Made a huge mistake now worried for career.

tovah · Jan 4, 2011

hello, i am going to put my 2 cents because this regulation is silly. But it is a reg, however you will probably just be inserviced on the proper edk procedures. You had a dr's order, and a hard script. Here is the reg, ltc nurses and dr.s can no longer call in a narcotic, you must have a hard script and it must be faxed to pharm. then pharm "reviews it" to ensure that it is from an authorized prescriber. Then the call and give you a number, then you get to pull it when you do this number must be beside the patients name. Ok this is to prevent deversion. Alright, here is my rant this is only done if you are going to open the emergency drug kit, well nurses in ltc have an entire cart with at least 24 patients medicine in it including narcs. Ok if you are a nurse who is going to take that kind of risk--wouldn't you just take it from the narc drawer, you know the one you are in control of. They did not put regs on appropriate response times for pharmacies. So at times you end up waiting way to long for permission to pull a prescribed med, this effects patient care and is unacceptable, and in long term care can amount to a citation for patient harm. LTC is a wonderful place to work, and now days it is more like a med surg floor. We get people right after surgeries of every kind, (usually within a day or two), numerous infections, pressure areas, wound vac, piccs, peg tubes, external fixation devices, and this is all on one floor with one nurse and two stna's so ltc is a wonderful learning experience which will definately hone your time mgt skills, clinical skills, and will give the chance to also use your skills in dealing with alzheimers, and other forms of dementia (the lt patients), and the emotional connections you make are priceless. I have worked both ltc, and hosp. both have given me wonderful learning opportunities but ltc has my heart.

Ok, now my rant on the reg itself--it is not an effective tool against the small percetage of nurses who are willing to divert others peoples medicines. I think that peer groups, educational programs, stress management programs, interventional programs are of more use. Nurses in every setting need to be observant, and when a fellow nurse needs help be willing to stand up to and for that nurse. Also employers also need to be more willing to help nurses who need it instead of passing them on to the next job. Anyway I feel this is an ineffective tool in the fight againsts impaired nurses having said that, a reg is a reg.

Forever Sunshine, ASN, RN · Jan 4, 2011

I would be so ****** if I were in your shoes. My patients who get pain pills such as percocet, dilaudid etc.. need their pain pills and they need it now. or if its for a patient who is so anxious they are smacking everyone in site, and the MD ordered stat xanax or ativan from the ebox. I'm not waiting for the pharmacist to pull an activation code out of his ass. I'm writing the order(depending on the MD) on the computer and I'm having the supervisor get it from the ebox. And I'm administering the med to the patient. All documentation can be done afterwards, which requires a supervisor to get the drug from the ebox and two LPN's to cosign the order. The patient needs the med. That needs to be our focus here. Not activation codes, not pharmacy, .. the patient. I don't know why more LTC facilities and their pharmacy don't have that in mind.

Yes there's diversion. But honestly. When I have a patient who's going haywire or is in extreme pain. Worries about diversion should be the least of our worries.

CapeCodMermaid, RN · Jan 4, 2011

It's a federal law that there must be a hard copy of the script or the DOC has to call the pharmacy to okay it. It's not your facility it's the law that only recently has started to be enforced. To date, as far as I know, no one has gotten arrested or suspended or anything else for not following the law to the letter.

I wouldn't worry about it. Nurses have done far worse things and still have a license. You did what you thought was best for your resident.

Nascar nurse, ASN, RN · Jan 4, 2011

LTC regulations are different then Acute care and are different in every state. It still sounds like a policy issue and not DEA/federal mandate.

WRONG...this is a DEA regulation and is the same for all 50 states. It is not a facility policy but a government regulation that has just recently been highly enforced.

For many years it was considered that the nurse was an "agent" (ie: an actual employee of the physician..not the facility)of the physician and therefore could obtain a narcotic medication out of the Ekit with just a physician's verbal order.

The DEA has now stated that the nurse is not an "agent" of the MD and therefore an actual hardcopy of the prescription must be obtained in the pharmacy (or the physician themselves must give the pharmacy a verbal order) prior to release of any narcotic from the EKit. This issue is being highly debated in congress as it has caused much hardship on LTC facilities and has made many residents suffer needless pain while waiting on the communication between pharmacy and physician.

Trust me, if this isn't how your pharmacy in LTC is handling this....they are out of compliance. There have been DEA raids on some pharmacies and some have been fined thousands of dollars for failure to follow the DEA regs. It's actually the pharmacy and pharmacist that can get in the most trouble for failure to follow the law. It's the poor nurses and ultimately the residents that are caught up in the misery.

DEA States that LTC Nurses Are No Longer Agents Of The Prescribers - Nursing for Nurses

NotFlo · Jan 5, 2011

It's a federal law that there must be a hard copy of the script or the DOC has to call the pharmacy to okay it. It's not your facility it's the law that only recently has started to be enforced. To date, as far as I know, no one has gotten arrested or suspended or anything else for not following the law to the letter.
I wouldn't worry about it. Nurses have done far worse things and still have a license. You did what you thought was best for your resident.

But she said the hard copy of the narcotic script was already on file at the pharmacy, the med had been sent stat, and she just needed to get a dose to get through the four hour wait until the pharmacy delivered the med. Why, in that situation, would you need a separate authorization code to get the dose from the ebox? I mean, obviously it's policy in her facility, thankfully in my facility once the order is written and the script is sent we can obtain a dose from the ebox if needed before the patient's supply arrives.

tovah · Jan 5, 2011

hello i found this website and it may clear up some of the language and if you would like to just know the law for yourself. i hope i am allowed to post this, it is very helpful and goes thru the law, the reason for the law, etc.

this is the article to look up.

stop the dea from criminalizing routine geriatric care in nursing homes

[color=#5174af]519 signatures

published by [color=#5174af]jabbar fazeli, md on nov 21, 2009

Forever Sunshine, ASN, RN · Jan 5, 2011

The ebox is there for a reason. Not to sit locked up in the med room looking pretty when you are out of a med or a resident needs a med now and pharmacy won't be there for a couple more hours.

allnurses Guide · Jan 5, 2011

An active, valid order when the pharmacy has the hard copy and the only problem is that you are out of that med, I don't understand why you would need the pharmacy to authorize it, which unless there is a 24/7 pharmacy would result in a needless delay in the patient getting their pain med. If the pharmacy must "authorize" why have an ekit at all? :confused:

Nascar nurse, ASN, RN · Jan 5, 2011

The ebox is there for a reason. Not to sit locked up in the med room looking pretty when you are out of a med or a resident needs a med now and pharmacy won't be there for a couple more hours.

But it's also not a candy machine that dispenses whenever the user chooses. The law stinks..BIG TIME...but unfortunately it is a law.

Nascar nurse, ASN, RN · Jan 5, 2011

hello i found this website and it may clear up some of the language and if you would like to just know the law for yourself. i hope i am allowed to post this, it is very helpful and goes thru the law, the reason for the law, etc.
this is the article to look up.
This is a complicated issue but below are a few of the ways this DEA action is impacting nursing home providers' practices and the care of nursing home patients:
1. If a new order for a narcotic drug is written in the nursing home chart, the provider has to write a hard script to go with that order.
2. If the medical provider writes an order to change a pre-existing order for narcotics, the provider has to repeat the same process and write a new script for the new change in dose or interval. This creates a disincentive to making appropriate order changes in patients with uncontrolled pain.
3. If the provider is not in the nursing home facility and gives a verbal order for a narcotic, he or she would have to fax a script to the nursing home before the pharmacy can dispense what he or she ordered. If a faxed script is not possible then a separate call is required to the pharmacist to authorize an emergency dispense. Hard scripts would then have to be written for the emergency authorization as well as the original order and be faxed to the pharmacy within 7 days. Of note, some pharmacies, like Waltz pharmacy in Maine, would not even take an emergency authorization unless the patient in the nursing home is having an "actual emergency" aside from the fact that they have a doctor's order that shouldn't wait till the next business day to be carried out. Ironically, CMS (Centers for Medicare and Medicaid) would consider such delay in care a violation in any federal or state survey of a nursing home. CMS expect nursing homes to carry out doctors orders without delay.
4. If the nursing home pharmacy can not deliver the ordered medicine in a timely fashion the staff at the nursing home are accustomed to using the "Emergency box" (E-box) in their facility to dispense the ordered medicine, while waiting for the pharmacy to deliver. The DEA's position now is that the nursing staff can not use the E-box without a separate prescription (in addition to the original order and script), otherwise they are considered in violation of DEA regulations. Emergency script for each "Emergency box" use in this impatient setting is what the DEA is now mandating. With this DEA interpretation, some nursing home patients may be deprived of an important stop gap measure traditionally used by nursing staff to ensure the timely dispensing of medications legitimately ordered by licensed providers.
5. In addition to writing the orders for narcotics and providing hard scripts, nursing home providers are now expected to ask for a specific number of pills even though their patients are in an inpatient setting. This means that most providers would write for larger number of pills to avoid having to repeat this process over an over again. Larger scripts means more drug wasting in the nursing homes.
6. If the strict interpretation of the DEA regulations are applied then the above issues with schedule II narcotics would also be applicable to other scheduled drugs (III-V). In fact some nursing home pharmacies are already taking this strict stance as standard of practice.
7. Last but not least, assisted living facilities are in a worse shape than nursing homes as a result of the new DEA enforcement practices. Despite having a contracted pharmacy, like nursing homes, and having more or less the same checks and balances as nursing homes, these assisted livings facilities are now required to mail hard scripts (not fax) to the pharmacy for all narcotic orders. Some assisted living facilities are reverting back to using regular outpatient office practices for their patients rather than utilizing onsite geriatric medical services because it makes it logistically easier to meet the DEA requirements.
8. At no point does the DEA allow nursing home nurses to act as the agents of the providers in prescription matters. This is contrary to the realities of geriatric work in nursing homes where the medical team is made up of providers and nurses. Nursing home nurses have traditionally been the eyes and ears and the right hand of the providers in every nursing home in the nation.
Great article. Thought I should just make it easy for some of the folks not used to LTC.

Bella'sMyBaby · Jan 5, 2011

Here is a quote from a Dept. of Health & Human Services communication:
The rules have changed in LTC. In other words, even though the nursing home doctor has ordered the narcotic, the pharmacy still needs a prescription or call-in from the doc. After the pharmacy has received the script or phoned-in order from the doctor, the nurse can go ahead and pull from the E-Kit. A written order is no longer acceptable in LTC for narcs. The pharmacy needs a script.
http://www.dhss.mo.gov/BNDD/oct2010.pdf

This Law is a disgrace to all LTC Nurses.

Just what a patient in pain needs.....a delay in receiving narcotics..... :cool:

TheCommuter, BSN, RN · Jan 5, 2011

This Law is a disgrace to all LTC Nurses.
Just what a patient in pain needs.....a delay in receiving narcotics.....

I agree.

The law has good intentions, but is misguided. It is supposed to deter nurses from diverting controlled substances. However, the nurse who wants to divert badly enough is going to find a way to do it, even if it is against the law.