Medication Administration Module


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Medication Administration Module

Medication Administration

May 2017

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Table of Contents

About this Module/Overview/Objectives……………………………………………...Page 3 Pre-test…………………………………………………………………………………Pages 4-5
Chapter 1……………………………………………………………………………....Pages 6-11
Overview Role of the Nurse in Medication Administration
Board of Nursing Assigning of Tasks to Unlicensed Assistive Personnel
Supervision of the Certified Medication Aide Personal-Accountability Medication Stewardship

Chapter 2……………………………………………………………………………...Pages 11-15
Medication Properties Special Considerations for the Administration of Medications to the Elderly Use of Antipsychotic medications in the residents with Alzheimer’s disease or other dementia related conditions
Assessment prior to medication administration Use of G-tubes in medication administration

Chapter 3……………………………………………………………………………...Pages 15-18 Rights of Medication Administration Medication Administration Record (MAR) The Rule of 3

Chapter 4……………………………………………………………...………………Pages 18-27 Texas Board of Nursing and Medication Administration Federal Nursing Facility Regulations F176: Self-Administration of Medications F329: Unnecessary Medications F 332 & F333: Medication Errors Impact of Working Conditions on Medication Errors Medication-Related Adverse Events State Nursing Facility Regulations

Chapter 5………………………………………………………………………….......Pages 28-32 Resources
Videos Learning Activities Scavenger Hunt Institute for Safe Medication Practices (ISMP) CMS hand-in-hand Module 4 Internet Resources

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About this Module:
When properly used, medications are a great resource for mankind; indiscriminately or improperly used, they can lead to anything from minor irritating problems to death. Medications are chemical compounds that modify human body processes. They may alter chemical reactions, fight, cure, or prevent disease, relieve disease symptoms, maintain health, aid in diagnosis, or alter a normal process. For example, psychotropic medications change behavior through altering, blocking, destroying, or augmenting brain chemicals. FDA studies show that medication errors injure about 1.3 million people in the United States each year and cause the death of 7,0001. Safe medication administration is essential to nursing practice, and nurses need to have knowledge and skill in the techniques of administering all pharmaceutical agents because the nurse is the last line of defense to protect a resident against a medication error. In order to ensure resident safety, the Medication Administration Module of this tool-kit was developed.
Overview:
Medications are administered to individuals to diagnose, treat, or prevent illness. Drugs are potentially dangerous, even if they are meant to improve our health. It is important that those you care for take any and all medications that they are prescribed, correctly, ensuring that the doctor’s orders are always followed. Medications have different ways in which they need to be given in order for them to work properly. The responsibility that you as the nurse have in medication administration will vary and be based on the needs of your residents and the policies and procedures that are in place at the facility in which you work. The administration of medications is a very important task that requires a great deal of attention while being performed, in order to be done safely.
Objectives:
The objectives for this module are:
a. Describe the LVN’s role in medication administration in a nursing facility.
b. Identify the three factors that can make medication administration difficult in the elderly.
c. Identify the federal regulations that involve medication administration.

1 Food and Drug Administration (FDA). Preventable Adverse Drug Reactions: A Focus on Drug Interactions. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/DrugInteractionsLabeling/ucm110632.htm

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Pretest:

1. Forgetting to administer a medication on time is an example of neglect.

True

False

2. All medications can be crushed.

True

False

3. Medication errors must be documented.

True

False

4. It is okay to sign off on a medication that someone else administers, even if you prepared the

medication.

True

False

5. In a Nursing Facility, the LVN can delegate to a Certified Medication Aide (CMA) the

administration of insulin.

True

False

6. If a resident refuses a medication, your only responsibility is to document the refusal.

True

False

7. You must have the informed consent for medication of a resident or responsible party signed prior to the administration of an antipsychotic medication.

True

False

8. When administering a medication, the right route must be considered. The nurse is responsible for ensuring that the medication can be administered in the route ordered.

True

False

9. It is the nurse’s responsibility to ensure that residents are free from any medication errors.

True

False

10. Residents of long-term care facilities have the right to self-administer medications.

True

False

11. According to federal regulations for nursing homes, a significant medication error causes the resident discomfort or jeopardizes his or her health and safety.

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True

False

12. It is not necessary to have a clinical indication for medication that is being administered to a resident.

True

False

13. A medication review should be done when a resident is readmitted to the nursing facility, even if they were only out for less than 24 hours.

True

False

14. Falling is not considered a medication related adverse consequence.

True

False

15. According to the Texas Board of Nursing, an LVN is not responsible for the clarification of a medication order that he/she does not understand.

True

False

Answers: 1. T 5. F 9. T 13. T

2. F 6. F 10. T 14. F

3. T 7. T 11. T 15. F

4. F 8. T 12. F

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Chapter 1:
Overview:
Medication administration is an everyday part of the care that is provided to residents in a nursing facility. Due to the potential danger of medication administration, it is imperative that the nurse understand the importance of performing the task safely. Becoming proficient in all of the aspects of medication administration will ensure that the residents are kept safe through all areas of the care provided to them.
The nurse needs to understand not only the routes of medication, but the ways in which medications affect the elderly residents in their care, as well as the federal regulations that discuss medication administration. In addition, the nurse must also be able to report medication errors as required by facility policy and procedure and adequately supervise unlicensed personnel who are responsible for medication administration.
Role of the Nurse in Medication Administration:
The Texas Board of Nursing (BON) in their position statement 15.252 directs the LVN to work within their scope of practice, as dictated by the Nurse Practice Act (NPA). The LVN, based on knowledge and clinical judgment is expected to:
1. Know the common medical diagnoses, drug and other therapies and treatments; 2. Administer medications and treatments and perform procedures safely; and 3. Monitor, document, and report responses to medications, treatments, and procedures and
communicate the same to other health care professionals clearly and accurately.
In the Texas Administrative Code (TAC), Title 22, Part 11, Chapter 217, Rule §217.11 Standards of Nursing Practice3, LVNs are required to:
1. (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same;
2. (D) Accurately and completely report and document…(iv) administration of medications and treatments; and
3. (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment.

2 Texas Board of Nursing. Practice – Texas Board of Nursing Position Statements. https://www.bon.texas.gov/practice_bon_position_statements_content.asp#15.25 3 Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule §217.11. http://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=2 2&pt=11&ch=217&rl=11

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LVNs, in their educational preparation are taught how to administer medications and treatments as ordered by a physician, podiatrist, dentist, or any other practitioner legally authorized to prescribe the ordered medication. The LVN is required to know and understand not only the BONs position on medication administration, but also that of their facility. The BON does not dictate a list of medications, routes of administration, or any other specific information that may be relevant to determining whether or not a task is within the scope of practice for a LVN, as they allow for LVNs who have the proper training to engage in certain practices that those without the training would otherwise be unable to do.
Assigning of Tasks to Unlicensed Assistive Personnel4:
According to the Texas Administrative Code (TAC), Title 22, Part 11, Chapter 217, Rule §217.11: Standards of Nursing Practice, (2) Standards Specific to Vocational Nurses, the LVN is a directed scope of practice under the supervision of the RN or any higher level licensure. The LVN, by his/her scope of practice is not allowed to delegate tasks to other individuals; however he/she is within their scope to assign specific tasks to unlicensed personnel, as long as the individual has the educational preparation, experience, and knowledge to handle the assigned task. With regards to medication administration, the LVN is capable of assigning this task to a Certified Medication Aide (CMA), as long as he/she maintains appropriate supervision of the CMA. The medication aide program is mandated by the Texas Health and Safety Code, Chapter 242, Subchapter N5, with regards to the administration of medications to facility residents, and they are widely used throughout nursing homes in the state. If the nursing facility has CMAs in place to assist with medication administration, there need to be safe systems in place to support the CMA role.
a. Supervision of the Certified Medication Aide: In a nursing home, it is ultimately the responsibility of the immediate supervisor, in most cases the LVN, to ensure that the CMA is practicing within their certification and performing medication administration safely. The LVN needs to be aware that checking the MAR for proper administration of resident medications is part of the oversight process. In the event that the LVN does not feel as though the CMA can effectively perform the requirements of administering medications, that information needs to be passed on to the RN who oversees the LVN’s practice. Medication administration in nursing homes is a complex process that requires a collaborative effort between the CMA, LVN, and the RN to ensure safe medication administration. Assigning the task of medication administration to the CMA allows for the nursing staff to focus on all the other aspects of resident care. Facility policy will dictate which aspects of medication administration a CMA cannot be responsible for, but in general, those include: the use of

4 Texas Board of Nursing. LVN Scope of Practice. https://www.bon.texas.gov/rr_current/217-11.asp 5 Texas Health and Safety Code, Title 4, Subtitle B, Chapter 242, Subchapter N.
http://www.statutes.legis.state.tx.us/Docs/HS/htm/HS.242.htm#242.608

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insulin, intravenous medications, and respiratory medications; evaluation and reevaluation of a resident’s condition; and resident assessment, just to name a few.
Personal Accountability:
Personal accountability, by definition is the willingness to answer for the outcomes that are a result of the choices you make, behaviors you display, and actions you take6. Nurses are held to a higher standard of personal accountability, as detailed in the National Association of Practical Nurse Education and Services Standards of Practice for Licensed Practical/Vocational Nurses. The LVN is held to a code of ethics that includes the nurse accepting personal responsibility (for his/her actions)7. Nurses are also expected to be responsible for their professional practice by developing and maintaining current knowledge, skills, and abilities. Prior to any administration of medication, the LVN must understand that he/she is personally accountable for every aspect of the administration process. Any time that the LVN feels as though he/she may not be able to perform the task effectively and safely, he/she must ensure that the RN is aware of the issue, in order to assist the LVN in obtaining the needed knowledge or training.
Medication Stewardship:
By definition, stewardship is the activity or job of protecting and being responsible for something. As a nurse, you are already in a role of stewardship, being responsible for ensuring the safety and high quality of the care you provide to your residents. You are also charged with engaging in practical reasoning with regards to providing all levels of resident care. As a steward of your profession, you have the ability to effect change. Medication administration is an area where you, as the steward, can effect positive change for the good of the residents. A nurse needs to ensure that he/she is being a good steward of their resident’s medications as a whole, however, there are three specific categories of medication stewardship that are of significant importance:
a. Antimicrobial Medication Stewardship8: The potential contribution that nurses can make to the management of antimicrobials within any care setting could significantly impact the development of antimicrobial resistance (AMR) and healthcare associated infections (HCAIs) and Multidrug Resistant Organisms (MDROs). In the past 10-15 years, there has been a significant increase in the prevalence of micro-organisms that are resistant to antimicrobial treatments. The inappropriate and overuse of antibiotics is recognized as a serious problem in nursing homes. Overexposure to antibiotics allows the emergence of bacterial strains that are resistant to treatment. When this occurs, it is harder to treat infections and complications develop resulting in increased costs, resident morbidity, and resident mortality. There are many instances within the nursing home in which systemic

6 Mind Tools. Developing Personal Accountability. http://www.mindtools.com/pages/article/developing-personalaccountability.htm 7 National Association of Practical Nurse Education and Services (NAPNES), Inc. NAPNES Standards of Practice for Licensed Practical/Vocational Nurses. http://www.napnes.org/Archives_NoAccess/standards.pdf 8 Journal of Infection Prevention. Covering more Territory to Fight Resistance: Considering Nurses’ Role in Antimicrobial Stewardship. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083718/

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antibiotics are not generally indicated; this means that the resident may have a positive result of a bacteria, however, providing them with antibiotics would be unnecessary9: 1. Positive urine culture in an asymptomatic resident. 2. Urine culture ordered solely because of change in urine appearance. 3. Nonspecific symptoms or signs not referable to the urinary tract, such as falls or mental
status change (with or without a positive urine culture). 4. Upper respiratory infection (common cold). 5. Bronchitis or asthma in a resident who does not have COPD. 6. "Infiltrate" on chest x-ray in the absence of clinically significant symptoms. 7. Suspected or proven influenza in the absence of a secondary infection (but DO treat
influenza with antivirals). 8. Respiratory symptoms in a resident with advanced dementia, on palliative care, or at the
end of life. 9. Skin wound without cellulitis, sepsis, or osteomyelitis (regardless of culture result). 10. Small (<5cm) localized abscess without significant surrounding cellulitis (drainage is
required of all abscesses). 11. Decubitus ulcer in a resident at the end of life. 12. Acute vomiting and/or diarrhea in the absence of a positive culture for shigella or
salmonella, or a positive toxin assay for Clostridium difficile.
b. Antipsychotic Medication Stewardship10: On March 2, 2015, the US Government Accountability Office (GAO) released an analysis of antipsychotic prescribing patterns in the United States, based on 2012 data gleaned from Medicare Part D Prescription Drug Event claims and the Minimum Data Set. Although progress has been made in reducing antipsychotic use in nursing homes, the GAO identified an antipsychotic prescription in onethird of all long-stay nursing home residents with dementia who do not have a diagnosis of schizophrenia or bipolar disorder—the two FDA-approved indications for antipsychotic medications. There are many reasons why this harmful prescribing practice continues, including lack of education and low staffing levels, but it is the responsibility of the nurse to advocate for his/her residents and work with facility administration as well as the prescriber, to come up with alternative ways to care for residents that can further reduce the use of antipsychotics in older patients with dementia. Given the strong evidence of the harms associated with off-label antipsychotic use, inappropriate prescribing is now being factored into nursing home quality measures as well as in the CMS Five-Star Quality Rating for nursing homes.
c. Pain Medication Stewardship11: Chronic pain is a common problem among nursing home residents that is often difficult to manage, mismanaged, or not managed at all. Yet uncontrolled pain or suboptimal pain management can decrease residents’ quality of life and lead to worsening of other medical conditions and increase the risk of immobility, falls, and

9 Agency for Healthcare Research and Quality. 12 Common Nursing Home Situations and Infection Control Guidelines for MRSA, C. Difficile, and VRE Pocket Cards. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safetyresources/resources/nh-aspguide/module1/toolkit2/pocketcards.html 10 Annals of Long-Term Care Clinical Care and Aging. Improving Medication Prescribing: Antibiotics and Antipsychotics. http://www.annalsoflongtermcare.com/article/improving-medication-prescribing-antibiotics-and-antipsychotics 11 Annals of Long Term Care Clinical Care and Aging. Managing Chronic Pain in Older Adults: A Long-Term Care Perspective. http://www.annalsoflongtermcare.com/article/managing-chronic-pain-older-adult-long-term-care

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other complications. Every resident deserves appropriate pain management, and the nurse must be adequately prepared with the knowledge and information to meet their residents’ needs. Pain medication stewardship is important because of its impact on the quality of the care residents receive. The opposite of the overuse of antimicrobials antipsychotics, and pain medications are often under used in the nursing home population. There are many factors that complicate and hamper the appropriate management of pain in older adults, including a high prevalence of dementia, sensory impairment, and disability. Other issues that may exacerbate the problem are erratic staffing patterns, high turnover of nursing and administrative staff, along with the limited presence of a physician. Having a good understanding of pain can enable nurses to develop an individualized plan of care for their residents who experience pain, ensuring more optimal pain management. The nurse must be able to:
1. Understand Pain: Pain is defined as an unpleasant sensation that is both a sensory and emotional experience associated with an actual and/or potential tissue injury. Pain can be present even when a person cannot communicate it, such as in the case of Alzheimer’s disease and other dementia related conditions. The LVN should be aware that pain can be acute or chronic and in many of the residents that they care for, it will be chronic pain and is whatever the resident says that it is.
2. Assess Chronic Pain: Assessment and proper diagnosis of chronic pain will depend on accurate historical and clinical information, along with evidence that is found during an examination. When assessing for pain, the resident’s perception of their pain is the most important factor and can be determined either verbally or through the use of a pain scale. While examining a resident reporting pain, the healthcare provider should assess the characteristics of this individual’s pain and how much is known about the pain, including the frequency or chronicity of pain and any precipitating and alleviating factors. Knowledge of any current and previous pain management approaches is essential to properly develop a plan of care.
3. Developing a Care Plan: When developing a plan of care, if the resident’s pain is excruciating, it is sometimes necessary to treat his or her pain before all relevant information has been gathered or the cause has been identified. Caution should be used when doing this, however, as medications administered to alleviate pain may mask the cause of the pain and may lead to not accurately identifying its source. Goals of a personcentered approach to developing a plan of care should be based on an individual’s preferences; knowledge of the pain’s location, characteristics, and causes; and knowledge of the patient’s condition, prognosis, risk factors, comorbidities, and existing medication regimen. It is important to establish realistic expectations regarding pain relief or pain management/tolerance. The nurse should also determine whether there are any underlying causes of pain that can be alleviated without the use of medications, put the plan of care into action, set a time frame for re-evaluating the patient’s pain management, and monitor the patient for complications and side effects of pain medications.
4. Managing Chronic Pain: It is essential to make individual, resident–specific decisions when managing a resident’s pain. As previously noted the nurse should first determine the cause of the pain and attempt to alleviate that cause and/or modify the resident’s activity and environment, focusing on non-pharmacologic management strategies, including lifestyle interventions. Thereafter, medications can be used, starting with over-

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Medication Administration Module