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INTRODUCTION: MEDICATION ADMINISTRATION 1 REV April 2016 DHS-Office of Licensing and Regulatory Oversight

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Page 1: 1 INTRODUCTION: MEDICATION ADMINISTRATION · eliminating medication. medications remain ... A medication administration system ... An antacid may relieve stomach irritation and discomfort,

INTRODUCTION:

MEDICATION ADMINISTRATION1

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

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INTRODUCTION

Implementing a safe medication administration system is an essential responsibility of the AFH licensee:

Administering medications involves more than giving residents their medications including:

Obtaining and managing medical orders;

Understanding each residents medications;

Proper storage;

Proper disposal.

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INTRODUCTION CONTINUED

Medications treat a wide variety of chronic conditions and diseases allowing people to live longer, healthier and more independently than in the past. Medications not used properly can have serious consequences including:

Significant injury to major organs, such as kidneys and liver; or

Death.

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INTRODUCTION CONTINUED

The AFH rules require licensees and their caregivers to:Know the reason the medication is taken;

Understand how the medication is expected to work;

Know the side effects of each medication;

Understand any client or resident specific instructions.

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ALERT

All substitute caregivers must have training on how to administer

medications properly and knowledge of each residents

medications BEFORE they administer any medication.

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AGE-RELATED CHANGES6

Normal aging alters medication absorption and elimination, which means the action of many medications in the elderly is less predictable than in younger adults:Each person reacts differently to medication

therapy;

Age-related changes can cause changes in how the person reacts to the medication in part due to:

Natural decline in kidney and liver function; or

Damage to kidney or liver function due to disease or other causes.

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AGE-RELATED CHANGES CONTINUED7

Age-related changes affecting the action of medications include:

Decrease in volume of blood and water in the body. Result:

Medication is distributed throughout the body in a more concentrated form.

Decrease in liver and kidney function. Result:

The organs are slower in breaking down and eliminating medication. medications remain active in the body longer and may build to toxic levels.

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AGE-RELATED CHANGES CONTINUED8

Decline in gastrointestinal function. Result:

Medication absorption is delayed.

More body fat than muscle. Result:

Because fatty tissue stores some medications, unpredictable and delayed medication action may occur.

Lower body weight in older adults. Result:

Normal adult dosage may cause overdose. Fewer medications are required with low body weight.

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ADMINISTRATION SYSTEM

A medication administration system includes:

Obtaining medical orders;

Transcribing medication orders on to the medication administration record (MAR);

Verifying medical orders against the MAR;

Administering medications;

Infection control practices;

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ADMINISTRATION SYSTEM

Monitoring and documenting;

Storage;

Disposing of discontinued, unused, contaminated or expired medication;

Disposing of sharps;

Disposing of contaminated supplies used when administering medications; and

Re-ordering medications.

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You and your staff must understand the resident’s orders and be able to perform the tasks required to administer the medications:

All caregivers must get training before giving medications;

Tasks such as taking a pulse may need to be performed before giving a medication;

Checking a pulse, blood pressure (BP) or blood sugar (CBG) before giving a medication is common in AFH.

11 ADMINISTRATION SYSTEM

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When dispensing medications all caregivers must use infection control procedures:

Proper hand washing techniques:

Wash hands before and after administering medications for each resident;

Wear gloves when appropriate administering:

Topical medications;

CBG testing;

Subcutaneous injections.

12 ADMINISTRATION SYSTEM

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MEDICAL ORDERS

The resident’s healthcare provider or specialist (prescriber) is responsible for approving all medications and treatments:

A written order or prescription for all medications;

Treatments, therapies and any special diet requirements; and

Written approval for over-the-counter (OTC), supplements and herbal treatments requested by the resident.

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WHO CAN PRESCRIBE?

Prescribing authority in Oregon includes:

Medical doctor (M.D.);

Doctor of osteopathic medicine (D.O.);

Doctor of podiatric medicine (D.P.M.);

Physician’s assistant (P.A.);

Nurse practitioner (N.P.);

Clinical nurse specialist (C.N.S.); or

Dentist (D.M.D. or D.D.S.).

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WHAT ARE MEDICATIONS?

Medications are any chemical treatment, medication or remedy used to:

Maintain health;

Treat disease or illness; and

Prevent or treat a symptom, including but not limited to:

Aches that are not related to disease (headaches, sprains, etc.); or

Difficulty sleeping.

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WHAT ARE MEDICATIONS?

Medications include:

Prescription medications — prescribed by a medical professional and dispensed through a pharmacy;

Over-the-counter medications (OTC) — can be purchased without a prescription including:

Cold remedies, aspirin etc.;

Alternative medications — herbal remedies such as Saint John’s Wart, nutritional supplements such as Ensure, and vitamins;

Home remedies.

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ALERT

No matter the type of medication, the risk for a medication

interaction increases with each additional medication the person

takes.

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THERAPEUTIC EFFECT

All medications have a therapeutic effect known as desired effects. Examples include:

Pain relief from pain medication;

Reduced high blood pressure from blood pressure medication;

Maintenance of appropriate blood sugar levels in diabetes; and

Reduced psychotic symptoms in psychiatric conditions.

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SIDE EFFECTS

Side effects may be desirable or undesirable. Examples of undesirable effects (not intended):

An antihistamine (allergy medication) may stop you from sneezing and having a runny nose, but it may also make you sleepy.

An antacid may relieve stomach irritation and discomfort, but may cause:

Constipation; and

Interfere with the effectiveness of other medications.

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SIDE EFFECTS CONTINUED

Side effects may be:

Minor and may not interfere with the individual’s quality of life; or

Can be enough of a problem that it interferes with the person’s quality of life:

AFH provider is expected to document all side effects and work with the resident’s healthcare provider if side effects negatively impact the resident.

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ALERT

Do not minimize an individual’s complaints regarding side effects. What may seem insignificant to

you can be a significant to someone else. Side effects are frequently the

reason people stop taking their medications.

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ADVERSE MEDICATION REACTION

An adverse medication (drug) reaction (ADR) is a less common or unexpected effect that generally means a medication is not right for that person:

Severity can range from moderate to extremely serious;

An ADR can occur soon after beginning a medication, or it can take weeks or months to appear.

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ADR CONTINUED

ADR must be:

Reported to the prescriber immediately; and

Documented in the resident’s record.

Examples of ADRs:

Sedation/insomnia (sleepiness);

Confusion;

Unsteady gait;

Blurred vision;

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ADR CONTINUED

Movement disorders;

Memory loss;

Rash;

Agitation, anxiety;

Seizures;

Stomach ulcers or bleeding;

Incontinence;

Hallucinations.

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SIDE EFFECTS|ADRs

Side effects and adverse medication reactions (ADRs) can be subtle and hard to identify. For example:

A red, bumpy rash from head to toe would be a clear indication of an adverse medication reaction.

It would be harder to identify an ADR if the same person stopped reading the newspaper due to blurred vision.

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SIDE EFFECTS|ADRs CONTINUED

Side effects and ADRs often go unnoticed or are misdiagnosed in seniors:

Physical reactions such as fatigue, falling or weight loss that may be mistaken as “normal” aging;

Symptoms may be mistaken for decline of an existing health condition or a new health condition;

May mimic diseases such as the confusion associated with dementia or Alzheimer’s disease.

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ALERT

Consider any sudden change in an older adult’s physical ability or

personality, especially after beginning a new medication, to be

an adverse medication reaction until proven otherwise.

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MEDICATION INTERACTIONS

A medication interaction is when one medication changes or alters the function of another medication. This includes:

Pharmacy-dispensed medications;

Medications purchased over-the-counter;

Alternative medications and supplements;

Home remedies; and

Foods and beverages can also interact with medications.

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MEDICATION INTERACTIONS CONTINUED

Medication interactions include:

Medication to medication:

Calcium supplement can reduce the effectiveness of medications used to treat low thyroid levels; or

Two different medications that cause drowsiness can significantly increase the risk of injury or falls.

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MEDICATION INTERACTIONS CONTINUED

Medication to food or beverage:

Grapefruit juice and fresh grapefruit can increase the amount of active ingredient for certain medications leading to increased adverse medication reactions.

Medication to disease:

An existing medical condition can make certain medications potentially harmful. For example someone with liver damage may have to restrict or avoid acetaminophen or other medications that can be harmful to the liver.

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MEDICATION INTERACTIONS CONTINUED

Seniors, persons with chronic health conditions or developmental or physical disabilities are at higher risk for medication-related problems:

Taking several medications increases the risk for an adverse reaction;

One or more chronic conditions — such as heart disease, high blood pressure, diabetes and arthritis — can affect how a medication works in the body.

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ACCESS TO INFORMATION

Caregivers must have immediate availability to medication references:

Online resources:medications.com

Current medication reference:Updated medication reference books are

generally available annually in October/November.

Current product inserts or medication summary:Must replace each time a refill is picked up;

AND

Each time an OTC is purchased.

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MEDICATION ERRORS

Medications are used to treat disease and ease discomfort or pain. When medication errors occur it may cause harm:

Medication errors are a common problem resulting in ER visits, hospitalizations and even death;

It is estimated that 98,000 individuals die each year due to medication errors:

Taking too much

Not taking; or

Taking inappropriately.

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All medication errors have the potential to be serious and cause harm:

Negative effects of a medication error may not be visible for years;

Overuse or overdose can cause damage to major organs such as kidneys and liver:

Overdose can even occur when a medication ordered multiple times a day is given too close together.

Medication errors may lead to corrective action and/or a finding of abuse.

34 MEDICATION ERRORS CONTINUED

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Common medication errors include but not limited to:

Giving a medication at the wrong time;

Not giving a scheduled medication;

Not giving a PRN medication when indicated;

Giving a medication using the wrong route;

Giving an incorrect dose;

Not rotating subcutaneous injections or transdermal patches;

35 MEDICATION ERRORS CONTINUED

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Giving the wrong medication;

Giving a discontinued medication;

Giving an expired medication;

Giving a medication to wrong resident;

Improperly stored medication;

Missing or incomplete documentation;

Improper disposal.

36 MEDICATION ERRORS CONTINUED

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37 HOW TO READ LABELS PRESCIPTION

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38 HOW TO READ LABELS OVER-THE-COUNTER

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39 HOW TO READ LABELS SUPPLEMENTS

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40 HOW TO READ LABELS HERBAL TEAS

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Herbal tea remedies can interfere with other medications or certain conditions. It is critical to read all labels even for herbal teas:Chamomile:

Negatively interacts with estrogen, tamoxifen and coumadin; and

Isn’t recommended for individuals with allergies to ragweed.

Licorice has a major interactions with coumadin and negatively interacts with digoxin, estrogen and Lasix;

Ginger can increase the risk of bleeding

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41 HOW TO READ LABELS HERBAL TEAS

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42 MEDICATION ROUTES

Medications can be introduced into the body through many routes. The prescriber will write what route the medication must be given:

If medications are not given as ordered it may result in:

Medication not working properly; or

Harm.

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MEDICATION ROUTES

G-tube/j-tube1;

Subcutaneous injections1;

Intramuscular (IM) injection2;

Inhalation into lungs;

Nasal (drops or inhalers);

Ophthalmic (eye);

Oral (taken by mouth);

Otic (ear);

Rectal;

Sublingual;

Transdermal (via skin);

Vaginal.

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1An RN must delegate a task of nursing before you can perform the task.

Common tasks of nursing include but are not limited to:

Subcutaneous injections, for example insulin;

Food, fluid or medication administration through a gastrointestinal (g-tube) or jejunostomy tube (j-tube);

Peritoneal dialysis;

Other tasks as determined by the RN.

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1The delegation process requires the RN to:

Evaluate the resident and caregiver(s);

Provide training to the caregiver(s);

Observe the caregiver(s) perform the task on the resident;

Leave step-by-step instructions on the task; and

Provide on-going supervision for the task that has been delegated.

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Each delegation is for one specific resident and cannot be transferred to other residents;

The delegated caregiver cannot teach other caregivers to do the task.

For additional information on your responsibility for delegated tasks take the self-study course: RN Delegation for Lay Caregivers at – http://tinyurl.com/DHS-AFHTraining

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MEDICATION ROUTES CONTINUED

Intramuscular2 (IM) injections cannot be delegated. Arrangements must be made with a licensed practitioner to administer. Options available:Request a referral for home health or, if the

resident is on hospice, make arrangements with hospice;

Contract with a nurse to perform the task; or

Make arrangements with the resident’s primary health care practitioner.

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2Intramuscular (IM) injections are allowed for anticipatory emergency medications. Giving IM injections is taught and cannot be delegated:

Epinephrine:

Allergic reaction emergencies;

Glucagon:

Severe low blood sugar emergencies.

June 2012

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2Caregivers must be trained by an approved trainer following the

training curriculum outlined by the Health Division’s Anticipatory

Emergency rules.

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MEDICAL ABBREVIATIONS

While gathering information and medical orders you may encounter medical abbreviations. If you do not understand, ask for clarification from an appropriate medical professional:The abbreviations listed on the following tables

identified with an asterisk (* ) should not be used:

This recommendation is based on high frequency of errors. The abbreviations were included since some individuals may still be using them.

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MEDICAL ABBREVIATIONS CONTINUED

Common Medical Abbreviations

Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.

@ At ad lib As desired

< less than AMT Morning> more than AMT/amt amount

a Before APAP Acetaminophen

ac Before meals AS* Left ear

AC* Acetaminophen ASA* Aspirin

Acetam* Acetaminophen ASAP As soon as possible

Acetamin* Acetaminophen AU* Both ears

AD* Right ear BID Twice (2 times) a day

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MEDICAL ABBREVIATIONS CONTINUED

Common Medical Abbreviations

Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.

BM Bowel movement drsg Dressing

BP Blood pressure FBS Fasting blood sugar

caps Capsules g-tube Gastrostomy tubecath Catheter hr Hour

c With HS/hs Hour of sleep

CBG Capillary blood glucose H/A Headache

C/O or c/o Complaint of HTN Hypertension

CP Chest pain Hx History

D/C Discontinue I&O Intake & output

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MEDICAL ABBREVIATIONS CONTINUED

Common Medical Abbreviations

Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.

IM Intramuscular mid noc Midnight

IV Intravenous min Minute

j-tube Jejunostomy tube mg Milligram

l liter ml Milliliter

L* left MOM Milk of magnesium

liq Liquid N/V Nausea/vomiting

lb Pound N/V/D Nausea/vomiting/diarrhea

mcg Microgram(s) NC Nasal cannula

meds Medications NKDA No known allergies

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MEDICAL ABBREVIATIONS CONTINUED

Common Medical Abbreviations

Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.

noc Night pm Afternoon

NPO Nothing by mouth PO By mouth or orally

O2 Oxygen PRN As necessary or needed

OTC Over-the-counter Q/q Everyoz Ounce Q2H/q2h Every 2 hours

p After Q3H/q3h Every 3 hours

pc/ pc after meals Q4H/q4h Every 4 hours

PCN Penicillin Q6H/q6h Every 6 hours

per By or through Q12H/q12h Every 12 hours

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MEDICAL ABBREVIATIONS CONTINUED

Common Medical Abbreviations

Abbreviations are case-specific. Abbreviations with an asterisk * should not be used or is recommended not to use.

QD or qd Each day or daily SL Sublingual

QH or qh Every hour SOB Shortness of breath

QHS/qhs* at bedtime SQ or sq subcutaneous

QID or qid* Four times a day Sx Symptom

QOD/qod* Every other day tab tablet

R Right TID or tid Three times a day

ROM Range of motion V/S Vital signs

RxPrescription medication wt Weight

s/s̄ Without

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MEDICAL ORDERS56

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57

The AFH provider is responsible for obtaining all necessary written orders and understanding:

The reason for the medication;

How the medication is expected to work; and

Any special instructions from the prescribing practitioner about the medications.

The AFH provider is responsible for carrying out the written orders.

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MEDICAL ORDERS CONTINUED

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58

The following must all have a written medical order from a prescribing practitioner:

Prescription medications;

Prescribed over-the-counter (OTC) medications including vitamins and other nutritional supplements;

Prescribed dietary supplements; and

Prescribed treatments and therapies.

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MEDICAL ORDERS CONTINUED

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OTC medications, vitamins, nutritional supplements or home remedies not prescribed, but requested by the resident, must be reviewed by the resident’s primary health care practitioner, approved and documented in the resident’s record.

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MEDICAL ORDERS CONTINUED

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Written orders from a hospital, emergency room or nursing home sent with the resident can be used initially ifsigned by a prescriber. These orders are temporary and must be followed up with written orders from the resident’s primary healthcare practitioner immediately.

60 ALERT

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Changes to medical orders may not be made without the prescribing practitioner’s approval;

All medical orders must be followed as prescribed unless the resident or their legal guardian refuses:

If a medical order is refused, the prescribing practitioner must be notified immediately by the AFH provider and documented in the resident’s record.

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MEDICAL ORDERS CONTINUED

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Changes to medication or treatment orders obtained by telephone must be followed up with a signed order from the prescribing practitioner, immediately:

Phone orders must be recorded in the resident’s record with the printed name and signature of the person taking the phone order;

Requests for signed orders must be made promptly after receiving any telephone order;

All attempts to request written orders must be documented in the resident’s record.

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MEDICAL ORDERS CONTINUED

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Changes in dose or frequency of an existing medication must be clearly identified:

Changes need to be written on an auxiliary label and affixed to the original medication container.

Be sure to inform the pharmacist of the changes before it is time to refill the order:

DO NOT have the prescription refilled without the pharmacist contacting the prescriber for the correct information.

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MEDICAL ORDERS CONTINUED

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MEDICAL ORDERS CONTINUED

Do not obscure the original order. Attach a label to the side of the bottle with the new orders clearly identified. Use until supply is gone.

New

3/1

6/2

01

1

take

30

mg

(1.5

ta

ble

ts)

by

mo

uth

in

am

KL

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MEDICATION ADMINISTRATION RECORD65

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A written medication administration record (MAR) must be kept for each resident:

Frequent changes to the dosage of some medications are common. The MAR must be kept current at all times;

Failure to keep the MAR up-to-date could result in a medical emergency for the resident.

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MAR

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The MAR must identify all medications and treatments ordered including, but not limited to:

Prescription medications;

Over-the-counter medications;

Dietary supplements, including vitamins and minerals;

Treatments;

Vital signs and/or weight; and

Blood sugar checks (CBGs).REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR CONTINUED

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The MAR must be legible and clearly indicate:

Name of each medication;

Dose;

Route (how it is to be administered) if other than by mouth;

Day and frequency (i.e. daily, or tid); and

Time the medication must be given.

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MAR CONTINUED

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Immediately after administering a medication or performing a treatment, therapy or procedure, the person doing the task must write his or her initials and the time in the appropriate place and note any information required:

Every set of initials must have a legible signature on the MAR for identification purposes.

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MAR CONTINUED

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If multiple caregivers have the same two initials, decide who will need to add an additional initial to include a middle name.

Make sure there is a printed name with a matching signature for every set of initials on the MAR.

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MAR CONTINUED

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Each new month write the month and year on a new MAR sheet:

Carefully write the medication, dose, route, days and times the medications are to be administered and any specific instructions on each resident’s MAR according to the written medical orders.

If you receive an order to stop a medication during the month, note that on the MAR immediately.

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MAR CONTINUED

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR SAMPLE

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MAR INFORMATION

All fields must be filled out:Resident’s full name;Name of resident’s healthcare provider:Recommended to also list phone number.

List of all allergies;Month and year.

Resident: Residents full name

Month/Year: Enter current month and year

Physician: Name of healthcare provider and phone #

Allergies: List all allergies

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR INFORMATION CONTINUED

Name of the medication (write exactly as written):

Strength of medication for example 20 mg.;

Write dose if strength and dose are not equal. For example give 10 mg (1/2 tablet);

Frequency, for example BID in AM and PM;

How to administer, for example PO;

Any special instructions such as hold if pulse less than 60 or blood sugar less than 100 etc.; and

Reason for the medication.

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR INFORMATION CONTINUED

Medication Hour 1 2 3 4 5 6 7 8

Lasix 20 mg, 1 tablet po each AM for CHF

Name of the drug; strength and dose if not equal t the strength; frequency; how to administer (route); any special instructions; and reason for the medication.

Use as many segments on the MAR as necessary.

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR INFORMATION CONTINUED

Medication Hour 1 2 3 4 5 6 7 8

Lasix 20 mg, 1 tablet po each AM for CHF

9 AMList the time to be given. You must list an actual hour.

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR INFORMATION CONTINUED

Medication Hour 1 2 3 4 5 6 7 8

Lasix 20 mg, 1 tablet po each AM for CHF

9 AM

8:30 AM

BC

Initial and indicate

the actual time give.

Initials: BC Signature - Best Caregiver Best Caregiver

Initials: Signature -

Each set of initials must have a signature and the name

printed on the MAR.

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78

Some medications, such as those used for pain, are written as “PRN.” This means the medication is given as needed:

All PRN medications must be written on the MAR;

All PRN medications, including over-the-counter medications, must have specific parameters indicating:

What the medication is for; and

Specifically when, how much and how often the medication may be administered.

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MAR PRN MEDICATIONS

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79

It is best if the prescriber writes the parameters when ordering PRN medications:

Ask your pharmacist to request this information when accepting a prescription order;

If a PRN medication does not include specific written parameters, an RN may be able to write parameters after assessing the resident:

RNs cannot write parameters for any medication including OTCs and supplements that does not have a medical order.

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MAR PRN MEDICATIONS CONTINUED

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The parameters should be recorded on the medication administration record (MAR):

Caregivers dispensing PRN medications must follow the resident-specific written instructions;

If the instructions are confusing or do not make sense seek clarification with the RN, pharmacist or prescribing practitioner before giving.

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MAR PRN MEDICATIONS CONTINUED

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81

Documenting PRN medications on the MAR must include the:

Time given;

Dose how much was given;

The reason for giving the medication; and

Whether or not it was effective.

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MAR PRN MEDICATIONS CONTINUED

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR PRN MEDICATIONS CONTINUED

Documentation:

Medication Hour 1 2 3 4 5 6

Hydroco/AC 5-500 Tab take 1 tablet PO every 4 hours as needed for jaw pain. May take 1 more tablet in 2 hours if no relief after the first dose. Maximum of 8 tablets in 24 hours

DS 5 PM

DS 7:15 PM

Medication Hour 1 2 3 4 5 6

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REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR PRN MEDICATIONS CONTINUED

Documentation example for a verbal resident:

Date Hour Medication Reason Results Hour

4/6/2014 3 PM Hydroco/AC 5-500 mg 1 tab

c/o jaw pain Still in pain 5 PM

4/6/2014 5 PM Hydroco/AC 5-500 mg 1 tab

Still in pain States no pain

7:15 PM

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MAR PRN MEDICATIONS CONTINUED

Documentation example for a non-verbal resident:

Date Hour Medication Reason Results Hour

4/6/2014 3 PM Hydroco/AC 5-500 mg 1 tab

Moaning and holding jaw where tooth was pulled

Still in moaning and appears to be in pain

5 PM

4/6/2014 5 PM Hydroco/AC 5-500 mg 1 tab

Still moaning Appears comfortable and participating in activities

7:15 PM

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85

The caregiver giving the PRN medication needs to document in the resident’s record the response to the medication. For example:

01/02/2011 Ms. M.M.A. complained of a headache at 10 am. Gave her two Tylenol tablets at 10:15 a.m. At 11 a.m. Ms. M.M.A. reported that she no longer had a headache.

01/05/2011 Ms. M.M.A. has not had a BM for three days gave 2 tablespoons of milk of magnesia at 8 a.m.

01/06/2011 Ms. M.M.A. had a BM this morning.

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MAR PRN MEDICATIONS CONTINUED

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86

Most scheduled medications for the same dose each day however, there are some medications that are not given every day:

For example, a medication used to treat hypothyroid disease frequently is scheduled for only five days a week;

The two days of the week, the medication is not to be given must be clearly marked on the MAR.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR SCHEDULED MEDICATIONS – ALTERNATING DAYS

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87

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MAR SCHEDULED MEDICATIONS – ALTERNATING DAYS

Medication Administration/Instruction Record

Resident: Mxxx Lxxxx Physician: Dr. Feelbetter

Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products

Medication Hour 1 2 3 4 5 6 7 8

L-thyroxine 125 mcg1 tablet every Mon, Tue, Thu, Fri & Sat

7AM BC BC BC IX BC BC

Medication Hour 1 2 3 4 5 6 7 8

Initials: BC Signature - Best Caregiver Best Caregiver

Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky

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88

Some medications may be ordered to give dosages on different days:

When different doses of the same medication are given on different days or different times, the medication needs to be listed on the MAR each time the dose is different:

In the following example L-thyroxine is given in two different doses on alternating days.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR SCHEDULED MEDICATIONS – ALTERNATING DOSES

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MAR SCHEDULED MEDICATIONS - ALTERNATING DOSES

Medication Administration/Instruction Record

Resident: Mxxx Lxxxx Physician: Dr. Feelbetter

Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products

Medication Hour 1 2 3 4 5 6 7 8

L-thyroxine 125 mcg1 tablet every Mon, Wed & Fri

7AM BC IX BC

L-thyroxine 125 mcg2 tablets every Tue, Thu, Sat & Sun

7AM BC

7:30 AM

IX BC 7:15 AM

IX

BC

Medication Hour 1 2 3 4 5 6 7 8

Initials: BC Signature - Best Caregiver Best Caregiver

Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky

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Insulin orders require additional information on the MAR:

When CBG testing must occur;

CBG value (blood sugar results);

Where the injection was given (rotation site);

What to do if blood sugar is too high or too low.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR SCHEDULED MEDICATIONS - INSULIN

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MAR SCHEDULED MEDICATIONS - INSULIN

Medication Hour 1 2 3 4 5 6 7 8

Novolog 15 units sq TID 5 minutes before eating meal. Hold if CBG less than 100

7:55* AM

8AM BC

CBG 110

Rotation Site 1

Novolog 15 units sq TID 5 minutes before eating meal. Hold if CBG less than 100

11:55* AM

11:55AM BC

CBG 106

Rotation Site 5

Novolog 15 units sq TID 5 minutes before eating meal. Hold if CBG less than 100

5:55* PM

5:55 PM BC

CBG 125

Rotation Site 9

*Times listed are 5 minutes before meals are served. See Novolog ALERT

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92

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MAR SCHEDULED MEDICATIONS - INSULIN

Some rotation charts do not have numbers or letters listed. If they are blank: • Add letters or

numbers;• Keep the chart with

the residents MAR;• List the corresponding

number or letter on the MAR

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93

Transdermal patches also require additional information to be written on the MAR:

Where the patch was placed (rotation site);

A time to remove if it is not replaced with a new one at the same time each day. For example Nitroglycerin transdermal patches can only be left in place for 8 – 10 hours depending on the order:

Failure to remove can create significant negative outcomes for the resident.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR SCHEDULED MEDICATIONS – TRANSDERMAL PATCHES

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94

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR SCHEDULED MEDICATIONS – TRANSDERMAL PATCHES

Medication Hour 1 2 3 4 5 6 7 8

Nitro TD Patch-A 0.1 mg/hrplace one patch daily for 10 hours

9AM 9:30 AMBC

Remove nitro patch 7PM BC

Rotation site L1

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MAR SCHEDULED MEDICATIONS – TRANSDERMAL PATCHES

• You may use the provided tracker;

• Instructions on appropriate placement is found in the product information sheet;

• This rotation (tracker) document is specific for Exelon.

L1 R1

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If the medication dose is changed, draw a line from the last dose given to the end of the month:

In a new line, write the new information regarding the medication, dose, route, day and time; draw a line to the start day.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR DOSE CHANGE

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97

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MAR DOSE CHANGE CONTINUED

Medication Administration/Instruction Record

Resident: Mxxx Lxxxx Physician: Dr. Feelbetter

Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products

Initials: BC Signature - Best Caregiver Best Caregiver

Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky

Medication Hour 1 2 3 4 5 6 7 8

L-thyroxine 125 mcg1 tablet every Mon, Tue, Thu, Fri & Sat

7AM BC IX

L-thyroxine 125 mcg1 tablet daily in the am

7AM 7:15 AMIX

BC

Medication Hour 1 2 3 4 5 6 7 8

Order d/c 7/72011

New order started 7/7/2011

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98

If a medication is either missed or if the resident refuses to take it, the caregiver must document this on the MAR circling the caregiver’s initials, and indicate why the medication was missed or refused.

The caregiver also documents in the resident’s record what action was taken (who was notified), as well as any follow-up instructions from the resident’s primary health care practitioner.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MAR MISSED OR REFUSED MEDICATION

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99

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MAR MISSED OR REFUSED MEDICATION CONTINUED

Medication Administration/Instruction Record

Resident: Mxxx Lxxxx Physician: Dr. Feelbetter

Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products

Medication Hour 1 2 3 4 5 6 7 8

Proventil 90/mcg/spray inhaler – 2 puffs thru mouth every 6 hours while awake

7 AM IX BC BC IX BC BC BC IX

1 PM BC BC BC IX BC BC BC IX

7 PM BC BC BC IX BC IX IX IX

Medication Hour 1 2 3 4 5 6 7 8

Initials: BC Signature - Best Caregiver Best Caregiver

Initials: IX Signature - Ifnx Xmnky Ifnx Xmnky

Date Hour Medication Reason Results Hour

1/3/2011 1 PM Proventil Refused stated didn’t need it

No difficulty breathing 7:15 PM

1/8/2011 1 PM Proventil Out shopping No difficulty breathing 7PM

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In the case of those residents with written authorization from their primary health care practitioner to self-medicate, you are still responsible for:

Knowing the reason for the medication

What the medication is expected to do; and

If there are any special instructions from the prescribing practitioner about the medications.

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MAR SELF-ADMINISTRATION

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101

Resident’s able to self-administer still require an updated MAR:

In order for you and your caregivers to document in the resident record that the resident is taking medications as ordered;

Is necessary in an emergency when information needs to be shared with emergency responders;or

On days the resident is unable to take their medications for example when resident is ill.

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MAR SELF-ADMINISTRATION CONTINUED

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MAR SELF-ADMINISTRATION CONTINUED

Medication Administration/Instruction Record

Resident: Mxxx Lxxxx Physician: Dr. Feelbetter

Month/Year: January 2011 Allergies: Codeine, Sulfa drugs, dairy products

Medication Hour 1 2 3 4 5 6 7 8

MultiVit 1 table every AM 8 AM

L-thyroxine 125 mcg 1 tab every AM 8 AM

Tylenol 325 mg 2 tablets every 6 hours as needed for headache

PRN

Milk of Magnesium 2 TB daily if no BM for 3 days

PRN

Medication Hour 1 2 3 4 5 6 7 8

Resident has order to self-

medicate all medications. See

resident record for documentation.

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When a resident has a medical appointment with her or his primary health care practitioner and/or specialist:

Take a medical visit report, SDS 0341, listing all medications (including over-the-counter) the resident is currently taking; and

Information regarding any concerns or issues with any medication.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

MEDICAL VISITS

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104

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MEDICAL VISITS CONTINUED

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105

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PSYCHOTROPIC MEDICATIONS

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106

Psychotropic, also known as psychoactive, medications act primarily upon the central nervous system where it affects the brain, changing an individual’s perception, mood, consciousness, cognition and/or behavior:

Psychotropic medications are not intended to be used:

For the convenience of the caregiver or facility;

Instead of implementing non-medication interventions, including redirection; or

To control individual behaviors that do not pose a risk to the individual or others.

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PSYCHOTROPIC MEDICATIONS

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107

Psychotropic medications are important tools used to treat:

Anxiety;

Attention Deficit Hyperactivity Disorder (ADHD);

Bipolar disorder;

Depression;

Obsessive-compulsive disorders (OCD);

Post Trauma-Stressor Disorders (PTSD);

Schizophrenia.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

PSYCHOTROPIC MEDICATIONS CONTINUED

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108

Psychotropic medications must be used with an abundance of caution in the elderly:

Research has demonstrated that the elderly are more likely to experience serious side effects with the use of these medications; and

Have side effects not typically experienced among younger individuals;

Any psychotropic medication that is not scheduled but prescribed as a PRN medication must have specific written parameters;

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PSYCHOTROPIC MEDICATIONS CONTINUED

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109

It is important to be aware of potential side effects and carefully monitor the resident taking these medications;

Sedatives/hypnotics are generally used to aid a resident with sleep. The use of these medications is discouraged for the elderly. The sedation effects can create problems such as:

Falls; and

Daytime sedation.

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PSYCHOTROPIC MEDICATIONS CONTINUED

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A psychotropic medication used for the sole purpose of treating a resident’s behavioral symptoms is a form of chemical restraint. The resident’s physician, nurse practitioner, a qualified nurse or mental health practitioner prior to prescribing a psychotropic medications must:Complete a behavioral assessment; and

Try alternative interventions before starting a psychotropic medication.

110 ALERT

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111

Psychotropic medications may mask an underlying problem:

The resident’s healthcare practitioner needs to rule out behavioral problems caused by:

Medication side effects;

Medication interactions; or

Infections.

If the reason for seeking a psychotropic medication is to address behaviors:

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PSYCHOTROPIC MEDICATIONS CONTINUED

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112

Alternative measures to any medication to control the behaviors must be tried first:

Should include consultation with a behavioral specialist.

All attempts to use alternative measures must be documented including any results; and

The resident’s healthcare practitioner must be notified of all attempts.

Alternative measures include such things as lowering noise level and environmental confusion, change of provider interactions with the resident and redirection of the resident.

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PSYCHOTROPIC MEDICATIONS CONTINUED

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113

Psychotropic medications must not be used to:Discipline the resident; or For the provider’s convenience.

Some inappropriate uses include the following: To decrease the amount of supervision the

resident requires;

To stop a resident from yelling;

To stop the resident from pacing or wandering including trying to leave leaving the AFH.

REV April 2016 DHS-Office of Licensing and Regulatory Oversight

PSYCHOTROPIC MEDICATIONS CONTINUED

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114

Use of a psychotropic medication to treat behavioral symptoms requires:

Prescribing practitioner’s orders;

A thorough assessment conducted by a qualified health professional; and

Resident’s or the legal representative’s consent.

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PSYCHOTROPIC MEDICATIONS CONTINUED

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Normal aging alters medication absorption and elimination, which means the action of many medications in the elderly is less predictable than in younger adults:

Each person reacts differently to medication therapy partly because of age-related changes.

Because of natural decline in kidney function, the body is slower to eliminate the medication.

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REFUSING MEDICATIONS

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Residents may resist taking medications for a variety of reasons:

A resident may not openly object, you must be alert to signs that medication is not being taken;

For example, a resident may pretend to swallow a pill, but actually store it in the mouth and spit it out later.

If a resident refuses to take a medication, ask why:

Try to understand the resident’s point of view.

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MEDICATION REFUSAL

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It is important that residents take their medications as ordered and on time. Call the prescribing practitioner or their healthcare provider and document what happened, what you did and what instructions you were given, if a resident:

Refuses to take medication;

Vomits medication within 20 minutes of taking the medication;

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Does not want to or avoids taking medications due to nausea, vomiting or diarrhea;

Reports observing (or you observe) parts of coated tablets in stool;

Shows sudden changes in mental status or behavior;

Shows sudden changes in eating, sleeping or elimination (for example, constipation or diarrhea) patterns.

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The resident has a right to refuse; you cannot force the resident to take a medication. It is inappropriate and a violation of a resident’s rights to put medication in a resident’s food or beverage in order to trick or bully the resident into taking their medication.

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Common reasons for a person refusing to take medications and suggestions for responding are presented in the next slide:

Do not hesitate to contact the resident’s primary care practitioner or the RN consultant when a resident refuses or discards needed medications.

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MEDICATION REFUSAL CONTINUED

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Common reasons for refusal to take medications

Reason (Complaint) Suggestion

Unpleasant Taste Use an ice cube to numb the taste buds for a few minutes before taking. Provide crackers, apple or juices afterward to help cover up the taste.

Unpleasant side effects Report to their healthcare practitioner. Sometimes changing when or how the medication is given helps with unwanted side effects.

Lack of understanding Provide simple reminders, e.g., “This pill helps lower your high blood pressure.” Use language the resident understands.

Denial of need for medication Discuss need, but do not argue or engage in a power struggle.

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MEDICATION STORAGE & DISPOSAL

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Medications for each resident must be:Stored in a separate box with the residents

name clearly marked; AND

Locked.

Medications requiring refrigeration must be:Stored in a separate box and locked; AND

If there are any refrigerated medications for the AFH family they also must be locked:

Small dorm refrigerator with a lock on the outside is useful for multiple resident with refrigerated medications.

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Refrigerated medications require monitoring:

To ensure proper temperature use a refrigerator thermometer:

Keep a daily temperature log:

If there is a power outage it will assist the pharmacist determining if the medication is still safe.

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Medication and associated supplies must be disposed of properly:Sharps OAR 411-050-0650 (5) Safety – use

approved sharps containers:Rigid plastic container with a lid that can be

secured;

Store in a safe secured area;

Must replace when full – do not overfill;

DO NOT dispose of in garbage:Contact your local pharmacy or waste disposal

company for instructions.

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Contaminated supplies such as bandages etc.:

Dispose of in a plastic bag within a covered garbage container.

Transdermal patches:

Follow manufacturer’s instructions.

Outdated or discontinued medication:

Dispose of immediately:

Follow local regulations.

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INFECTION CONTROL

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Wash hands:

Before setting up a resident’s medication; and

After administering the medications:

If no sink, place hand sanitizer in:

Every room resident care is given; and

In the area where medications are set-up.

Use gloves when appropriate -SQ injections, gels etc.:

Must wash hands before putting gloves on and wash again after removing gloves.

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Pill boxes, pill cutters/crushers, CBG monitors, Lancet holders,

etc.

Are personal items and MUST NOT be shared. Personal items must be

labeled with the resident’s name.

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TRAINING

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OAR 411-050-0625:

Requires 12 hours of training annually for the:

Licensee;

Caregivers; and

Resident managers, floating resident managers.

Requires all providers (licensees, resident managers, floating resident managers and shift caregivers) to take a Department-approved Six Rights of Safe Medications Administration within the first 12 months from date of licensure or approval.

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Don’t wait to take the mandatory Six Rights training:

The information provided in the Six Rights training contains critical information needed once you have admitted residents with medications. It is recommended:

You take it within the first month of admitting a resident; and

Your caregivers take the course too.

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Additional resources on a wide range of medication topics can be found on DHS’s Safe Medication Administration website:www.tinyurl.com/DHS-SafeMeds

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QUESTIONS135

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Where do

you find?

What?

?