a group home for adolescents between the ages of 11 and 17. Most are actually between 15 and 17 yrs of age. All girls. I noticed a few things with the way they handle meds. 1st: they have a rule that if you pack a med you cannot dispense it to a resident. So basically when I am giving meds to the residents, they cannot have been packed by me. Makes me feel very uneasy because I always want to give a med packed only by me because I know what I'm packing and I don't know what someone else is packing. That's the first red flag. 2: there's a standing prn order for acetaminophen 335 mg tabs 1-2 every 4 hours as needed. Well the supply we have is 500 mg tablets and the residents always ask for 2 (which is 1000mg). I've noticed in the log book that employees are giving 2. For me, I give 1 because 2 exceeds the dosage prescribed by the doctor. 3: the residents have a standing order for diphenhyrdamine 50mg tabs as needed for allergies. ALL the girls take 2 tablets before bed for sleep every night. Also it is being logged in the med book that they're giving it for.sleep. My boss (not a nurse) says we cannot deny them the medication since it's a standing prn order, we have to give it if they ask. Is this true? I think they're abusing it. As a nurse can I get into trouble for logging that i gave benadryl for sleep even though it's usage is for allergies and that's what it says on the standing order? I could use some advice from my more experienced nurses. Im the only licensed nurse in the facility so i feel like i have much more to lose then they do. Thanks

[elkpark]

Welcome to allnurses!

This is what happens when you have non-nurses managing non-nurses in clinical settings that involve things like giving medications. You are right, of course. I would encourage you to discuss your concerns again with your boss, and perhaps bring the physician into the discussion. I would also get my own copy of the state licensing agency and state mental health agency rules and regs that apply to your type of facility (they are often available online for free, or you can get a set for some nominal fee from the state agency). You might want to encourage your boss to set up a meeting with staff (surveyors) from the state agenc(ies) that regulate your type of facility.

If the diphenhydramine is ordered for "allergies," the girls should only be taking it for allergies, not for sleep, and, if the girls are having trouble sleeping, that should be addressed with the physician and as a legitimate treatment issue (is this a matter of poor "sleep hygiene"? What other (nonpharmacological) kinds of interventions or changes might be helpful?), and not covered up with the use of diphenhydramine outside the ordered indication. If the girls are taking 1000 mg of Tylenol instead of 650 and it's ordered q 4h, taking it q 4h for a full day because someone isn't feeling well can easily put them up into the "danger zone" of potential liver damage. Do the Tylenol orders specify anything about a maximum dosage per day, as they would in a hospital setting? Why do they only stock 500 mg tablets when all the orders are for dosages of 650 mg?

You may want to contact your BON and ask them about your concerns and what guidance they can offer. A lot of BONs will discuss clinical questions and concerns that individual nurses have on an anonymous basis.

Is this an individual group home, or is it part of a larger system? Is there some kind of nursing leadership higher up in the system? Who created the rules about packing meds and this idea that you can't refuse to give the girls a medication if they ask for it, even if it's not indicated? This is another example of why it's always risky for nurses to be working in situations in which they report to non-nurses.

You're right that you have more to lose than the other staff. If something goes pear-shaped regarding the medications, you will be the person who will be held responsible for that, not unlicensed non-nurse staff. I would be working hard to get these issues resolved, and, if that didn't appear to be happening, I'd be looking for another job. What you're describing is not a situation in which I'd be comfortable continuing to work. I hope you'll be able to get this sorted out! Best wishes!

[Lev, MSN, RN, NP]

Great answer elkpark!

[canoehead, BSN, RN]

Giving meds someone else has poured would be a deal breaker for me.