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 kids.
londonflo said:

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. 

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

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. )

Ah  gotcha! The LTC I do per diem at still uses paper orders...

Specializes in Critical Care.
1 hour ago, kbrn2002 said:

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.

The OP was not proposing giving a medication that wasn't ordered.  If one patient has 25mg metoprolol ordered and then it's discontinued we don't then go through the whole facility and dispose of all of the 25mg metoprolol and order new stock.

It's not medicare or insurance fraud since it would be illegal to have already charged the patient for doses of a medication that were not administered, if you couldn't give the available medication because it was already billed to a previous patient then that would be medicare / insurance fraud.

I think what you're talking about a patient's own medications which were provided by the patient, which are typically self-administered in these settings.

Specializes in Geriatrics, Dialysis.
MunoRN said:

The OP was not proposing giving a medication that wasn't ordered.  If one patient has 25mg metoprolol ordered and then it's discontinued we don't then go through the whole facility and dispose of all of the 25mg metoprolol and order new stock.

It's not medicare or insurance fraud since it would be illegal to have already charged the patient for doses of a medication that were not administered, if you couldn't give the available medication because it was already billed to a previous patient then that would be medicare / insurance fraud.

I think what you're talking about a patient's own medications which were provided by the patient, which are typically self-administered in these settings.

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.

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.

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

Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.
On 6/2/2021 at 9:06 AM, NutmeggeRN said:

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?

She said the orders for chemotherapy weren’t taken off, not that they weren’t written. It was the diet orders that weren’t written. 

Specializes in kids.
41 minutes ago, Hannahbanana said:

She said the orders for chemotherapy weren’t taken off, not that they weren’t written. It was the diet orders that weren’t written. 

Noted, I misunderstood

Specializes in Psychiatric.
NutmeggeRN said:

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.

All the medications are owned by the state, regardless of who they are given to. The inmate is never charged for the medication. We have very little in stock as our clinic med room is very small. The state pharmacy services every state facility (hundreds of patients, if not thousands) and with a combined crew of 15 or so pharmacists and pharm-techs, is unable to process things as timely as it should. I was merely attempting to meet the need of my patient and relieve his discomfort. All I ever wanted to do was be a good nurse. I could not find a law in the state pharmacy law book. My agency has no policy barring this practice. I read NursBlaq's posting of Federal DEA law, twice, and could not find where it included non-controlled meds in it. It clearly gave a definition of what a controlled med was for purpose of that law - schedule I - VI. Hydroxyzine  does not fit in any of those categories and in some countries is OTC. I attempted to reach out to my state BON weeks ago through phone and then via email, but received no response. Allnurses was not my first attempt to get an answer. This is the first time I had ever done this and given, what seems, what a murky area it is, I will probably never do so again unless it is to save a life. I just wanted to know if I should prepare to lose my license and put my home up for sale to avoid foreclosure!

Specializes in kids.
Catedi said:

All the medications are owned by the state, regardless of who they are given to. The inmate is never charged for the medication. We have very little in stock as our clinic med room is very small. The state pharmacy services every state facility (hundreds of patients, if not thousands) and with a combined crew of 15 or so pharmacists and pharm-techs, is unable to process things as timely as it should. I was merely attempting to meet the need of my patient and relieve his discomfort. All I ever wanted to do was be a good nurse. I could not find a law in the state pharmacy law book. My agency has no policy barring this practice. I read NursBlaq's posting of Federal DEA law, twice, and could not find where it included non-controlled meds in it. It clearly gave a definition of what a controlled med was for purpose of that law - schedule I - VI. Hydroxyzine  does not fit in any of those categories and in some countries is OTC. I attempted to reach out to my state BON weeks ago through phone and then via email, but recieved no response. Allnurses was not my first attempt to get an answer. This is the first time I had ever done this and given, what seems, what a murky area it is, I will probably never do so again unless it is to save a life. I just wanted to know if I should prepare to lose my license and put my home up for sale to avoid foreclosure!

Now may the time to address that with  the higher ups, so that the patients needs are met in the future My lens is from the LTC point of view where all pts are private pay, very different scenario than you!

Specializes in oncology.
londonflo said:

The orders were not taken off..so he had no food (dinner or breakfast,) no orders processed for chemo.

NutmeggeRN said:

Bolding is mine....so you had no orders and you went ahead and provided pre chemo and chemo meds???? oye...

"Not taken off" means the orders were on paper but not processed into a system like a computer. So the various departments did not receive paper or computer messages about the orders.  I do not believe any pharmacist or hospital, for that matter will fulfill pre-chemo and chemo meds without a MD orders. In fact all agencies and MD clinics who expect In patient hospitalizations with chemo must contact the hospital several days in advance to make sure the inventory is there. 

NutmeggeRN said:

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

You misunderstood me. Receiving Chemo is a scary time for patients, whether it is their first dose or tenth dose. In oncology we always strive to create a calming atmosphere, and skill and expertise play an important role. Of course students cannot initiate chemotherapy (or blood products for that matter) but they can administer premeditations. Experiences like these are vital to apply classroom concepts in the clinical setting. Sometimes it is best for a nurse or family member if the RN assigned to that patient administers the medications to prevent further anxiety. My role is to determine whether the student (s) administering the pre meds will cause anxiety in the patient.

BTW I was concerned that he had no evening meal or breakfast and fixed that promptly following the hospital channels, because chemotherapy is best tolerated/effective in a well nourished patient. The lack of meals was equally as frustrating.

Specializes in Corrections, Ortho, Uro, FNP.

I work in a prison and most times when the offender is waiting on medications, it is taken from stock meds.  However, as long as the medication card in question was never personally possessed by an inmate, it can be placed into the stock as long as the name is removed and the name of the med, dose, and exp date are clearly visible.  At least this has been the standing rule in the two prisons I have worked at.

Prison life is very different than that of anywhere else and the same rules do not usually apply.  Many times even state corrections and federal institutions have different rules.  OP, you follow their rules and don't worry about it or what other posters are saying on here.  I agree with another poster that you do NOT want to make it seem as though you are doing favors/favoring one inmate; we both know what will happen next.  Safety is the primary goal, your safety first, no matter what so please never forget that.

Stay safe my friend. 

+ Add a Comment