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 oncology.

How do the Correctional Facilities handle  STAT meds? I have no experience/knowledge/intuition about giving PRN meds in a correctional institution, BUT if the medication would deescalate an anger situation, I would "borrow from Peter to pay Paul".  Isn't that the point of the RX?If the requisition for a medication takes days, then what is the point of it?

On 5/23/2021 at 10:18 PM, NurseBlaq said:

No, it is not alright as the medication was not prescribed to that patient. They will have to wait until their prescription arrives.

So you are saying "that pill that has inventory number XXX!X can only be given to patient XYZ

On 5/26/2021 at 11:51 AM, NurseBlaq said:

This practice is not an acceptable standard of care in any setting, and bypasses the checks and balances provided by the pharmacy.

I guess I am too old to understand this current practice, but I have borrowed medications many times (returned the new meds) and thought I was managing (providing care that would enhance a patient's return to health or at least an  equilibrium) my patient, not the pyxis, not the computer management system.  I was practicing as a professional nurse. If we are going to be limited to what pharmacy contracts are established,  Limiting my care for the patient...I will fight for the patient and for the care that is prescribed versus nursing the pharmaceutical contract. 

BTW Nurse Blaq, you have already gone after me once before.....Let's agree to disagree...  And let's provide the BEST care the patient deserves.

Specializes in kids.

If not law, it is no doubt policy as well as in  the agreement/contract with the providing pharmacy. If said order is given, and the med is not available in an EKit, the MD who who ordered it needs to be notified and another plan made.

Then there needs to be a conversation with the powers that be as the the contents of the stock kit, so the situation does not arise again.

17 hours ago, londonflo said:

How do the Correctional Facilities handle  STAT meds? I have no experience/knowledge/intuition about giving PRN meds in a correctional institution, BUT if the medication would deescalate an anger situation, I would "borrow from Peter to pay Paul".  Isn't that the point of the RX?If the requisition for a medication takes days, then what is the point of it?

So you are saying "that pill that has inventory number XXX!X can only be given to patient XYZ

I guess I am too old to understand this current practice, but I have borrowed medications many times (returned the new meds) and thought I was managing (providing care that would enhance a patient's return to health or at least an  equilibrium) my patient, not the pyxis, not the computer management system.  I was practicing as a professional nurse. If we are going to be limited to what pharmacy contracts are established,  Limiting my care for the patient...I will fight for the patient and for the care that is prescribed versus nursing the pharmaceutical contract. 

BTW Nurse Blaq, you have already gone after me once before.....Let's agree to disagree...  And let's provide the BEST care the patient deserves.

Yes, that's what I'm saying. If a prescription is for XYZ patient, you can't give patient ABC the meds. Those aren't my rules, but they are THE rules.

As for the second paragraph, I'm not getting how YOU and me so-called coming for you has to do with this thread and the topic. Fighting for the patient has nothing to do with the legality of taking meds from one patient and giving them to another. That's not fighting for the patient, it's illegal according to the links I've posted in this thread explaining why. Maybe give them a look. There is nothing to disagree on, those are the rules and that was the basis of OP's question at the start of the thread. All the extraness is unnecessary. Just say you want to be offended and call it a day. ?

5 hours ago, Tacocat said:

I did a brief stint in corrections. We were trained that we could not administer medications to a patient that were dispensed under the name of a different patient. Did it happen anyway? Sure.

If the medication was not floor stock, the patient had to wait until it was delivered. Most vital medications were stocked, so it was rare that something critically important was unavailable. If the medication are unavailable, I would double-check with the prescriber as to the indication for the drug and if they would put in an order for a temporary substitution -- hydroxyzine isn't necessarily a critical med. 

The issue comes if there's ever a medical record or pharmacy audit. If your charting indicates that the medication was administered, but the pharmacy record indicates that it wasn't dispensed and delivered until 2 days later, is "I borrowed it from a med card that was supposed to be destroyed" going to be valid to your administrator?

 

Exactly! This is the rule for any setting but for whatever reason it's me coming for someone and people not understanding the rules even with links posted to back it up, since those were requested as well.

Specializes in Community/Public Health.
9 minutes ago, NurseBlaq said:

Exactly! This is the rule for any setting but for whatever reason it's me coming for someone and people not understanding the rules even with links posted to back it up, since those were requested as well.

I do think some of it falls to nursing judgment. In my limited experience, a patient isn't going to have any major complications if they don't receive their inaugural dose of Atarax, and you can explain that the doctor submitted the prescription and it should come in with the medication delivery the next day. In the event of a medication of vital importance, you can usually call pharmacy services and they can do a STAT delivery.

If it's for itching or allergies, you can confer with the provider to see if there's a reasonable alternative in stock of the same class -- generally we would tell the provider "you ordered X, but it won't come until tomorrow. We have ABC in stock, are any of these appropriate?"  And then it's the provider's choice whether the patient goes without or they offer a one-time dose of an alternative.

Lastly, I would ask to clarify the policy. If it's permissible, problem solved. If not, you can either admit to the med error or you can silently file that information away so you don't repeat it. 

 

Specializes in Critical Care.
4 hours ago, NurseBlaq said:

Yes, that's what I'm saying. If a prescription is for XYZ patient, you can't give patient ABC the meds. Those aren't my rules, but they are THE rules.

As for the second paragraph, I'm not getting how YOU and me so-called coming for you has to do with this thread and the topic. Fighting for the patient has nothing to do with the legality of taking meds from one patient and giving them to another. That's not fighting for the patient, it's illegal according to the links I've posted in this thread explaining why. Maybe give them a look. There is nothing to disagree on, those are the rules and that was the basis of OP's question at the start of the thread. All the extraness is unnecessary. Just say you want to be offended and call it a day. ?

Exactly! This is the rule for any setting but for whatever reason it's me coming for someone and people not understanding the rules even with links posted to back it up, since those were requested as well.

A "prescription" is physician's order for the medication, dose, route, etc, which is different from the medication itself.

If the prescribed medication is the property of the patient then yes, you're correct, a different patient should not be given something that is the property of someone else, but this is not what the OP is describing.  Medications sent to the facility by a pharmacy, even if sent there because they are needed because patient xyz has a order for them, are not the patient's personal property.

Tacocat said:

I do think some of it falls to nursing judgment. In my limited experience, a patient isn't going to have any major complications if they don't receive their inaugural dose of Atarax, and you can explain that the doctor submitted the prescription and it should come in with the medication delivery the next day. In the event of a medication of vital importance, you can usually call pharmacy services and they can do a STAT delivery.

If it's for itching or allergies, you can confer with the provider to see if there's a reasonable alternative in stock of the same class -- generally we would tell the provider "you ordered X, but it won't come until tomorrow. We have ABC in stock, are any of these appropriate?"  And then it's the provider's choice whether the patient goes without or they offer a one-time dose of an alternative.

Lastly, I would ask to clarify the policy. If it's permissible, problem solved. If not, you can either admit to the med error or you can silently file that information away so you don't repeat it. 

I would push for an emergency stash to protect myself in the future but that's just my $0.02. Either way, OP now has answers and understands, as do others as they have stated. We all know what should be done but getting administration to do what's right is another issue for another thread.

Specializes in Geriatrics.

There is always a book way to do things and then a real world way of doing things. And that’s the sad facts. You are responsible for your own license, do what your comfortable with within your scope. 

1 hour ago, Hannahbanana said:

Except for controlled substances, theft, or fraud, Muno is correct that there is no LAW regarding the practice of borrowing from Peter to pay Paul and repaying Peter when Paul’s blister pack finally shows up. The word “illegal “ has a particular meaning in law, LOL. 

What we’re talking about is a policy, not a law. If the OP is concerned, then a written missive cc’d widely to the institution and the state regulatory board is in order to obtain clarity AND to suggest better policy language to protect patients and nurses. If the response is, well, not responsive, do it again until somebody wakes up and pays attention. This is probably going to be the only way to fix her dilemma (which is likely shared by others).

So you just skipped the part about facilities being fined, losing their license, and so forth and so on huh? There are also cases where nurses have been fired and lost licenses for drug diversion due to this exact thing, and they weren't narcotic drugs but facts be damned.  Noted.

ETA: According to the definition of illegal, it also means rules, hence policy. Do I need to provide the definition of policy too since semantics seems to be a thing with y'all. Any BS to be asinine I guess. ?

Definition of illegal

 (Entry 1 of 2)

: not according to or authorized by law : unlawful, illicit also : not sanctioned by official rules (as of a game)

https://www.merriam-webster.com/dictionary/illegal

Specializes in Critical Care.
On 5/31/2021 at 10:35 AM, NurseBlaq said:

So you just skipped the part about facilities being fined, losing their license, and so forth and so on huh? There are also cases where nurses have been fired and lost licenses for drug diversion due to this exact thing, and they weren't narcotic drugs but facts be damned.  Noted.

ETA: According to the definition of illegal, it also means rules, hence policy. Do I need to provide the definition of policy too since semantics seems to be a thing with y'all. Any BS to be asinine I guess. ?

Definition of illegal

 (Entry 1 of 2)

: not according to or authorized by law : unlawful, illicit also : not sanctioned by official rules (as of a game)

https://www.merriam-webster.com/dictionary/illegal

There's certainly some truth to your argument if we're talking about medications that were the patient's personal property and are provided to the facility by the patient, but based on the OP's descriptions it appears more likely that facility staff are administering medications.

I think some of the confusions comes from the practice of maintaining facility stocks of medications that are organized and stored specific to each patient.  This is typically to help ensure medications aren't being wasted due to being misplaced or excessively ordered (some facilities may mistakenly also believe that this helps reduce medication errors).

The OP's question was specific to scope of practice, regulations, and laws, in which case the criteria of administering medications is well defined; 25mg of metoprolol is 25mg of metoprolol.  

Specializes in kids.
On 5/31/2021 at 12:41 PM, londonflo said:

We had a correctional facility patient (who came every few weeks)  came in ( as usual) for his chemotherapy the next day. The orders were not taken off..so he had no food (dinner or breakfast,) no orders  

Made dash for pharmacy to make his chemo,and put the pre-meds in the system.  I knew the patient well,  he was kind to students, tolerating the protocol of his pre-chemo med well with at least 3 students have a part in it.. 

Bolding is mine....so you had no orders and you went ahead and provided pre chemo and chemo meds???? oye...I don't even understand what his being kind or 3 students have to do with it? Did I misunderstand you?

Specializes in Geriatrics, Dialysis.
On 5/23/2021 at 11:28 PM, Catedi said:

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. 

It is certainly based on law that you absolutely can not administer a medication to any patient that is not specifically prescribed for that patient.

That's true for any setting but especially pertinent in settings like corrections, home care or LTC when the med might just be available so the temptation is there to just use it. Don't give in to that temptation! Using a med prescribed for another patient even if it is no longer needed for that patient not only violates the basic rights of med administration it is also insurance fraud since the med was paid for by the insurance of the patient it was prescribed for. 

While it's not common facilities can be cited for Medicare fraud and potentially lose their ability to accept Medicare patients, receive massive fines and worst case scenario lose their operating license if insurance fraud is pursued in these cases.

Specializes in oncology.
NutmeggeRN said:

.so you had no orders and you went ahead and provided pre chemo and chemo meds???? oye...I don't even understand what his being kind or 3 students have to do with it? Did I misunderstand you?

The paper orders were in the chart. The orders were sent with him  on paper (the night before)  from the prison but were not entered into the system. 

I brought this situation up because there was an old practice of checking charts on nights to make sure charts were not racked before the orders were "taken" off. I guess this whole "Computerized Provider Order entry" has changed some of our previous practices. Our hospital has a  state contract with the prison system and the hospital loses money when practices are inefficient. 

londonflo said:

The orders were not taken off..so he had no food (dinner or breakfast,) no orders processed for chemo. And he never asked for food. ( And This is the only time in 45 years that I complained that his orders should have been caught in the midnight audit,) ( I worked that floor for years and we always checked  orders that weren't  racked before the RN knew about them. )

Paper orders were sent.. Old system, old nurse here!

NutmeggeRN said:

.I don't even understand what his being kind or 3 students have to do with it?

A pretty rushed experience since there is more to the story....I was just specifically talking about the med snafu. (the patient had to go to dialysis within a certain time period.. and chair times are tight. )

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