PARTICIPANT GUIDE Assistance With Self-Administration of Medication Janu

Assistance with Self-Administration of Medication January 2010
Participant Guide
Assistance with Self-Administration of Medication for DCS Youth in Group Home Settings
Tennessee Department of Childrens Services
Participant Guide
Table of Contents
Welcome from DCS Commissioner 3 Introduction 4 Legal Basis for Training 5 Methods of Medication Administration 6 Requirements for Unlicensed Personnel to Assist Youth with Self-Administration of Medications 7 Guiding Principles for Assisting Youth with Self-Administration of Medication 8 Responsibilities in Assisting Youth with Self-Administration of Medications 9 Legal Issues Childrens Rights, Refusal of Medication, and Confidentiality 10 Obtaining Information about Medications 12 Common Medication Abbreviations and Symbols 12 Major Classifications of Medications 13 Controlled Substances 14 Purpose of Prescribing Medication 15 Forms of Medications 15 Routes of Medication Administration 16 Actions and Effects of Medication 17 Drug or Medication Overdose 18 Tennessee Poison Control Center 19 Universal Precautions 20 Worksheet #1 22 Five Rights of Assisting with Medication Self-Administration 23 Important Things about Assisting Youth with Medication Self-Administration 24 Medication for Pass and School 26 Transporting Medications between Placements 27 Providing Assistance with Self-Administration of Medication 29 Documentation Rules 38 Safe Storage and Control of Medication 40 Disposal of Medication 41 Communicating with Youth about Medication 42 Teaching Youth about Their Medication 43 Medication Errors 44 When a Medication Error Occurs 44 How to Prevent Medication Errors 45 Informed Consent 47 Components of Informed Consent 47 Informed Consent for Psychotropic Medication 47 Communication about Medication Evaluations 48 Documentation of Informed Consent 48 Worksheet #2 49
Participant Guide
STATE OF TENNESSEE DEPARTMENT OF CHILDRENS SERVICES Phil Bredesen Governor Viola P. Miller Commissioner
Dear Service Providers, The Department of Childrens Services is extremely proud of all of you who provide loving care for our youth. Without you, our youth would not have the opportunity to experience positive relationships and live in nurturing environments. Caring for the emotional and physical needs of these youth is of great importance. I realize that this also can be a great challenge. The department wants to ensure that you have the information and resources you need to care for our youth, so we have created a training specifically to address how you can assist DCS youth in the self-administration of medications. Your participation in this training will give you a better understanding of how to safely store medication as well as ensure that youths in your facility administer their medications safely. We will also discuss how to communicate with youth in your care about the medications they take and to recognize side effects. I hope you enjoy this training and find it both helpful and useful. I thank you for your dedication and commitment to serving our youth and for your vigilance regarding medication and health issues. If you have any questions or need ongoing assistance, please feel free to contact the DCS Well-Being Unit Nurse in your region. Sincerely,
Viola P. Miller, Ed.D.
7th Floor, Cordell Hull Building, 436 Sixth Avenue North, Nashville, Tennessee 37243-1290 Telephone No. (615) 741-9699 Tennessee Department of Childrens Services 3
Participant Guide
Introduction
It is the intent of the Department of Childrens Services (DCS) that each youth within its care maximize their potential growth and development and attain his/her highest level of functioning through a total therapeutic program individualized to their needs. One component of that program can be prescriptions medication. Assistance with Self-Administration of Medication for DCS Youth in Group Home Settings is designed to provide competency based training to unlicensed staff so they may safely assist with the self-administration of medications in settings authorized by law. Unlicensed staff may assist with self-administration of medication in accordance with procedures that enforce and enhance the five principles of medication administration, known as the five rights. These simple, effective best practice rights will promote safety, maximize benefits, and reduce the risk of self-administration of medication to a minimum. Unlicensed personnel who received this training will establish a knowledge base about the medications they may frequently encounter, develop observational and reporting skills relative to those medications, and recognize opportunities to effectively address medication-related issues. This will provide better and safer care to youth in our group home settings. Those who successfully complete the Assistance with Self Administration of Medication for DCS Youth in Group Home Settings course are not certified or licensed in any way, and are not trained or authorized to make any type of judgment, assessment or evaluation of a youth. Objectives include: Learn the principles of assisting with the self-administration of medication Know how to use medication references Describe safe procedures to assist with the self-administration of medication Define accurate documentation Identify safe storage, control and disposal of medication Recognize errors in assisting with the self administration of medication Define components of informed consent for psychotropic medication
Participant Guide
Legal Basis for Training

Legislation was passed in 2007 that amended Tennessee Code Annotated 68-1-904 to allow for training of unlicensed personnel to assist youth with the self-administration of medication in group home settings. The training shall be provided only to unlicensed staff members who are employed by agencies that are licensed under Title 37 and contracted to provide services to custody youths in group home settings. Assisting youth with the self-administration of medication is not the same as actually administering medication to a youth. Additionally, this legislation prohibits unlicensed individuals from assisting youth with the selfadministration of vaginal, rectal, intravenous, intramuscular, and certain subcutaneous injectable medications (as defined by the rule).
Participant Guide
Methods of Medication Administration

There are three ways in which youths can receive medication. These include having their medication administered by licensed personnel (e.g., nurses), having unlicensed but trained staff assist them with their own self-administration of medication, or administering medications directly to themselves (e.g., self-administration). Medication Administration by Licensed Personnel: This situation occurs for youths in residential treatment facilities or hospital based facilities. All medications are stored via double-locks, and nurses prepare the medication for the youth to take. Nurses document the administration of each medication on a MAR (Medication Administration Record), which is kept in the youths medical chart. Self-Administration: Self-administration of medications means the youths are responsible for taking their medicines at the proper time or when they are needed rather than staff giving them their medicine. The prescribing provider must write an order outlining which medication the youth can self-administer and when or under what circumstances. A copy of that order is sent to the DCS Well-Being Unit Nurse and a copy is kept on file at the youths placement location. The self-administration program must be developed according to the youths needs and capabilities. The youth must be trained by a licensed healthcare provider to take his or her own medicine. The prescribing provider and group home/residential staff will provide ongoing training and evaluation of the youths progress. Medicines for youth who are on a self-administration program must be stored so no other youth have access to them in the facility.
Assisted Self-Administration: This situation occurs for youths who are in group home settings. Medications are still stored via double-locks and managed by personnel, yet staff members do not administer the medications to the youths. They assist the youth during his/her selfadministration via supervision, guidance, and monitoring. This method of medication administration is the focus of this training.
Participant Guide
Requirements for Unlicensed Personnel to Assist Youth with Self-Administration of Medications

Only unlicensed individuals working with youths in group home settings that are licensed under Title 37 and under contract to provide services to youth in state custody who are in group home settings are eligible to receive this training. Unlicensed staff members may assist with self-administration of medication only if they have successfully completed the approved training program for Assisting with the SelfAdministration of Medication. In DCS Group Homes, the Director, Case Managers, and Childrens Service Officers are eligible to receive this training. At least six (6) hours of training from a licensed registered nurse must be documented for each unlicensed individual who will be assisting youth with the self-administration of medication. DCS and each provider agency who trains unlicensed personnel in their group homes will maintain a tracking system to determine who has been successfully trained. Once individuals are competently trained, they will assist youth with self-administration of medication as assigned by the Agency Director. Unlicensed staff will renew training to assist in the selfadministration of medication at least every two years.
Participant Guide
Guiding Principles for Assisting Youth with Self-Administration of Medication

Any unlicensed individual who is trained to assist youth in the selfadministration of medications should: 1. 2. 3. 4. Know about the youths general health and condition that is being treated with medication. Assist with self-administration of medications accurately and safely. Have basic knowledge about the medication(s) to be given. Make correct observations about how a youth responds to medications, including over-the-counter medicines, and can write down and report these observations. Know about side effects that can occur with medications. Know that there is no medication that is harmless. Know safe, clean and proper storage of various types of medications. Know his/her limitations and who to call with questions about medication administration. Appropriately practice infection control and universal precautions.
5. 6. 7. 8. 9.
10. Contact a licensed and knowledgeable person when in doubt about any procedure or direction.
Participant Guide
Responsibilities in Assisting with Self-Administration of Medications

Unlicensed Personnel may assist youths with self-administration of medication when all of the following conditions are met: 1) A physician, nurse practitioner, dentist, or physicians assistant has prescribed the medication (exception: over-the-counter medications which must be taken according to manufacturers directions or as directed by the youths prescribing provider or pharmacist). 2) The medication is one of the following: oral medication, topical medication, eye drops/ointments, ear drops, nose drops, inhalers and auto-injectors (e.g., Epi-pen). Unlicensed staff MAY NOT assist with medications such as vaginal medications, rectal medications, intravenous, intramuscular and certain subcutaneous injectable medications (as defined by legislation). 3) The unlicensed staff member has successfully completed an approved training program regarding assisting with the selfadministration of medication and has passed a written exam. 4) The staff member is considered by the facility nurse or agency director/supervisor to be competent and possesses the ability to perform the required tasks to assist with the self-administration of medications. 5) All governmental regulations and general agency requirements and policies are met. It is very important for you to understand your limitations of authority and responsibility. You must never attempt to perform tasks when you do not feel comfortable, have not been trained, or that are outside of your legal ability to do so. If your employer asks you to do something that makes you uncomfortable and you have not been trained to do, you must refuse. Contact the youths healthcare provider and/or the DCS Well-Being Unit Nurse for further assistance.
Participant Guide
Legal Issues Childrens Rights, Refusal of Medication, and Confidentiality

Mature Minor - Tennessee law presumes that children 14 years of age and older have the maturity to consent to or refuse medical treatment or medication, but it has to be determined on a case-bycase basis by the prescribing healthcare provider. A mature 14 year old or older youths decision to refuse medical treatment or medicine shall not be overridden by DCS staff, Contract Agency staff, or the biological parent/guardian. Mental Health Law Older youths have special rights with regard to mental health services. Per TCA 33-8-202, children with serious emotional disturbance or mental illness, who are 16 years old or older, have the same rights as adults with respect to outpatient and inpatient mental health treatment, medication decisions, confidential information, and participation in conflict resolution procedures. Refusal of Treatment or Medication - If a youth refuses treatment or medication, every effort should be made to determine the basis for the refusal. The healthcare provider should be notified and the youth should be appropriately counseled regarding the impact of the refusal. The healthcare provider can be notified when the youth refuses medication on the first occurrence but the healthcare provider must be notified when the youth refuses for 48 hours. There are some medications that, if stopped abruptly, can cause serious consequences. When youth is prescribed medication, the healthcare provider should be asked if they should be notified immediately or within 48 hours if the youth refuses to take the medication. If the healthcare provider wants to be notified immediately, make a note on the Medication Observation Record (MOR) to call the healthcare provider at the first refusal. It is also important to make that information known to all other staff who are assisting with self-administration of medication. The youth should sign DCS Form CS-0093 Release from Medical Responsibility. A copy of the form should be forwarded to the DCS Family Service Worker and the DCS Well-Being Unit Nurse. The parent should also be notified if applicable (Note If the youth is age 16 years or older, the youth should consent to parental notification if the treatment/medication being refused is related to mental health services).
10
Participant Guide
When a youth refuses medication and the medication is not administered according to the orders from the prescribing provider, by definition this is considered a medication error. The prescribing provider can be notified any time a youth refuses prescribed medication, but the prescribing provider must be notified if a youth continues to refuse medication for 48 hours. DCS also uses the 48 hour time frame for the submission of an incident report related to medication refusals. First make contact with the prescribing provider to determine the appropriate course of action. If the prescribing provider indicates the medication can be discontinued, no incident report is necessary because the youth is being taken off the medication. Notification should be made to the DCS Family Service Worker, the DCS Well-Being Unit Nurse, and the youths parent (if applicable) that the medication has been discontinued. If the prescribing provider indicates the youth should continue on the medication and the youth has missed the medication for a period of 48 hours, an incident report should be submitted. Details of the discussion with the prescribing provider and their direction about the medication refusal should be included in the incident report. When a competent youth refuses treatment or medication, the healthcare provider must determine the following: Going without the treatment or medication will result in harm, and The treatment is medically necessary, and There are no other available alternatives If these conditions are met, the DCS Family Service Worker will consult with DCS Legal Counsel to determine if judicial intervention is needed. Confidentiality - You must always protect the confidentiality of the youth in your care. Health information about the youth must be kept private except when it is necessary for the youths health, when it is required by law, or when a parent or a youth 16 years or older gives written permission to tell another person.
11
Participant Guide
Obtaining Information about Medications

When a medication is obtained from a pharmacy, a reference sheet is included that gives information about the drug including name, common uses, warnings, how to use the medication, cautions, possible side effects, overdose information, and any additional information that may be important. You should keep these information sheets with the medications for future reference. Other reliable sources for medication information are the youths doctor, pharmacist, nurse, or a current drug reference book. Recommended sites on the Internet for obtaining medication information include: FDA website: fda.gov/cder/drug/DrugSafety/Drugindex.htm WEB MD website: my.webmd.com/drugs/ Medline Plus website: nlm.nih.gov/medlineplus/
You may also contact the DCS Well-Being Unit Nurse with questions.
Common Medication Abbreviations and Symbols

a ac am bid c cc (ml) cap c/o d/c Dx hs MOR mg ml (cc) npo before before meals morning twice daily with cubic centimeter capsule/s complains of discontinue diagnosis bedtime medication observation record milligram milliliter nothing by mouth OTC p pc pm po prn qid Rx s stat tab tbsp tsp tid XR, XL, CR, LA, SR over-the-counter after after meals afternoon by mouth (oral) as needed four times a day prescription without immediately tablet tablespoon teaspoon three times a day extended release
12
Participant Guide
Major Classifications of Medications

Analgesic relieves pain Antacid reduces or eliminates acids in the stomach Antianxiety decreases anxiety Antiasthmatic treats asthma Antibacterial/Antibiotic kills or slows the growth of bacteria Anticoagulant slows blood clotting Anticonvulsant prevents or stops seizures Antidepressant relieves depression Antidiarrheal stops or decreases diarrhea Antidote counteracts overdoses of medication or toxic substances Antiemetic controls nausea and vomiting Antifungal treats fungal infections Antihistamine reduces symptoms of allergies Antihypertensive decreases high blood pressure Antipsychotic treats psychosis and controls behavior Antipyretic reduces fever Antitussive relieves cough Antiulcer treats heartburn and decreases secretion of stomach acid Antiviral manages or prevents viral infections Bronchodilator treats bronchospasm in asthma Cardiovascular Agent treats heart and circulatory disorders Diuretic increases urine output Expectorant induces cough and movement of fluid from respiratory tract Gastrointestinal Stimulant stimulates motility of the upper GI tract and accelerates stomach emptying Glucocorticoids reduces inflammation and suppresses the immune system Hormones treats hormone deficiency including diabetes, hypothyroidism and menopause Hypoglycemic Medication treats and controls diabetes Laxative stimulates and loosens the bowels Nonsteroidal Anti-Inflammatory Agents control pain, fever and inflammatory conditions such as muscle or joint pain Over-the-Counter (OTC) medications that do not require a prescription Psychotropic treats behavior/mental health issues Sedative/Hypnotic induces sleep Skeletal Muscle Relaxants stops muscle spasms and relieves painful musculoskeletal conditions Stimulant - schedule II controlled substance which produces central nervous system stimulation Topical Steroid reduces inflammation of various skin conditions due to dermatitis, insect bites, poison ivy, and the like Some medication may be used for reasons other than those listed above. This is commonly called off label use.
13
Participant Guide
Controlled Substances
Controlled substances (drugs) are substances covered by the Controlled Substances Act (CSA), Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970. The CSA places all regulated substances into one of five schedules. This placement is based upon the substances value as a medicine, how much harm it can cause, and if it can be abused or cause addition. Schedule I are the most dangerous drugs that have no recognized medical use, while Schedule V are the least dangerous drugs. See Controlled Substance Schedule.
14
Participant Guide
Purpose of Prescribing Medication

The term drug or medication refers to a substance or mixture (other than food) that is used to do one or more of the following: 1. Maintain health 2. Treat disease 3. Relieve symptoms 4. Prevent disease 5. Alter body processes 6. Diagnose disease
Forms of Medications
Medications are found in three basic forms: Liquid preparations are those containing a drug that has been dissolved or suspended in a solvent such as water or alcohol. Liquids include elixirs, emulsions, fluid extracts, inhalers, liniments, mixtures or suspensions, sprays, solutions, syrups, tinctures. Solid preparations are tablets, capsules, troches or lozenges, and suppositories. Semi-solid preparations include ointments, suppositories, lotions, and creams.
Drugs are mixed with various ingredients to make them suitable for administration. There are ingredients to make oral medications taste better. There are different concentrations or strengths of drugs. Other ingredients allow medications to be applied to the skin or placed into the body such as the eyes or ears. These combinations of drugs with various ingredients are called drug preparations.
15
Participant Guide
Routes of Medication Administration

There are different routes for medication to be taken. Routes that can be used by unlicensed personnel to assist in the youths self-administration of medication include: Oral medications are given by mouth, swallowed, and then enter the stomach. These medications are digested in much the same manner as food. After being dissolved, oral medications are absorbed into the bloodstream and then work throughout the body. Buccal medications are placed in the cheek pocket, at the back of the lower jaw. The medication is absorbed through the mucous membranes that line the inside of the cheek. Sublingual medications are placed under the tongue where they are held until dissolved by saliva. The medication is absorbed by the rich blood supply within the area. Eye (ophthalmic) medications are put into the eye by means of a dropper (liquids) or a tube (ointments). Ear (otic) medications can be placed into the ear by means of a dropper. Dermal patch is a method of having medicine absorbed through the skin. The patch is placed directly on the skin in the specified area. Inhalation medications are sprayed or inhaled into the lungs. Medication is absorbed through the tiny sacs (alveoli) of the lungs. Medications used for this route are in the form of gases or fine droplets, sprays, or mists. Nasal medications are put into the nose by means of drops or sprays. Absorption is through the mucous membrane lining of the nose. Any other route of medication administration is not to be used by unlicensed staff when they assist youth in the self-administration of medication. This includes vaginal medications, rectal medications, intravenous, intramuscular and certain subcutaneous injectable medications (as defined by legislation).
16
Participant Guide
Actions and Effects of Medication

Although medications are given because of the helpful effect they have, they can also be very dangerous. Persons licensed to prescribed medications know the actions of the medications and how they should be used. Remember there is no harmless medication and there is no absolute correct dose. Each depends on the result the medicine has with that specific youth at a specific time. Therefore, observing the youths response to a medication is very important. The following words will define actions, effects, and reactions encountered when medications are given: Action is the way a medication produces changes in body cells and tissues. Effect is the physical or psychological changes in body cells and tissues as a result of administration of the medication. Dose is the amount of the medication given at one time. Side effect/adverse reaction is an unwanted effect that may range from something small like a dry mouth to something life threatening like breathing problems. A side effect may also be a desirable effect. For example, Trazodone is an antidepressant prescribed to treat depression, but it also makes one drowsy and can be given to help a youth sleep. Hypersensitivity is an allergic response to a medication. It may be a rash that may or may not progress to problems with breathing. Anaphylaxis, the severest form of hypersensitivity, may occur with impending death if there is not intervention. Interaction means that two or more medications react together to change the effect they have on the body. Similarly, certain foods can interact with some medication to change the intended effects on the body. Tolerance is when a higher dose of a medication is needed to get the same effect that a smaller dose once got.
17
Participant Guide
Drug or Medication Overdose

A drug overdose is the accidental or intentional use of a drug or medicine in an amount that is higher than is normally used. Overdoses can occur with prescription medications, over-the-counter (OTC) medications, and street drugs, and can be life threatening. Mixing certain medications or street drugs with alcohol can also kill. Physical symptoms of a drug or medication overdose vary with the type of drug(s) taken and can include: Difficult breathing Slurred speech Lack of coordination or unsteady walk Shaking (tremors) or agitation Slow or fast pulse/heartbeat Low or high body temperature Small or large eye pupils Reddish face Heavy sweating Stomach pain, nausea and vomiting Drowsiness, sleepiness or confusion Violent or aggressive behavior Delusions and/or hallucinations Unconsciousness which may lead to coma
*Note: a diabetic who takes insulin may show some of the above symptoms if he or she is having an insulin reaction. Drug emergencies are not always easy to identify. You are not expected to know when a drug overdose is serious. Call 911 or your emergency response number immediately if you find a youth who you think is experiencing a drug overdose. The paramedics and emergency room staff will want to know: What medication/drug(s) was taken? Try to locate the medication container. How much of the medication/drug was taken? When was the medication/drug taken? Was the medication/drug taken with alcohol or any other drugs or chemicals? What symptoms is the youth experiencing? Is the youth conscious? Is the youth breathing?
18
Participant Guide
Be very careful when dealing with a drug or medication overdose. Each youth responds differently, and reactions are hard to predict. Some youth who are taken to an emergency room may not develop any physical signs of poisoning. Others will become quite ill. Do not jeopardize your own safety. Some medication/drugs can cause violent and unpredictable behavior. Call for professional help. Do not try to reason with someone who is on drugs. Do not expect them to behave reasonably. Do not offer your opinions when giving help. You do not need to know why medication/drugs were taken in order to help the youth and give first aid. If a youth has ingested a household or workshop substance in your facility, you can call the Tennessee Poison Control Center:
Tennessee Poison Control Center
1-800-222-1222
19
Participant Guide
Universal Precautions
Universal precautions are an approach to infection control in which all human blood and certain body fluids are treated as if they are known to be infectious. Universal precautions are guidelines to be followed to help to prevent the spread of infection. Infectious organisms can be spread from person to person by: Blood and other body secretions Droplets breathed, sneezed, or coughed out from the nose or mouth Skin-to-skin contact Sexual contact
Universal precautions should be followed when you are exposed to blood, semen, vaginal secretions, or body fluids that contain visible blood. Universal precautions do not apply to nasal secretions, sputum, sweat, tears, urine, feces, vomit, or saliva unless there is visible blood present. The first line of defense against the spread of any infectious disease is good hand washing using soap and water, or an antiseptic alcohol hand rub if hands are not visibly dirty. You and the youth must always wash your hands before assisting with medications or treatments as part of the Universal Precaution process. Hand washing procedure: 1. 2. 3. Wet hands first with water. Apply an amount of soap sufficient for lather to cover all surfaces of hands. Rub hands together well, covering all surfaces including fingers for a minimum of 20 seconds. Pay particular attention to fingertips, nails and jewelry. Rinse thoroughly with running water. Dry thoroughly with paper or cloth towel. If you are in a public place use the paper towel to turn off the faucet and open the door.
4. 5. 6.
20
Participant Guide
The following guidelines should be followed with the care of any youth: Gloves Wear disposable gloves when you touch items or body surfaces soiled with blood or body fluids that contain blood, and when you perform first aid procedures involving treatment of open sores such as changing a bandage. If a glove gets torn or damaged, take your gloves off and wash your hands; then put on new gloves. Do not wash gloves. Discard them after each use. Gloves are not a substitute for hand washing. Wash your hands after wearing gloves in case the gloves have been damaged. Hand Washing - If you get blood or body fluids that contain blood on your hands or any other body surface, wash your hands and the exposed part of your body immediately and thoroughly with soap and water for several minutes. If running water and soap are not immediately available, a waterless antiseptic cleaner or moist towelette may be used until you can thoroughly wash your hands. Clean up of spills of blood or body fluids with visible blood: Contact supervisor regarding spill. A spill kit should be used when available. If no spill kit is available, follow these steps: 1. 2. 3. 4. 5. Put on disposable gloves. Wipe up blood or body fluids with absorbent paper towels. Place contaminated paper towels in a plastic garbage bag. Clean and rinse area with a disinfectant. Wipe the surface with a 1:10 dilution of household bleach in water. This means mixing 1 ounce of household bleach with 9 ounces of tap water (1:10 dilution). Dispose of paper towels and gloves in same plastic garbage bag removing gloves last. Secure the bag with a tie. Dispose of the bag in the garbage. Wash your hands thoroughly with soap and water for several minutes.
6. 7. 8. 9.
All staff should refer to their agencys specific training on universal precautions as well as their agencys Exposure Control Plan and Bloodborne Pathogens Manual for additional detail.
21
Participant Guide
Worksheet #1
Angela is 16 years old and has been prescribed Celexa for depression. The medication was started 2 weeks ago at her appointment with a Nurse Practitioner at the community mental health center. This morning when you get ready to assist Angela in her self-administration of Celexa, she informs you that she does not want to take it anymore. What do you do?
22
Participant Guide
Five Rights of Assisting with Medication Self-Administration

Right Person The name on the prescription bottle should be checked to ensure that the medication is prescribed for the correct youth. One youth at a time should take medication. The youth should remain in full view of the staff member while the medication is taken by the youth The youth may be asked to open his/her mouth, stick out the tongue, swallow again, and/or drink more water to ensure the oral medication has been properly ingested. Right Drug All medication should be taken from the original labeled container. The youth taking the medication should review the medication label prior to taking the medication to verify that it is the correct drug. The label should be read three (3) times: when the container is taken from supply, when the medication is removed from the container, and when the container is returned to supply. Any special directions must be followed when taking medicines (e.g., take with food or with a full glass of water). Right Dose The medication label should be reviewed prior to the youth taking the medication to make sure he/she is taking the right amount of the medicine. One dose of the medication should be taken at the correct time. Always be very careful when medications have different dosages ordered for different times. These schedules must be followed accordingly. Some medications are prescribed in certain dosages or strengths; in order to give the right dose, more than one tablet must be taken or a tablet must be split to equal the right dose. Right Time Medications are to be taken at the right times or intervals and for the right number of days or doses. Youth must always take all their medicine unless the prescribing provider says to stop. A missed dose cannot be made up at the next scheduled time without approval from the prescribing provider. Right Route Verify the transcribers order or manufacturers direction concerning route of administration prior to giving the medication.
Tennessee Department of Childrens Services 23
Participant Guide
Important Things to Know about Assisting Youth with Self-Administration of Medication

1. Provide prescription medications only with orders from a licensed physician, nurse practitioner, dentist, or physicians assistant. Overthe-counter medications must only be provided according to the manufacturers direction or as recommended by the youths prescribing provider or pharmacist. It is the responsibility of the person providing medications to be familiar with the conditions of the youth such as allergies, ability to swallow, etc. The person providing the medications has the responsibility to know the medications intended use, purpose for which it is being given, usual dose, side effects that might occur, and any warnings or cautions of a specific nature concerning the medication. Prescription medications are dispensed by a pharmacy and must remain in the original container with the following information on the label: 5. Youths name Name of the medication Dosage of the medication Route of administration Frequency of administration Quantity issued Name of the prescribing provider Prescription number Date the medication was dispensed Expiration date Pharmacy name, address and phone number
2.
3.
4.
Each prescribed medication and over-the-counter medication is recorded on a Medication Observation Record (MOR) or equivalent form. The form should include the youths name, date of birth, allergies, facility name, month and year, name of the medication, dosage, route, time interval or frequency, any special instructions, and the prescribing providers name. Lastly, the Medication Observation Record has boxes for staff initials to sign when the youth self-administer their medication. Each youths specific medications should be secured in an individual storage compartment and kept secured with a double-lock barrier. Medications must be identifiable up to the point of being taken. The youth taking the medication should be told the purpose of the medication and expected effects.
24
6. 7. 8.
Participant Guide
9.
The principles of universal precautions are to be followed when assisting with youths self-administration of medication.
10. Each Medication Observation Record (MOR) must be read carefully. If not clear, refer to the original order sheet/prescription label or check with the pharmacist. 11. Medication should never be taken from an unmarked or damaged container, or if the label is unreadable. 12. All containers must be kept closed to prevent any changes to the medication from occurring. Any change in color, consistency, or odor must be reported to the designated supervisor, pharmacist, or facility nurse. 13. Any medication that cannot be properly identified or that looks altered is not to be taken. 14. Any medication in a container with an illegible label should not be taken. 15. When assisting with youths self-administration of medication, provide privacy to the youth when it is indicated. 16. Medications that have been prepared and not taken by the youth for any reason (refusal, absence, dropped on the floor) are to be discarded. 17. If the youth refuses the medication, two attempts to have the youth take his/her medication should be made within the designated time frame (one hour before through one hour after the scheduled time of administration) before it is recorded as refused. Continued medication refusal must be reported to the designated supervisor, facility nurse, the youths prescribing provider, and the DCS Family Service Worker. It can be dangerous for some medications to be stopped abruptly, especially psychotropic medications. Note on the MOR if the prescribing provider needs to be alerted immediately if a medication is refused. This should be communicated when the prescription is written. If unsure if it will be dangerous for the youth not to take the medication, call the facility nurse or prescribing provider immediately. 18. The parent should also be notified about a youths continued refusal of medication. If the medication is a psychotropic medication, the parent should only be notified if the youth is less than 16 years old (youth age 16 years and older must be consulted before parental notification). The youth should sign DCS Form CS-0093 Release from Medical Responsibility. A copy of the form should be forwarded to the DCS Family Service Worker and the DCS Well-Being Unit Nurse.
Participant Guide
Medication for Pass and School

Frequently youth in custody have family visits, outings, or may need to take medication during the school day. When possible, youths should take medications before or after school hours; you should talk to the prescribing provider or pharmacist to arrange a workable schedule. For an occasional outing, a medication dose could be given before or after the event. Some youth do have to take medication during school hours or on a temporary family visit. If the youth needs to take the medication at another location and the original container cannot safely be transported with the youth, a duplicate labeled prescription container from the pharmacy should be used. When possible, upon request the pharmacy will place the medication in the duplicate container. This will ensure a licensed pharmacist is involved in the dispensing process to prevent medication errors. Putting a few pills in an envelope is not allowed. If individual bubble blister packs are separated for later use and distribution, each blister pack must include an original pharmacy label, not a copy of the label. Medication for Pass (DCS Form CS-0836) must be completed for youth that need to take medication while on pass. The form must include the name of the medication(s) being sent, medication count(s), instructions explaining when the medication(s) is to be taken including any special directions, and a space for the pass caregiver to document that the medication(s) was taken. The form is returned with the youth at the end of the pass. Narcotic medication should not be sent for pass unless special arrangements have been made with the prescribing provider. Youth taking narcotic medications must not be involved in situations in which side effects could pose a safety issue (e.g., sleepiness while operating machinery or driving, etc.)
26
Participant Guide
Transporting Medications Between Placements

When a youth is being transported with medication(s) to a new placement, Medication Transfer (DCS Form CS-0813) is completed. Medications must remain in the original labeled container. The current placement caregiver/staff lists the medication(s) on the form including the name of the medication(s) and the quantity being sent. The form is signed by the current placement caregiver/staff and the transporting staff verifying the medication name and the amount of medication on the form matches the medication actually being sent. If possible, the medication containers may be placed in a tamper proof packet or stapled envelope. Upon arrival at the new placement, the receiving placement caregiver/staff verifies and signs the form that the medication and amount sent matches what is written on the form. Any discrepancies are to be reported to both sending and receiving placements and an incident report completed. Arrival at Placement with Medication 1. The DCS Family Service Worker must be aware of the medications the youth is taking and must ensure those medications are transferred with the youth when placement is changed. They are also responsible for ensuring a followup medication appointment is arranged for the youth at the new placement if this is indicated. Medications should be transported in their original prescription container, which should contain the youths name, the name and strength of the medication, the date the prescription was filled, the name and address of the dispensing pharmacy or practitioner, and directions for use. 2. Medication should not be used if the dispensing date is not current, if the medication was not prescribed for the youth, if the amount of medication remaining indicates the youth has not been taking it as prescribed, if the medication is expired, or if the medication shows evidence of tampering or deterioration (i.e., discoloration, rancid odor, etc,). In these instances, a licensed healthcare provider should be contacted for further instructions. 3. If the youth is on psychotropic medication, DCS Form CS-0627 Informed Consent for Psychotropic Medication (or equivalent form) documenting consent given by the appropriate party, must accompany the youth to the new placement. 4. If a youth comes into custody or has been on runaway status and has missed his/her medication for 72 hours or longer, the prescribing provider should be notified for instructions before restarting medication.
Participant Guide
Departure from Placement with Medication 1. When a youth is discharged home or transferred from one placement to another, the medication(s) should be sent with the youth in the original, labeled container. 2. The medication(s) should be given to the DCS Family Service Worker or adult accompanying the youth unless the prescribing provider has approved the youth to receive the medication. If the youth is 18 years or older, the medication may be given to him/her at discharge. 3. DCS Form CS-0627 Informed Consent for Psychotropic Medication (or equivalent form) documenting consent from the appropriate party must accompany the youth if he/she is on psychotropic medication and is changing placements. 4. A thirty (30) day supply of medication should be sent with the youth when possible. However, the quantity of medication sent should not exceed the quantity of medication remaining for the duration of treatment. If a thirty (30) day supply of medication is not available, the current placement must coordinate with the new placement regarding continued medication maintenance and appointments. If the youth is being transferred to a hospital setting, medications typically are not sent unless the youth will not be returning to that placement. However, a list of the youths medications (including name, dose, route, and frequency of the medication) must be sent if medications do not accompany the youth.
28
Participant Guide
Providing Assistance with Self-Administration of Medications

General Principles
1. 2. The youth and staff member should wash hands. The staff member should gather the medicine, medicine cup or medicine syringe, measuring utensils needed for the youth to self-administer the medication, and the Medication Observation Record (MOR) or equivalent form. The staff member should retrieve the medication (bottles or blister packs) from the double-locked storage area. The staff and youth must read the label of the container carefully to be sure it is the right medicine and checked with the Medication Observation Record When preparing pills, the cap of the bottle should be removed and placed topside down on the table. Medication should be handled in such a way that the fingers do not come in contact with it. The prescribed number of tablets can be placed in the lid or cap of the bottle for the youth to take. When liquid medications are being prepared, the cap of the bottle must be on securely so that the bottle can be shaken to mix the medicine. The cap should then be removed and placed topside down on the table. When pouring liquid medicine the bottle should be held with the label in the palm of the palm to avoid soiling it. The medication should be poured by holding the medicine cup or medicine syringe at eye level or pouring it into a spoon. The lip of the bottle should be wiped with a moist piece of clean paper towel before recapping it, and the cap should be put back on the bottle securely. Observe and monitor the youth while he/she takes the medicine and answer questions as needed. You may check the youths mouth if needed. Have the youth open their mouth and stick out their tongue to see if the medication has been swallowed. If you think the youth is holding medicine in their mouth, sweep their mouth with a tongue depressor or gloved finger in the pocket between the teeth and gums. Note any unusual reactions or symptoms before or after the youth takes his/her medication. Report this to the prescribing provider.
3. 4. 5.
6.
7. 8.
9.
10. Clean equipment, including pill splitter, mortar and pestle, oral syringes, etc., with soap and water, and also wash hands. 11. If the youth has difficulty swallowing the medicine, check with the prescribing provider to see if it can be crushed or added to food or liquid to make taking it easier.
Participant Guide
Oral Tablets and Capsules

1. 2. 3. 4. 5. The staff member and the youth both wash their hands. The staff member gets the MOR and the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. The medication must be checked with the MOR before proceeding. The pills should be removed from the container in such a way that they are not touched by fingers. The pills should be dropped into the cap of the container or in a small cup and given to the youth to take with an appropriate liquid. The container should be recapped. The staff member must observe the youth as the medication is swallowed. If necessary, the staff member can do a check of the mouth to be sure the medication has been swallowed. Record that assistance was provided on the MOR and return the medication to locked storage.
6. 7. 8. 9.
Breaking Scored Tablets/Pills and Crushing Tablets/Pills Scored Tablets/Pills

Sometimes a medication label will instruct the youth to take half a tablet or pill. Tablets and pills that have been scored can be broken to provide a correct dose. A scored tablet has been imbedded with a line for easier and even breakage. A pill cutter or your thumbs may be used to break a scored tablet or pill. Gloves should be worn when handling the medication.
Crushing a Tablet/Pill
Some tablets and pills can be crushed for those people who have trouble swallowing. The prescribing provider or pharmacist can tell you if a medication can be crushed. Some medications are not meant to be crushed. In general medications which are sustained-released, controlled release, extended release or which have an enteric coating may not be crushed.
Oral Liquid Medication

1. 2. 3. 4. 5. 6. The staff member and the youth both wash their hands. The staff member gets the MOR and the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. The medication must be checked with the MOR before proceeding. When liquid medications are being prepared, the cap of the bottle must be on securely so that the bottle can be shaken to mix the medicine. The cap should then be removed and placed topside down on the table. When pouring liquid medicine the bottle should be held with the label in the palm of the palm to avoid soiling it.
30
Participant Guide
7. 8.
Always use a cup or container with lined measurements. The medication should be poured by holding the medicine cup at eye level. Use your thumb to mark off the correct level on the cup. 9. Give the cup to the youth and observe the youth swallow the medication. 10. The lip of the bottle should be wiped with a moist piece of clean paper towel before recapping it, and the cap should be put back on the bottle securely. 11. All equipment should be washed with soap and water, and hands should be washed again. 12. Record that assistance was provided on the MOR and return the medication to locked storage.
Topical Medication
1. 2. 3. The staff member and the youth wash their hands The staff member gets the MOR and the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. 4. The medication must be checked with the MOR before proceeding. 5. The staff member should look to see if the affected area is changed in any way before the youth applies the medicine and also look for any unusual reactions or symptoms after the medicine is applied. Report these things to the facility nurse and the prescribing provider. 6. The area should be cleaned if indicated. Clean from clean to dirty in only one direction, one time to avoid spreading germs to the area. A clean wipe should be used for each area if necessary. 7. The cover of the medication should be removed and the cap should be placed topside down on the table. 8. The correct amount of medication should be taken from the container onto a glove, tongue blade, tissue, q-tip, etc. Do not double-dip applicator back into the medication. 9. The youth should apply the medication to affected area; avoid rubbing the skin. 10. A bandage can be put on if appropriate or per MD/NP directions. 11. Replace cap, discard applicator and gloves and wash hands. 12. Record that assistance was provided on the MOR and return the medication to locked storage.
Nasal Medications
1. 2. 3. 4. 5. 6. The staff member and the youth wash their hands. The staff member gets the MOR and the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. The medication must be checked with the MOR before proceeding. The youth should be positioned in a sitting position with head tilted backward or to the side. The medication should be shaken and drawn up into the dropper (which should not be chipped, cracked or broken).
31
Participant Guide
7.
The youth should aim the tip of the dropper toward the nasal passage and apply correct number of drops. The staff member should instruct the youth to breathe through the mouth as the drops are put in. 8. You may assist with dispensing the nose drops at the request of the youth. 9. Discard any medication remaining in the dropper before returning the dropper to the bottle. Rinse the tip of the dropper with hot water, dry with tissue and recap promptly. 10. For sprays, the tip of the container should be placed just inside the nostril. The youth should close off the opposite nostril and inhale slowly through the nose as the container is squeezed; hold the breath for several seconds and then exhale slowly. Repeat in the opposite nostril as required. Have the youth remain in position with head tilted back for 1-2 minutes so the solution will come into contact with all of the nasal surface. 11. Replace cap and wash hands. 12. Record that assistance was provided on the MOR and return the medication to locked storage.
Eye Drops/Ointments
1. 2. 3. 4. 5. The staff member and the youth wash their hands. The staff member gets the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. The medication must be checked with the MOR before proceeding. Staff should look for any changes in the affected eye before the youth applies medicine. Staff should also watch for any unusual reaction or symptoms following the medicine application and report them to the facility nurse and the prescribing provider. The medication should be shaken, and drawn up into the dropper (which should not be dirty, chipped or cracked). The youth should tilt his/her head back and look at the ceiling. Then, the youth should gently draw lower lid down with forefinger. If an ointment, a thin layer should be applied along the inside of lower lid without touching the tip to eye. If drops, the correct number of drops should be dispensed gently near the center of the lower lid. The dropper should not touch the eye in order to prevent contamination. You may assist with dispensing the eye drops or ointment at the request of the youth. Have the youth close their eye for 1-2 minutes and not to squeeze or rub them. Have the youth wipe off excess solution with a tissue. Replace cap and wash hands. Record that assistance was provided on the MOR and return the medication to locked storage.
6. 7. 8. 9. 10. 11. 12. 13. 14.
32
Participant Guide
Ear Drops
1. 2. 3. 4. 5. 6. The staff member and the youth wash their hands. The staff member gets the MOR and the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. The medication must be checked with the MOR before proceeding. The youth should have his/her ear as horizontal as possible, either by lying on a bed with head turned or sitting in a chair with head tilted sideways. Staff should look for any changes in the affected ear(s) before the youth puts in the medicine. Staff also should look for any unusual reactions or symptoms following the medicine instillation and report these to the facility nurse and the prescribing provider. The medicine should be shaken and drawn up into the dropper (which should not be chipped, cracked or broken). Eardrops should be administered by having the youth pull the ear gently backward and upward and put the number of drops ordered into ear canal. The dropper should not touch any part of the ear canal in order to prevent contamination. You may assist with dispensing the ear drops at the request of the youth. The youth should keep his/her ear tilted several minutes and put a soft cotton ball loosely in the ear. If drops are to be put in both ears, wait at least five minutes before putting drops in second ear. Replace dropper and cap and wash hands. Record that assistance was provided on the MOR and return the medication to locked storage.
7. 8.
9. 10. 11. 12. 13.
Inhalant Medication
The staff member and the youth wash their hands. The staff member gets the medication from locked storage. The name on the container and the name of the medication should be double-checked with the youth. 4. The medication must be checked with the MOR before proceeding. 5. The inhaler should be shaken to mix the medicine in the chamber. 6. The youth should hold inhaler between index finger and thumb and remove cap, then insert the inhaler mouthpiece or spacer if needed. 7. The youth should exhale or breathe out slowly through pursed lips, then insert mouthpiece and squeeze the canister between the thumb and fingers. The youth should breathe in slowly at the same time. 8. The youth should withdraw the mouthpiece and hold his/her breath for several seconds, and then breathe out slowly. 9. If a second puff is ordered, wait at least 30 seconds for valve pressure to rebuild. Again shake before reusing the applicator. 10. The youth should rinse the mouthpiece with warm water and recap. 11. The youth may wish to rinse his/her mouth with water. 12. Record that assistance was provided on the MOR and return the medication to locked storage.
1. 2. 3.
Participant Guide
Transdermal Medication Transdermal medications are usually in the form of patches. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. The staff member and the youth wash their hands. The staff member gets the transdermal patch from locked storage. The name on the package and the name of the medication should be double-checked with the youth. The medication must be checked with the MOR before proceeding. Have the youth open the package and remove the patch. The youth will write on the patch the date, time if appropriate, and their initials. The youth will remove the backing from the patch, using care not to touch the actual medication with their hands. The youth should apply the patch to a dry, hairless part of the body according to package instructions. The previous patch should be removed. The youth should watch for old patches that should be removed or absence of a patch that should be present and report that to the staff member. The youth should alternate the application sites to avoid skin irritation. The youth should alert the staff member to any skin irritation which should be reported to the facility nurse and prescribing provider. The youth should wash hands after applying the patch and dispose of supplies appropriately. Record that assistance was provided on the MOR and the location of the new patch on the youths body.
Auto-injector for Allergic Emergencies At first appearance of signs and symptoms of serious allergy reaction (facial swelling, hives, difficulty breathing) or as directed, the youth should be prepared to use epinephrine (adrenaline) by injection. 2. While the youth is preparing to use an injection, someone must call the local emergency number (usually 911) to immediately transport the youth to nearest health care facility or hospital emergency room. 3. The safety cap should be removed if present. 4. The youth places the tip of Epi-pen or needle at right angle to front of and just to the outside of the thigh in the fleshiest part of the leg. 5. The youth presses into the thigh hard or pushes plunger to release medication and holds for a few seconds before removing needle. 6. The youth should massage the area for ten seconds. 7. Be prepared to assist the youth with the auto-injector if he/she is experiencing breathing difficulty. 8. Dispose of sharps appropriately 9. *It is important to periodically check the expiration of medications that are not used on a regular basis but are needed in an emergency. 10. Documentation of the use of an auto-injector must include where the situation occurred, what precipitated the situation, who was involved, and what allergic reaction was observed prior to use. The facility nurse and prescribing provider should be notified of the situation and condition of the youth after transport to a health care facility or emergency room.
1.
Participant Guide
Over-the-Counter Medications Group homes should maintain a supply of over-the-counter (OTC) medications that are kept double locked. When assisting a youth in self-administration of over-the-counter medication, these safeguards should be followed carefully: Check the label for possible side effects or interactions with other drugs. This information will appear in the Warnings section. Check the label to be sure you are not providing two medicines that contain the same ingredient. Read the Active Ingredient section for this information. Always read and follow the directions on the label. Be sure you understand what the label says before dispensing any medication. Consult with the youths healthcare provider or pharmacist for instructions if the youth is on prescription medications.
If a youth requests an over-the-counter medication, follow the same instructions as above (for the type of medication) and record on the MOR what medication was taken, the reason for the medication, and that assistance was provided and return the medication to locked storage.
35
Participant Guide
Staff members will not be administering insulin to youth, but the following information is important to know so that staff can monitor and help diabetic youths as needed in their selfadministration of insulin. These are the steps that the youth will take when self-administering insulin. Subcutaneous Self-Administration of Medication (Insulin) The youth needs the following supplies
Alcohol wipes, insulin and syringes. Syringes come in three sizes: 100 units, 50 units, 30 units; U100 is standard. Parts of the syringe: Barrel the units of measure are marked on the barrel Plunger tip of plunger shows how much insulin has been drawn up Needle needles are sterile and should not touch anything before it is injected into the skin.
Insulin types
Short-acting insulin. Intermediate-acting insulin. Long-acting insulin. Combinations of the above.
Some insulins are clear and some insulins are cloudy in appearance.
Instructions for a youth to prepare a single dose of insulin

1. 2. 3. 4. 5. 6. 7.
Wash and dry their hands. Mix insulin by gently rolling the bottle between their palms. Clean the cap with an alcohol wipe. Pull air into syringe to the number of units needed. Inject the air into the bottle. Draw insulin into syringe. Check with the youth that the dose is correct and that there are no air bubbles. 8. Withdraw the needle.
Instructions for a youth to preparing a mixed dose of insulin
1. Draw air into the syringe for the total amount of the insulin injection. 2. Inject the amount of air into the long or intermediate-acting insulin for the number of units of that type of insulin they will be injecting. 3. Withdraw syringe from that bottle. 4. Inject the rest of the air into the shorter acting insulin bottle. 5. Draw up the short-acting insulin, get rid of any air bubbles in the syringe and withdraw the needle with the correct number of units in the syringe. 6. Next, insert needle into the bottle of longer-acting insulin, withdraw the exact number of units of longer-acting insulin needed and withdraw the needle.
Participant Guide
1. Injection sites include: Abdomen Thighs (front and sides) Upper outer arms Buttocks 2. The youth should rotate injection sites to help keep the skin and tissue healthy. 3. The youth should inject into these sites in the subcutaneous (fatty) tissue between the skin and muscle. 4. Insulin should not be injected into a muscle.
Choosing the injection site
Instruction for a youth to inject the insulin

1. 2. 3. 4. 5.
Wipe the skin with alcohol. Pinch the skin up into a fold. Dart needle into the skin at a 90-degree angle (i.e. straight into the skin). Inject the insulin by pressing down on the plunger all the way. Pull the needle out and hold the alcohol pad over the injection site to stop any bleeding.
Storing insulin: (Staff need to ensure proper storage)
1. Keep unopened insulin bottles in the refrigerator but do not freeze. 2. Opened bottles can be stored in a cool, dark place; refrigeration is not necessary. 3. Keep insulin out of heat and sunlight. 4. Keep track of the expiration date on the bottle. Dispose of syringes and lancets using the proper container as recommended by the youths healthcare provider.
Insulin Pumps
The most recent advance in insulin delivery is the insulin pump. It is composed of a reservoir or cartridge, a battery-operated pump, and a computer chip that controls the exact amount of insulin to be delivered. The pump is attached to a thin plastic tube that has a soft plastic needle at the end which is inserted under the skin, generally on the abdomen. The pump delivers a continuous amount of insulin 24 hours a day. The amount of insulin is programmed and is administered at a constant rate which varies depending on factors like exercise, activity level, and sleep. A bolus dose (burst of insulin) is taken before meals, based on amount of carbohydrates to be eaten, and at times when blood sugar is too high based on the users programming.
Refer to the prescribing provider for specific information.
37
Participant Guide
Documentation Rules
1. All medications are ordered by a physician, nurse practitioner, physicians assistant, or dentist (exception: over-the-counter medications which must be taken according to manufacturers directions or as directed by the youths prescribing provider or pharmacist). The medication order is transcribed to a Medication Administration Record (MAR) by a nurse or a Medication Observation Record (MOR) by trained unlicensed staff. The MOR is used in preparing and documenting assistance with medication self-administration and contains the following information: Youths full name Name of the medication Dosage of the medication (including concentration if appropriate) Route of administration Times the medication is to be administered Any specific administration directions Date the medication was ordered Date the medication should be discontinued (if available) In addition, the MOR has a place for staff to sign initials after assisting in each medication administration, plus an area for the complete signature and title of the person assisting the youth. The MOR should be kept in a place where it is readily available. Documentation is done immediately after the youth takes the medication. Never document that a medication was taken before the youth actually takes it. Make sure you are familiar with the medications listed on the MOR, doses ordered, and abbreviations used. For each medication that you assist with, your initials, and the time if the medication is ordered PRN, must appear below the correct date and opposite the medication and time. Your initials and full signature must be found in the appropriate space on the bottom of each MOR. If you make an error in recording, draw a single line through the incorrect entry and write your initials and the date above the line. Do not erase or use correction tape/fluid on a medical record or MOR. If the record is called into court, erasures provide reason for legal questions to be raised. Record immediately on the MOR after assisting in the youths selfadministration of the medication. This is the only way you can be sure that you are charting the right medication, at the right dosage, given to the right person, at the right time, and by the right route.
38
2.
3.
4.
5.
6. 7.
8. 9.
10.
Participant Guide
11.
If a medication cannot be given as ordered due to a contraindication, put your initials in the appropriate box, circle the initials, and note the reason for withholding in the comment section on the MOR. You may use the legend that is provided on the MOR as appropriate in place of your initials. Notify your supervisor, facility nurse or designated person and tell them the reason for withholding. Call the prescribing provider if appropriate. If the youth refuses the medication after two attempts within the designated time frame (one hour before through one hour after the scheduled time of administration), put your initials in the appropriate box, circle the initials, and note the reason for the refusal in the comment section on the MOR. If medication is refused for two (2) days, notify your designated supervisor, the facility nurse, the prescribing provider, and the DCS Family Service Worker. Because it can be dangerous for some medications to be stopped abruptly, a note should be included on the MOR if the prescribing provider needs to be alerted immediately if a medication is refused. This information should be obtained from the prescriber when the prescription is written and documented on the MAR/MOR. If unsure if it will be dangerous for the youth not to take the medication, call the facility nurse or prescribing provider immediately. The parent should also be notified about a youths continued refusal of medication. If the medication is a psychotropic medication, the parent should only be notified if the youth is less than 16 years old (youth age 16 years and older must be consulted before parental notification). The youth should sign DCS Form CS-0093 Release from Medical Responsibility. A copy of the form should be forwarded to the DCS Family Service Worker.
12.
13. 14. 15. 16. 17. 18. 19. 20.
Remember that charting is not done correctly unless it contains your initials verified with your full signature and title on the MOR. Writing or printing is acceptable. Always use ballpoint pens, never pencils or felt tip pens. Always write neatly and legibly; spell correctly. Accepted abbreviations may be used. Use the correct column and appropriate line and correct record. Do not chart for another staff member. Do not leave blank spaces on the MOR or progress record. Draw lines to prevent illegal entries. Do not use personal opinions or judgmental statements. The medical record is strictly confidential and it is essential to hold all matters concerning the youth in confidence.
39
Participant Guide
Safe Storage and Control of Medication

1. All prescribed medications and over-the-counter (OTC) medications must be double locked in Group Homes. 2. All medication must be stored in the original labeled container or in containers with a label provided by the pharmacy. 3. Medication cannot be left out for a youth to take at a later time. 4. Medications for a youth on a self-administration program (ordered by the prescribing provider) must be stored in such a way as to make them inaccessible to all other youths in the home. 5. Medication that requires refrigeration must be stored in a separate locked refrigerator. 6. All prescription medications that are in pill form, patches, etc. must be counted at least daily. Liquids, creams, and other medications that cannot be counted should be checked to make sure they are not empty or expired. A written log of this count must be kept with the medication. The written log may be part of the MAR or the MOR. 7. Narcotics and controlled substances must be counted every shift.
40
Participant Guide
Disposal of Medication
1. Medication that is discontinued, expired, unidentifiable, or has a missing or illegible label is not to be dispensed and must be destroyed. 2. Medication that is refused or contaminated (dropped on the floor, spit out, unusual color, leaking, etc.) must be destroyed. 3. Two trained staff persons must be present to witness the disposal of medication in Group Homes. 4. When medication is destroyed in Group Homes, a Medication Disposal Record (DCS Form CS-0712) or equivalent form must be kept and the following information must be included: date and time, name of the youth for whom the medication was prescribed, name of the medication and dose, amount of medication destroyed, reason the medication is being destroyed, means of destruction per agency policy, and signatures of trained staff destroying/witnessing. 5. There are no government guidelines for destroying medication. Pharmaceutical recommendations for the disposal of medications include: Return it to the pharmacy or local hospital if they have a disposal program. Dispose of it at your community household hazardous waste collection program. Dispose of it in the garbage with the following precautions: Scratch out the name for security purposes Add some water to the pills, or an absorbent material like flour or cat litter to liquid medications. Put the containers in a paper bag or other closed container to conceal them. Put them in the garbage as close to trash pickup time as possible.
41
Participant Guide
Communicating with Youth about Medication

Communication with the youth is a very important aspect of care and includes talking, listening and observing. The following are important considerations: Respect the youths rights at all times. Talk to the youth in terms they understand to avoid confusion. Look for and report the youths physical, mental, and emotional condition, reactions and behavior, what they say about their illness and their likes and dislikes. Look for and report abnormal signs and symptoms such as shortness of breath slow or fast breathing fever chills sweating cough pain (location, duration, description) blue color to lips or nails (cyanosis) nausea and/or vomiting drowsiness or dizziness excessive thirst unusual drainage rash skin color, redness, breaks or tears swelling in ankles or feet, face, hands blurred vision pain, burning, frequency or color and/or odor change in urine bloody, watery, hard, black or other abnormal changes in bowel habits any unusual sign, symptom or change noted any accident or incident any side effects to their medicines
42
Participant Guide
Teaching Youth about Their Medication Each youth should know as much as possible about their medications. Ask the facility nurse or prescribing provider for help in teaching the youth about their medication in a way that they will understand. Each medication comes with a reference sheet from the pharmacy. The reference sheet includes information about the medication including name, common uses, warnings, how to use the medication, cautions, possible side effects, overdose information and any additional information that may be important. Go over the reference sheet with the youth and write down any questions the youth has to take to the prescribing provider at the next appointment. You may call the prescribing provider if the questions are urgent. The youth should know and understand why a medicine is being prescribed, how the medicine will affect them, when he/she should be taking the medicine, for how long they must take the medicine, and the side effects. Some youth may need many simple explanations or reminders over time before they fully understand their medication. The facility nurse, the pharmacist, and the prescribing provider can assist with this teaching.
43
Participant Guide
Medication Errors
A medication error is defined as any violation of the five rights: 1. Wrong person This error involves two people; one youth receives a possibly dangerous drug they should not be taking, and another youth who did not get the medication they needed. 2. Wrong medication The youth would be receiving a potentially dangerous drug. They would not receive the benefit of the drug that they should have received. 3. Wrong dosage The dosage of each medication is carefully calculated by the prescribing provider and adjusted to each youths needs. Too little would not be effective; too much could be potentially dangerous. 4. Wrong time In order to maintain a consistent level of medication in the body, medications are given at specific times. If the time schedule is not followed, there will be too little drug or too much drug in the body system at that particular time. 5. Wrong route When administering a drug by the wrong route, the drug may be ineffective and/or may cause tissue damage or bad reactions.
When a Medication Error Occurs

1. When an error occurs you must notify your supervisor, facility nurse or designated person immediately, according to agency policy and procedure. That person will give instruction for the immediate medical care of the youth and will call the prescribing provider if necessary or required. 2. Any instructions given by the prescribing provider including monitoring and further treatment must be documented including who provided the monitoring and further treatment and how and where it was provided. 3. Notify the parent/guardian about the error and what safety plan is in place to observe/treat the youth. 4. An Incident Report is completed and entered into the Incident Reporting system per DCS policy.
44
Participant Guide
How to Prevent Medication Errors

1. Become familiar with the agency medication order process and administration system. Many systems are designed to include additional checks and balances. Know where to obtain medications for a particular youth at the right time. Know where to go for medication information. Lack of information has been identified as a common cause of adverse drug events. Resources include physicians, pharmacists, nurses, drug references, and certain recommended sites on the Internet include: 3. 4. 5. FDA website: fda.gov/cder/drug/DrugSafety/Drugindex.htm WEB MD website: my.webmd.com/drugs/ Medline Plus website: nlm.nih.gov/medlineplus/
2.
Verify orders as much as possible. The transcription process is fraught with places for potential error. Your Group Home should use standard medication administration times. This helps to avoid errors in timed administration. When assisting with self-administration of medications, inspect products for possible defects (cracks in capsules, cloudy fluids, sediment in solutions). Report these as soon as possible to your supervisor, facility nurse and pharmacist. Verify the identity of the youth every time before assisting them with self-administration of any medication. Keep medication clearly labeled as long as possible. Leave in unit dose packaging or original container until dispensing time. Document the youths self-administration in the appropriate records as soon as possible. Document in the correct record. Do not borrow or use medication prescribed for another youth, even if it is the same medication that is prescribed. Instead investigate why the medication is not there. There may be compelling reasons for the medication not to be given (pending order confirmation or a hold order).
6. 7. 8. 9.
45
Participant Guide
10. When assisting in the youths self-administration of over-the-counter medications follow the manufacturers instruction carefully. Consult with the youths healthcare provider or pharmacist for instructions if the youth is on prescription medications. 11. Observe for any and all effects of the medication, including the presence of adverse reaction. It is just as important to document the desired effect, as it is to report a rash. 12. If any medication calculations are necessary, it is wise to check them with another staff person especially if pills or tablets must be split. 13. Be familiar with administration devices before allowing youths to use them and understand their benefits a well as potential disadvantages. The wide variety of delivery systems (inhalers, topical ointments, etc.) requires attention to their proper use. 14. Any order that does not make sense, has abbreviations that you do not understand, has ambiguous directions, is difficult to read, or is prescribed for a disease or problem the youth does not have, should be questioned. Notify your supervisor, facility nurse and prescribing provider for confirmation. 15. Avoid distractions and be particularly careful in times of high stress or short staffing when you are working under pressure. These are the times when you are more susceptible to make mistakes.
46
Participant Guide
Informed Consent
Informed consent is based on the fundamental principle that every person has the right to control his/her own bodily integrity. Everyone has a right to receive sufficient information to enable him or her to make an informed decision about whether to consent to or refuse tests, treatment or medication. This includes risks and benefits of consenting and risks and benefits of not consenting.
Components of Informed Consent

The prescribing provider should provide a verbal and/or written explanation about the test, treatment or medication, explained in a way the patient fully understands and includes: Diagnosis for which the test, treatment or medication is prescribed Nature of the medication, treatment, test, or procedure Name of the medication, including both generic and brand name Dosage and frequency of medication Expected benefits Possible risks and side effects Availability of alternatives Expected outcome without the proposed intervention
Informed Consent for Psychotropic Medication

The DCS Family Service Worker or Contract Agency Case Manager should inform the parent or guardian when a foster youth has an appointment with a psychiatrist, pediatrician or nurse practitioner so the parent or guardian may be included in any decisions about treatment or medications. If psychotropic medications are prescribed and the youth is age 16 years or older, the youth may give their own informed consent. For youth under age 16 years, the parent or guardian is designated to make the informed consent decision. If the parent or guardian is not available to participate in a discussion with the prescribing provider despite documented reasonable efforts, the DCS Well-Being Unit Nurse is designated to make the informed consent decision. DCS Family Service Workers and Contract Agency Case Managers cannot give informed consent for psychotropic medications.
47
Participant Guide
Communication about Medication Evaluations

When a youth attends any health related appointment (with the exception of the EPSDT medical screening), a copy of the Health Services Confirmation and Follow-Up Notification (DCS Form CS-0689) should be taken with the youth. DCS tracks all health services received by children in state custody. This written documentation of the health related appointment should be sent or given to the DCS Family Service Worker and the DCS Well-Being Unit for tracking purposes. There is another form used for appointments related to psychotropic medication which provides more detailed information related to psychotropic medication changes. When a youth attends an appointment for medication evaluation, the psychiatrist, pediatrician or nurse practitioner should complete DCS Form CS0629 Psychotropic Medication Evaluation (or equivalent documentation). This is especially important if there are any changes in the psychotropic medications being prescribed including dosage changes, timing/frequency changes, route changes, or if medication is being stopped. This documentation is then sent or given to the DCS Family Service Worker and the DCS Well-Being Unit Nurse for tracking purposes.
Documentation of Informed Consent

When a psychotropic medication is prescribed, the psychiatrist, pediatrician or nurse practitioner should complete DCS Form CS-0627 Informed Consent for Psychotropic Medication (or equivalent form). The consent form should be signed by the youth if age 16 years or older or by the parent or guardian. If the parent or guardian is not available to participate in a discussion with the prescribing provider despite documented reasonable efforts, the DCS Well-Being Unit Nurse is designated to make the informed consent decision. Regardless of who gives the consent, the consent documentation should be provided to the DCS Family Service Worker and the DCS Well-Being Unit Nurse for tracking purposes. When it is not possible to obtain written documentation of the informed consent, the prescribing provider can document on the consent form that the consent was given verbally and note by whom (e.g., parent, DCS Well-Being Unit Nurse). Ideally a second person should witness the verbal consent, whenever possible, and document the witness of the verbal consent on the consent form. A copy of the verbal consent documentation should be provided to the DCS Family Service Worker and the DCS Well-Being Unit Nurse for tracking purposes.
If you have any questions about informed consent or the DCS forms required, please contact the DCS Well-Being Unit Nurse.
48
Participant Guide
Worksheet #2
Jamie is 13 years old and was placed in your facility last evening. The DCS Family Service Worker left a prescription bottle of Ritalin when he dropped Jamie off last evening and instructed the evening staff that Jamie takes one pill every morning. This morning you are ready to start assisting in the self-administration of medications and you realize there are only two pills left in Jamies Ritalin bottle. You also remember from your training that you are supposed to have a signed Informed Consent for Psychotropic Medication and you do not see one in Jamies file. What do you do?
49

PARTICIPANT GUIDE Assistance With Self-Administration of Medication Janu

Enviado por

Dados do documento

Descrição original:

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

PARTICIPANT GUIDE Assistance With Self-Administration of Medication Janu

Enviado por

Direitos autorais:

Formatos disponíveis

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Viola P. Miller, Ed.D.

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Legal Basis for Training

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Methods of Medication Administration

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Requirements for Unlicensed Personnel to Assist Youth with Self-Administration of Medications

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Guiding Principles for Assisting Youth with Self-Administration of Medication

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Responsibilities in Assisting with Self-Administration of Medications

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Legal Issues Childrens Rights, Refusal of Medication, and Confidentiality

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Obtaining Information about Medications

Common Medication Abbreviations and Symbols

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Major Classifications of Medications

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Purpose of Prescribing Medication

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Routes of Medication Administration

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Actions and Effects of Medication

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Drug or Medication Overdose

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Poison Control Center

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Tennessee Department of Childrens Services

Assistance with Self-Administration of Medication January 2010

Five Rights of Assisting with Medication Self-Administration

Assistance with Self-Administration of Medication January 2010

Important Things to Know about Assisting Youth with Self-Administration of Medication

Tennessee Department of Childrens Services