Scope of Practice and medications?

Nurses Safety Nursing Q/A

My question is: If a physician writes a valid order for a non-controlled medication in a prison setting and the medication (Hydroxyzine) has not yet arrived, is it beyond the nurse's scope of practice to provide the inmate with an available dose of the medication not specifically RX'd to him, from a sealed and sterile blister-pack that was scheduled to be returned to pharmacy services, if this action is safe and appropriate to perform for the patient at the time, and it is verified by a second RN that the medication is unexpired, the Right Medication, the Right Time, the Right Dose, and the Right Route?

I could not find any nursing or pharmacy laws or policy to prohibit such an action, as provided in the Ohio RN and LPN Decision Making Model. This act is also not prohibited in my facility's current policy. 

Specializes in Critical Care.
kbrn2002 said:

Nope, that's exactly what I am talking about. I worked LTC for 25+ plus and I am very familiar with the rules and regs, at least in that industry.  When a particular med, say your Metoprolol 25 mg is ordered and delivered by pharmacy that med has been paid for by that patient's payer source.  It's just like if you went to your local pharmacy and filled a prescription. You pick up and pay for the entire ordered prescription, it's not like CVC doesn't charge you until you take the pills. 

Of course for the average person if the med is discontinued you should just destroy any unused doses but in LTC the rules are a little different. In LTC if that med is then discontinued any remaining supply is supposed to be returned to the dispensing pharmacy for credit or destroyed depending on facility/pharmacy polices and procedures. Either way any remaining amount of the med is credited back to that resident.  

Borrowing that leftover metoprolol for another resident is considered  insurance fraud and possibly diversion if the state wants to push that as well.   LTC facilities have been disciplined when this borrowing is discovered.  Does that mean it doesn't happen? Nope, I'm sure it still happens all the time but some facilities including the one I used to work for were very strict about enforcing this with discipline at the least being a write up and the worst termination  if a nurse is caught borrowing leftover meds. 

The proper procedure to follow for obtaining a needed med was contacting pharmacy to fill the prescription  ASAP. If the med wasn't able to be delivered in time for the ordered administration the MD had to be called and updated. Then we would usually just get get a verbal order to start the med when available.

Your understanding certainly isn't uncommon, I was part of a workgroup tasked with improving hospital to ECF / LTC transfers and this misunderstanding was one of the major barriers.  In the workgroup was one person from AHRQ and a regulatory compliance rep from CMS, so their understanding of the process from a regulatory standpoint would seem reliable.

Whether the patient's ECF / SNF stay is covered by Medicare part A, Medicare part D, or any of the private plans that generally mimic part D, it's illegal to charge the patient for medications that were not administered.  The facility pays for the medications that make up their stock they are administering from and cannot charge the patient until the medication has been administered.

Medications that a pharmacy has dispensed to an individual cannot be returned for refund because they cannot be legally re-sold, but medications that have been provided to a licensed facility and maintained as stock medications can be legally returned to the pharmacy.  There is no exception for residents of a LTC, if they are their personally owned medications they cannot be returned.

This is different for ALFs, where medications typically aren't administered but instead staff "assist with self-administration".

The "diversion" that can occur related to "borrowing" is giving a patient a medication for which they do not have an order by taking it from either communal stock or stock meant for a particular patient.

As I've said before, there are certainly issues pertaining to facility policy that could make this a bad idea, although these are all avoidable with better policies.  For instance, if whether a medication has been given or not is determined by the number of doses in a patient-specific stock, or if the only way of knowing if the order had been pharmacy reviewed was whether the medication had been delivered.  But as to the OP's question, the regulatory standards of medication administration don't hinge on how a facility chooses to organize their stock of medications.

NurseBlaq said:

All of this! You get it. Some people just intentionally want to misunderstand in an effort to be right. ?

If you feel I've intentionally misunderstood something feel free to point that out to me, but the passive-aggressive snark is getting old.

Specializes in Geriatrics, Dialysis.
MunoRN said:

Whether the patient's ECF / SNF stay is covered by Medicare part A, Medicare part D, or any of the private plans that generally mimic part D, it's illegal to charge the patient for medications that were not administered.  The facility pays for the medications that make up their stock they are administering from and cannot charge the patient until the medication has been administered.

This is where we diverge in our interpretation of this. Your scenario continues to assume that the medications are dispensed from the pharmacy directly to the facility as "stock" meds to be distributed as needed to the residents. In that case you are correct. Many facilities, including the one I worked for changed to a system that allows this. All meds are stocked in and  dispensed from a machine, similar to the PYXIS most hospitals use. 

However many if not most LTC facilities don't utilize this technology, heck there are plenty of LTC that are so behind in technology that they are still using paper charting. 

In those cases the pharmacy dispenses meds in blister packs that are labeled for individual use by the resident they are prescribed for and those can not legally be "borrowed" for use by another resident. Those resident labeled medications are considered the property of the resident they are dispensed for, much like any med dispensed for home use. They are not intended to be converted to facility stock if not used for the resident they are prescribed for.

Depending on facility and pharmacy policy and procedure the unused meds in the blister packs are either returned or destroyed with the exception of controlled meds which can't be returned after they are accepted by the facility per Federal law. 

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

The header is inaccurate. The nurse was not administering a drug that was not properly prescribed. We all know you can’t do that.

There’s a good case to be made that nursing judgment allows for precisely the solution posited, I.e., taking it from another blister pack to insure that the patient doesn’t go without a properly prescribed medication due to a glitch in the supply chain.

Nobody is shorted, nothing is stolen, no controlled substances were involved. I am astonished at the tempest in this teapot. 

Specializes in Psychiatric.

Is this your opinion or is your answer based on law or do you have any indication that this violates a standard that I can't find? I'm not being snarky here, I just want to know for sure. This is a prison setting and there are also many drugs we keep around that aren't necessarily specifically RX's for anyone that we give if there is an order and the inmate needs it - such as anti-biotics or Inderal, until the pharmacy sends their medicine. The inmate has episodes of self-harm and violent acts against other inmates and staff. Given his agitated state, I thought it appropriate to give him his first dose so he could go to sleep, for his safety and the safety of others. But, of course, I don't want to do so again given that it may be a violation of the law. It was a one-time situation where I thought I made the right call in the best interest of my patient. 

Specializes in Psychiatric.

I did not mean that prisoners were void of nursing standards, I just meant it is a residential type facility and where there is an off-site pharmacy and the client would have gone without his medication for maybe a few days. 

Thank you for your feedback. 

Specializes in Community health.

I am interested in this too. I don’t work in a similar setting (I don’t even give meds at my job!) but I think it’s an interesting question. If anyone has a link to real info (a law, as the OP asked, or P&P from a similar setting, or a BON document), I’d like to read it. 

Do not know of any law or such, but wanted to say it was done at the LTC facilities where I worked and not a second thought occurred. We received pharmacy deliveries late at night so I don’t think that was an excuse.

Specializes in retired LTC.
2 hours ago, NurseBlaq said:

 .....  Use for another patient constitutes fraud, as the medications have been charged to the patient for which it was prescribed and must be credited back to that same patient.
Governing bodies such as the Joint Commission set standards prohibiting such practice, and facilities tolerating such behavior risk losing their license, and fines.

https://www.medical-legalnews.com/hot-topics-in-the-legal-arena-borrowing-meds-from-one-patient-to-give-to-another/

Honestly, I really don't think that the crediting of returned medications is in anyway shape or form a realistic possibility. Just the sheer quantity of meds t be returned from all types of facilities across this country is mind-boggling (at the least!). Gotta be gazillions! Does anyone here REALLY TRULY believe that ret'd meds are credited?!?!!?? (Big Pharm racket, but that's another thread!)

But for this post, it's the rule that meds should not be borrowed. End of sentence. Personally, I have mixed thoughts about this, and to be honest, I have borrowed in the past, REGULARLY. But I made the effort to remedy the situation that forced me into borrowing.

Specializes in Psychiatric.
4 hours ago, NurseBlaq said:

When a resident’s medication is permanently discontinued, per the 2014 Drug Enforcement Agency’s (DEA) Disposal of Controlled Substances Final Rule, it must be properly disposed of within three business days.

https://www.deadiversion.usdoj.gov/fed_regs/rules/2014/2014-20926.pdf

You still can't use medication prescribed to another person just because you have a similar prescription. You all should know this as nurses.

No offence, but this rule only pertains to controlled medications. Hydroxyzine is a non-controlled medication. There is no DEA oversite of non-controlled medications. Although I get your point - it is not standard nursing practice. 

12 hours ago, MunoRN said:

What the OP is describing is not a violation of any law, practice act, or scope of practice.  

In situations where the nurse is assisting someone in taking medications they already own, typically in ALF or ECF settings, it is true that you can't take from one patients medications to give to another patient.

But what the OP is describing is administering medications from the facility's stock, not medications already owned by the patient.

Facilities often manage on-hand stock based on whether there is a patient who needs that medication, but that doesn't mean if that medication is stocked that it is only for that patient.  

For instance, if 12.5 mg Coreg is not commonly administered in a particular facility or unit so it is not regularly stocked there, then a patient is admitted for whom that medication is ordered, the unit supply would be stocked with that medication.  If that patient is then discharged and another patient is admitted for whom 12.5 mg coreg is also ordered, there is no requirement to throw away the doses stocked on the unit and replace them with the same medication, obviously that would be silly.

In terms of nursing practice, not utilizing the facility stock on hand and instead delaying the medication for a new stock of the same medication (for no reason) could be argued to be a failure of the nurse to their professional standards.

No, it is not stock. OP clearly said it was to be returned from another patient and there are no stock meds. The whole damn thread, including replies, are talking about borrowing meds from other patients and here you come with the know-it-all condescension. What's your problem? You always have this opposition view to people trying to be in the right all the time, even to the point of intentionally not comprehending what's being said and even clarified in the thread just to be an antagonist. It's a common theme with you in these AN threads and has been going on for quite some time. Narcissistic behavior on full blast. It's a clear pattern.

Specializes in Community health.
NurseBlaq said:

You always have this opposition view to people trying to be in the right all the time 

Quote

Narcissistic behavior on full blast.

This seems... excessive. 

I've enjoyed reading all the replies. As I said, I don't give meds at my job, so this issue isn't one I've ever faced and I'm glad to read people's views on it. Thanks to those who linked to documents especially. 

CommunityRNBSN said:

This seems... excessive. 

I've enjoyed reading all the replies. As I said, I don't give meds at my job, so this issue isn't one I've ever faced and I'm glad to read people's views on it. Thanks to those who linked to documents especially. 

No, it's not excessive. As I said, it's been an ongoing thing all over threads on AN for months on end. That poster has a superior-than-thou attitude and I'm tired of it. The thread can be about the color of the sky is blue, everyone in the thread can be discussing the color of the sky, and that poster will come in talking about the color of water is blue/green/whatever and try to shut down everyone as if they're better than when it isn't even the topic of discussion. Solid narcissistic behavior. I'm over it!

We were clear as day discussing using meds from other patients and the legality of it, not stock meds. Who the hell was in here arguing stock meds? We all have enough sense to know how stock meds work. That whole fake rant was a nonfactor yet here we are.

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