School/residentail care of DD children

txredheadnurse, BSN, RN · Mar 9, 2010

I have a few questions. How do the UAP document the meds they give? How do you do your double locking of controlled substances in the cart you described in your posting and how are the controlled substances accounted for by the UAPs? I mean do they count those meds with another employee and is that count done by two UAPs documented?

Do you go in and randomly count the controlled substances or just verify them when you refill the cart?

I know I seem like I am harping on the controlled substances but this is one area that is particulary vulnerable to misuse. I case manage group homes for DD clients and in those homes are unlicensed staff that assist with self medication. We have had instances of controlled drugs being diverted and were required to call in law enforcement. To help reduce the risk we instituted the staff doing per shift counts which are verified at random intervals by the nurses. It makes it more difficult for controlled substances to be diverted and shows we are holding the UAPs accountable. Also having a standardized documentation/paper trail shows we are monitoring as well as we can in a non medical type facility staffed by non nursing personnel.

wyowyome · Mar 9, 2010

txredheadnursere: school/residentail care of dd children

i have a few questions. how do the uap document the meds they give?

because i have medication boxes for each child, i sign the mar labeled with each drug/dose/times i have filled the boxes each week, and the uaps initial on a "tech mar" that states the meds in the box (that i pre-filled) were given by them at the appropriate time (am, lunch, bed, etc..). the meds in the boxes (and descriptions) are written on the back of the med boxes so staff knows what they are giving and what they are supposed to look like.

how do you do your double locking of controlled substances in the cart you described in your posting and how are the controlled substances accounted for by the uaps? i mean do they count those meds with another employee and is that count done by two uaps documented?

ummmm... until i started there was no control of controlled meds. i think the nurse before me just didn't care. lazy? i now keep the meds in a locked nursing-home type cart. in one cart i keep all the kid's rx bottles in individually labeled baskets (i use these to fill the boxes) and in the other cart i keep all the filled med boxes, etc. for access by the uaps. we installed a camera system aimed directly at the 2 carts so we can investigate why staff might need to access the "stock" cart. i presently "eyeball" the controlled substances when i refill the boxes, but am trying to implement a safer process. i am considering keeping all the controlled stuff separate from the rest, in a locked wall-mounted cabinet. i could then count the supply weekly with the cottage manager?

do you go in and randomly count the controlled substances or just verify them when you refill the cart?

neither, yet. but it is my plan... we do frequent random drug testing of employees, so that helps! the only probs we've had so far were staff not involved with med passing.... i help choose who does pass meds (we only have a few), and to be honest, i don't think most of them know a controlled substance from a tylenol...

i guess it comes down to my instinct about who i let pass meds or not. truth is, with these kids, if the uap wanted to divert the meds, all the locks/counts/cameras in the world couldn't keep them from it. i really think we have honest people just trying to take care of these children the best they can. i am just trying to write policies to make it legal and safer, because as an rn it is my duty.

thank you for your response!

txredheadnurse, BSN, RN · Mar 9, 2010

Sounds as if you are making good strides to getting things done in a logical fashion. However the controlled substances by DEA guidelines have to be under double locks. That is if the med cart is locked then there needs to be an additional lockbox or drawer inside the general med storage area in which the controlled substances are kept. The lock to the room does not count as 1 lock is my understanding; i.e. locked room & locked cart still requires an additional lockbox or drawer inside the cart. In addition any personnel handling those meds should be documenting on a daily basis with another person the actual count of each controlled substance on hand. I realize stuff can and does get diverted but this shows you are making a good faith effort to be accountable on a routine basis and gives you a paper trail in case there is an incident.

I am not familiar with the licensing policies in your state but here in Texas any unlicensed personnel assisting or administering meds must document on a sheet (what you call your tech MAR) but I personally don't think you should be documenting any meds you do not actually administer. Count or inventory control logs are a good idea but if a non nursing person was trying to figure out who gave what med when two different MARs would be very confusing to them. It can be a challenge to try to see nursing processes from the perspective of a non nurse when working in a non medical facility. Sometimes I have to really ponder on things whenever someone else questions them because it is so self-evident to me as a nurse why I do or don't do something.

Per training ideas if your state uses certified medication aides check with the regulatory agency who credentials them for curriculums. Or better yet if the school would hire or pay for CMA training for the staff administering meds that would be great.....if your state has such a thing as a CMA. Otherwise in my state any RN doing medication delegation is usually required to teach on each individual and their individual meds to each staff designated to give meds to that client. The documentation is usually in the form of an in service coupled with at least 3 observed medication passes documented in checklist form which is signed by both the monitoring nurse and the staff. The staff receive an annual refresher and do 1 observed med pass also.

It is also a good idea to have a list of common medical abbreviations, poison control number and an outline of how to give meds stored in the tech MAR notebook as a quick reference. Any med errors need to be documented on an incident form and I would suggest you in service that staff if they make a med error to include omitting meds. This shows you are monitoring, training and aware of what is happening.

wyowyome · Mar 9, 2010

again, thank you for your responses!

that is if the med cart is locked then there needs to be an additional lockbox or drawer inside the general med storage area in which the controlled substances are kept. the lock to the room does not count as 1 lock is my understanding; i.e. locked room & locked cart still requires an additional lockbox or drawer inside the cart. in addition any personnel handling those meds should be documenting on a daily basis with another person the actual count of each controlled substance on hand. super plan! i can start this today. we do lock the room, but i could also put the controlled stuff in the lock box installed inside the bottom of my carts. i keep my md's rx pads in there... never even thought of that! thank you. now- as for documenting counts daily- just don't know how feasible that is? i can't find legal requirements, either? some places (the er i work in- requires bid checks) and others, (nursing homes) count weekly....so it seems to be a personal choice of the facility. does the dea mandate a certain number of counts as far as you know? i could try to meet up with the cottage manager a few times a week so we could count the meds together- then we could see which staff were working if something did turn up missing?

i am not familiar with the licensing policies in your state but here in texas any unlicensed personnel assisting or administering meds must document on a sheet (what you call your tech mar) but i personally don't think you should be documenting any meds you do not actually administer. i only document that i filled the med boxes with the accurate medications for those days/times. the uap only documents that they gave the medications that were in the box on that day/time. so, i am not documenting that i physically administered the med- the uap is initialing that they did (except during the day when i also initial the "tech mar", because i am physically giving the meds). i initial on my mar (uap's don't sign this) that i filled the med boxes per the physician's orders. i do the "right" person/dose/med/time part of med administration, then it is up to the uap to do the "right" person/ time/route. does that sound appropriate? i know there are many agencies that do not believe in medication dispensers, but after taking into account this facilities specific needs, i have decided it does, in fact, make medication passing safer. the blister packs were overwhelming for uaps, who then got nervous and made mistakes or just gave up passing meds all together...

count or inventory control logs are a good idea but if a non nursing person was trying to figure out who gave what med when two different mars would be very confusing to them. uaps don't use the actual mar- just i do. they only initial the tech mar when they give a child the meds from the pocket of the dispenser that i filled using the actual mar. i keep track of both mars so it can be shown that i did, in fact, fill the box correctly and the uap did, in fact, administer the meds from the dispenser.

per training ideas if your state uses certified medication aides check with the regulatory agency who credentials them for curriculums. i cannot find that we do use "certified medication aides"... from what i can tell the bon has been working on it for years, but never has actually created a plan? wy is the "cowboy state" and we tend to be the last place laws are instituted.... when i contacted the bon they said they saw no legal reason i shouldn't be training these uap's in my facility- and that maybe i should contact the board of pharmacy for suggestions on a decent training plan??? see? gray areas!!!or better yet if the school would hire or pay for cma training for the staff administering meds that would be great.....if your state has such a thing as a cma.my "boss" is great and would have no problem paying for any training i thought we could use. i did find a training course established by the developmental disabilities division and the wy department of health called "medication assistance for unlicensed personnel" that was last updated sept. 09. i really like the info. in it, but it is super intensive. i would like to use it and have contacted them about what i need to do to get them here to train our staff or what i need to do to become "certified" to train my own staff, but i am still awaiting response (weeks!) i think i will start planning to train my staff using it anyways- it's not like there are laws about it!!!??? for craps sakes, how do i convince my boss to pay for this stuff it it isn't mandated and is available online??? maybe she could just write me a bonus check instead!!!ugggh.

it is also a good idea to have a list of common medical abbreviations, poison control number and an outline of how to give meds stored in the tech mar notebook as a quick reference. any med errors need to be documented on an incident form and i would suggest you in service that staff if they make a med error to include omitting meds. this shows you are monitoring, training and aware of what is happening. i agree. i have even considered taking pictures of what each child's meds look like for quick reference in the book... but it would be much easier if drug manufacturers could agree on what a drug should always look like! (big pet-peeve). we do chart med errors on our "incident report" that includes what happened, who was contacted, how child was monitored, etc. i even found a developmental disabilities division site for submitting med errors electronically, so i am planning to contact them to be sure i should be doing that.

txredheadnurse, BSN, RN · Mar 10, 2010

again, thank you for your responses!
super plan! i can start this today. we do lock the room, but i could also put the controlled stuff in the lock box installed inside the bottom of my carts. i keep my md's rx pads in there... never even thought of that! thank you. now- as for documenting counts daily- just don't know how feasible that is? i can't find legal requirements, either? some places (the er i work in- requires bid checks) and others, (nursing homes) count weekly....so it seems to be a personal choice of the facility. does the dea mandate a certain number of counts as far as you know? i could try to meet up with the cottage manager a few times a week so we could count the meds together- then we could see which staff were working if something did turn up missing?
my understanding is that dea wants a two person count whenever there is a shift change...however many times that might be. unless there is a large number of controlled substances this should only take 5-10 minutes each time it happens. i would suggest that for the controlled substances at least they should be packaged in blister packs. this makes it much easier to count and there is no "handling" of loose pills dispensed in a bottle. this may seem like overkill but imo whenever dealing with medications in a non medical facility with uap better safe than sorry. i have been burned a few times so i have learned to put safeguards into place so i can say i have done all i could to be accountable for drugs. the staff may already have some kind of system in place to document they exchanged keys or other things at shift change so this wouldn't be a radical process to them. as a side note every nursing home i have ever worked at requires each shift change count controlled substances before the offgoing shift leaves. counting the the bulk meds can be done by you when you do your weekly med setup. some kind of spread sheet to keep track of when refills are due etc can also be helpful for you so the children never run out of meds.
i did find a training course established by the developmental disabilities division and the wy department of health called "medication assistance for unlicensed personnel" that was last updated sept. 09. i really like the info. in it, but it is super intensive. i would like to use it and have contacted them about what i need to do to get them here to train our staff or what i need to do to become "certified" to train my own staff, but i am still awaiting response (weeks!) i think i will start planning to train my staff using it anyways- it's not like there are laws about it!!!??? for craps sakes, how do i convince my boss to pay for this stuff it it isn't mandated and is available online??? maybe she could just write me a bonus check instead!!!ugggh.
as far as i know an rn is not required to become certified to delegate medication adminstration to uap. although an extensive & intensive course would be great it might not work out on practical terms for you to be able to invest that much time for the process. i would suggest you review the material and pick out the stuff you feel is really important for the uap to know in order to give meds safely and correctly. honestly they don't really need in depth knowledge of drug categories or how to do dosage calculations. they do need to know how to compare labels against mars, how to give a med (whole, crushed, with food or mixed with a liquid), to take their time so the clients can swallow the meds without problems (i have seen folks try to give someone 8-10 pills in 1 spoonful of pudding!!) common side effects and when to notify you of a possible adverse reaction.
i agree. i have even considered taking pictures of what each child's meds look like for quick reference in the book... but it would be much easier if drug manufacturers could agree on what a drug should always look like! (big pet-peeve). we do chart med errors on our "incident report" that includes what happened, who was contacted, how child was monitored, etc. i even found a developmental disabilities division site for submitting med errors electronically, so i am planning to contact them to be sure i should be doing that.

i would also suggest adding a picture of each child and placing it on both the mar and the dispensing box. this serves as an additional identifier. imo a picture of the med is not as useful as learning to compare the label against the mar each and every time. that way if the color or shape changes no big deal....the name stays the same .

txredheadnurse, BSN, RN · Mar 10, 2010

One additional training resource is a DVD produced by a company called ResCare. Just google for the website. It is geared towards UAP giving meds in group homes and shelters. It is pretty good and I prefer using different types of media to train. Not everyone retains lecture or written handouts as well as they would seeing someone actually do a medication pass in a group home.