1 AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

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4 Resolution: 222
5 (A-09)
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7Introduced by: American Medical Directors Association
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9Subject: Recognition of the “Nurse as Agent” of the Prescriber in Long Term Care
10 Settings
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12Referred to: Reference Committee B
13 (Monica C. Wehby, MD, Chair)
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16Whereas, The US Drug Enforcement Administration (DEA) does not recognize nursing facility
17staff as agents of the prescriber/physician in long term care facilities (LTCFs); and
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19Whereas, Current enforcement activities regarding the prescribing and dispensing of controlled
20drugs for long term care patients have prompted repeat phone calls to physicians across the
21country to confirm an order previously given to a nurse; and
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23Whereas, The DEA has interpreted federal policy as follows (66 Fed Reg. 20834; April 25,
242001):
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26If the pharmacist contacts the physician after speaking with the nurse, all requirements will be
27satisfied, and the physician will receive only one communication. Although it is common
28practice for the nurse to communicate a patient’s needs to the physician, it is suggested the
29nurse contact the provider pharmacy, and the pharmacist then contact the physician. This
30procedural change would assist the pharmacist in fulfilling the requirement to communicate with
31the prescriber prior to filling the prescription; and
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33Whereas, The DEA’s interpretation of policy requires both prompt access to physicians and
34proximity of physicians to a prescription form and a fax machine at all times, creating the
35administrative burden of adding multiple steps to an already complex communication process,
36and a delay in the delivery and administration of pain relieving medication; and
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38Whereas, Long-term care pharmacists are not on-site, do not have access to the resident’s
39chart and have very limited knowledge of the resident’s overall health care condition; and
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41Whereas, Physicians assess the needs of their patients, develop monitoring plans, and clarify
42the goals of medication therapy with the nurse, not the pharmacist; and
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44Whereas, A recent survey of State Pharmacy Boards by the National Association of State
45Boards of Pharmacy found that 14 of 16 respondents officially recognized long term care facility
46nursing staff as agents of the prescriber in their state pharmacy laws; and
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48Whereas, The National Association of State Boards of Pharmacy Model Act also includes
49language that authorizes nursing facility staff to act as an agent of the prescriber provided the
50nursing staff is authorized to do so in the facility’s written policies and procedures in accordance
51with applicable state and federal laws; and
 1 Resolution: 222 (A-09)
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1Whereas, Long-term care facilities provide 24-hour care for their patients, but physicians are
2unlikely to be able to respond in person to all urgent or emergent needs of facility patients; and
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4Whereas, When urgent or emergent changes arise, a timely response to the needs of the
5patient dictates the common need for the facility nurse to take a verbal order to begin
6assessment and/or treatment; and
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8Whereas, The nursing facility structure is supposed to allow for rapid relief of pain symptoms as
9noted by recent regulatory changes issued by the Centers for Medicare & Medicaid Services in
10the State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care
11Facilities. One of the regulations requires residents to be given rapid relief of “excruciating pain”
12as defined in F-Tag 309; therefore be it
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14RESOLVED, That our American Medical Association urge the US Drug Enforcement Agency to
15amend its regulations to recognize nursing facility staff as agents of the prescriber/physician in
16long term care facilities. (Directive to Take Action)
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18Fiscal Note: Implement accordingly at estimated staff cost of $1,188.
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20Received: 05/14/09