Marisol Center for Healing: Medication Observation and Documentation PDF

Marisol Center for Healing: Medication Observation and Documentation​ Carlos E. Perez, PharmD November 14, 2023 Training Content  Introduction to Medication Observation  Medication Storage  On-Person Medications List  Refrigerator Temperature Log  Admission Medication List  Medication Observa...

Marisol Center for Healing: Medication Observation and Documentation​ Carlos E. Perez, PharmD November 14, 2023 Training Content  Introduction to Medication Observation  Medication Storage  On-Person Medications List  Refrigerator Temperature Log  Admission Medication List  Medication Observation Record (MOR) Sheets  Countable Medications List  Medication Return Form Introduction to Medication Observation © 2021 EMO Health. All Rights Reserved. What is Medication Management? Medication Management is the process of overseeing resident medications to ensure that medications are being handled properly by staff and taken as prescribed by patients The goal is for the resident to develop the knowledge, skills, and habits necessary for them to take their medications appropriately, and on their own, once they leave the program BSAS Regulation 105 CMR 164.406 (G) Observing vs. Administering Self-Administering Medication Administering a Medication HANDING the resident their medicine IN the bottle or blister pack GIVING the resident a dose of medication from the bottle or blister pack to take Observing the resident remove the medication from the bottle and take it Taking a pill, film, patch OUT of bottle or blister pack and giving it to resident to take Putting medication into a med cup and Helping a resident open a safety or childproof cap, but not removing any medicine giving it to the resident to take Pouring a liquid medicine for a resident Goal of Medication Observation Observation IS supporting residents take medication safely & appropriately and notifying a supervisor immediately when a medication is taken incorrectly or improperly. Observation IS NOT controlling what medication or how much medication a resident takes. Principles of Medication Management Medication management is a shared responsibility Resident is responsible for taking medication as prescribed (i.e., taking prescription and over the counter medications according to the labeled instructions on the bottle/container) Staff are responsible for following the 6 Rights of Medication Management THE 6 RIGHTS OF MEDICATION MANAGEMENT RIGHT PERSON RIGHT MEDICATION RIGHT DOSE RIGHT TIME RIGHT ROUTE RIGHT DOCUMENTATION Step 1: Greet and Be Discreet You can learn a lot about someone from the medications they take. Active communication and good documentation prevents costly med errors. Patients can look alike. Greet the patient by name (positive identification). Patients can have similar names. Always use the patient’s full first and last name on all medication records, bins, etc. Use another identifier such as their birthday (Day/Month) if two patients have the same first and last name. Step 1: Greet and Be Discreet Patients have a right to privacy and the observation process should reflect this right. Make sure the hallway is clear to prevent people from overhearing medication information (potential HIPAA violation). Make sure medications and medication records are put away and out of sight. Step 2: Retrieve Medications Retrieve the patient’s bin(s) and binder and place them in front of the patient. Verify that the correct resident in front of you. Always double check! You can open the patient’s medication bin. You may assist with opening a medication container (such as a safety cap). Do NOT remove any medication (pills, films, etc.) from the container. Do NOT pour out any liquid medication. Step 3: One Med at a Time The patient may remove the medications from their box but should not open them until you are ready (you set the pace) They can place the medications to the side to sort them. The patient should show you the first medication they wish to take Another method is to read the first medication to the patient and ask them if they want to take it. All patients have the right to refuse to take any medication for any reason. Step 4: Observe Resident Take Medication Staff and patient review the medication directions Observe the patient remove the medication and place it into the med cup. Patient HOLDS OUT the cup for staff to check. Visually inspect BEFORE the resident ingests a medication – once the medicine is ingested you can’t get it back. Step 5: Document Observation Medication misuse is a SYMPTOM of Substance Use Disorder and should be treated therapeutically by trained professionals/clinicians If the contents of the cup are incorrect or misuse is a concern: You can verbally remind or instruct the patient to take a medication as prescribed (according to the directions on the bottle/blister pack). You can read or ask the patient to read the directions out loud. Ultimately, your role is to OBSERVE and NOTIFY a supervisor when medication overuse, underuse, or misuse occurs. Observation – Best Practices PAY ATTENTION! Monitor carefully! No cell phones or other distractions Do not document while the resident is taking the medication One medication at a time YOU control the pace! Medication Storage © 2021 EMO Health. All Rights Reserved. Medication Check-In Part of medication storage and security is putting medications away as soon as possible to prevent pilferage and protect patient privacy All Marisol program staff are responsible for securing the patients' medications PROCEDURE: When new medications are brought into the program (i.e. new resident intake, pharmacy delivery) the medications should be brought to the medication room Put refrigerated medications away asap Place all other medications in a plastic bin and label with a patient sticker Ensure that the nurse doing the resident intake process is aware of these medications and their location for documenting Resident Medication Storage All medications are stored in a resident-specific plastic bin. Each bin should be labeled with a patient sticker After each medication pass, all bins must be locked inside their corresponding resident’s locker When a medication or a new order arrives to the program check the prescription label with the active MOR sheet Refrigerated Medications Medications with refrigeration storage requirements (detailed on the manufacturer package/container) must be stored in the fridge asap after arrival to the facility Delaying proper storage can damage the medication Do not remove the medication from its original package Packaging protects medications from light exposure Store refrigerated medications in the middle of the shelf (Not the door) No food or drink– risk of food-borne contamination Morning shift Monitors and documents refrigerator temperature once daily Medication Refrigerator Temperature Log Morning shift nurse is responsible for checking the fridge thermometer and logging the temperature daily Temperature range must remain between 36-46°F If temperature is out of range, notify the nurse manager immediately If temperature is out of range, contact GBLTC Pharmacy to determine if medications can be safely used Medications Allowed on Person Medications used to treat acute episodes, such as rescue inhalers and Epi Pens® may remain in the patient’s possession Document on MOR sheet by filling in the “kept on person” bubble, and write the product’s expiration date on the “exp date” section Remind the patient of proper use and take note of safety information/warnings on packaging List is posted on the medication wall Medication Basics © 2021 EMO Health. All Rights Reserved. Reading a Prescription Label Reading an OTC Package Label Strength vs. Dose The medication dose and strength are not the same. Be careful when documenting on a medication sheet or record. STRENGTH: the amount of active ingredient in one unit of the medication Strength: 60mg ex., milligrams (mg), milliliters (mL) DOSE: the amount of medication taken at any one time (by a specific patient) ex., take two tablets, take 5mL 60 mg Dose: 2 tablets (120mg) 60 mg Interchangeable Medication A product containing a drug in the same amounts of the same active ingredients in the same dosage form as other drug products. Most common example : brand-generic interchange: BRAND NAME GENERIC Motrin/ Advil 200mg tabs Ibuprofen 200mg tabs Tylenol 500mg tabs Acetaminophen 500mg tabs Adderall XR 20mg Capsules Amphetamine/ Dextroamphetamine Salts ER 20mg Capsules Proair/ Ventolin 90mcg Inhaler Albuterol 90mcg Inhaler Formulation XL, ER, SR, and DR products are not interchangeable Example: Wellbutrin XL, Wellbutrin SR, and generic forms Prescription salt forms are not interchangeable Example: metoprolol succinate versus metoprolol tartrate Nicotine Patches Nicotine Gum Nicotine Lozenges Are these nicotine formulations interchangeable? NO Route and Frequency ROUTE of administration is how a medication is ingested, i.e., how the medication enters the body. FREQUENCY is how often a medication is taken. For example, once daily, twice daily, three times daily. Medication Documentation © 2021 EMO Health. All Rights Reserved. Medication Cycle ALL medications must be: Documented Upon arrival When taken/ingested If changed or discontinued When returned to the resident When disposed Observed When taken by a resident Stored Securely in the refrigerator or cabinet/storage unit Medication Documentation All medications that enter the program must be documented Including resident’s Over the counter (OTC) Medications Document all medication prior to storing them (including refills) Admission Medication List Filled out by the nurse doing the resident intake All medications brought to the program by the resident are documented and counted Prescription medications OTC products On-person medications The proper documentation of all medications brought into the program by residents: Establishes a clear chain of custody of medications Ensures accountability of all medications Prevents misunderstandings and confusion for both the program and the residents Filling Out Admission Medication List Robert Kraft 1/1/1948 Bee Sting 1. Place patient sticker with the resident’s information on the top left of the form 2. Fill out “Allergies” field. If no 3. allergies, do not leave blank. Write “NKDA” or “No Allergies” If the resident has no medications, check the box stating “No Medications at time of admission” Filling Out Admission Medication List 4. Selecting one medication at a time, transcribe the medication name, strength and directions exactly as written on the pharmacy label or OTC product package 5. All medications brought to the program must be counted at admission. Use a medication counting tray and spatula and record the number of medications 6. Once the Admission Medication List is filled, the Nurse will decide whether to continue or discontinue these medications while at Mirasol. Circle “C” if continued or “D” if discontinued BEE STINGS Robert Kraft 1/1/1948 Alprazolam 1 mg Take 1 tablet at bedtime 42 Metformin 500 mg Take 1 tablet twice daily 16 Held Medications Resident medications that are inactive/ not continued are documented on the Admission Medication List These inactive medications can either be disposed or held for the resident while they’re in the program. Robert Kraft’s Held Meds Held medications are placed in a tamper resistant bag labeled with the resident’s name and stored separately from the active medications. They will be returned to the resident upon discharge. AUDIENCE PARTICIPATION A new patient, John Smith, DOB 10/31/83 arrives the program today with the following medications. How would the admission nurse complete the Admission Medication List? Allergies: Aspirin AUDIENCE PARTICIPATION Aspirin ASPIRIN John Smith JOHN SMITH 10/31/1983 10/31/1983 Adderall XR XR ADDERALL Centrum Mens MultiVites per before 20mg take11capsule capsuleby daily in the morning 20 mg Take mouth once 8 daily in the morning 1 tab Take 1 tablet daily with food ---- Take 2 gummy vitamins day. Chew thoroughly swallowing 260 8 120 Medication Observation Sheets After documenting the resident’s medications in the Admission Medication List, we will document each medication on either a Countable MOR Sheet or a Non-Countable MOR Sheet Countable Medications If unsure if a medication is a countable medication, refer to this partial list. Scan QR code for a more comprehensive list Countable medications are usually medications with higher potential risk of being misused or diverted Controlled medications are documented on the Countable MAR and counted at each shift change Countable Medications Countable Medications are substances with a higher risk of misuse and/or diversion. Some examples are: Adderall Vicodin Gabapentin Pharmacy labels may contain a red “C” on the label, RX number may start with C, or may contain an auxiliary label MOR Sheet- Header Fill in the top box with patient name, date form is filled out, and staff initials Transcribe verbatim (word for word) the medication name (including formulation), strength, complete directions for use from the pharmacy label. MOR Sheet- Header If it’s a new medication, fill in “New Med” bubble, count the medication, and enter the starting quantity. For On-Person medications, select the bubble and write in the product expiration date from the medication package. Countable MOR Sheet Document shift counts directly on MAR sheet Count is documented in real time to reduce errors in counts and smoother documentation during med hour STEPS TO FOLLOW 1. Count the medication prior to taking the medication and document the START count​ 2. After observing the amount taken, document the TAKEN quantity​ If a resident takes half a pill or partial tablet write 0.5 or 1.5 3. Re-count the medication to confirm the END count.​ If the count is off notify the Program Director immediately Medications Allowed on Person John Smith Epipen Inj. 11/13/23 CP 0.3mg 2 4/24 Inject 0.3mg intramuscularly as needed for anaphylaxis House Medications All house medications are documented on the Non-countable MOR Refer to the OTC medication packaging and drug facts label for the recommended dose and directions. Write these in the MOR sheet. Morning Nurse is responsible for checking the house medication expiration dates monthly Expirations written as MM/YY = expires on the last day of the month Medication Refills Before storing medications that are picked up from the pharmacy: Determine if a medication is a refill Review the patient’s current MORs Refill MAR with Exact Same Medication name Formulation Strength Directions New Order Medication not currently documented on a MOR Same medication and formulation but new dosage or new directions Same medication, different formulation ex. Bupropion XL switched to Bupropion SR Documenting Refills Confirm medication received is a refill and not a new RX Determine if the medication received is a countable or noncountable medication Select the appropriate MOR sheet Document the date, time and enter the quantity of medication received Resident does not need to initial, only staff John Kennedy 10/1/23 Metformin E.R. CP 500 mg Take 1 tablet by mouth Once daily 10/1/23 8:01 am 10/1/23 11:05 am 1 JK 30 CP CP AUDIENCE PARTICIPATION While working in the med room, you receive a pharmacy delivery which includes two medications for resident Paul Blart (DOB 2/2/1982). P.B.’s CURRENT MEDICATIONS: METROPROLOL SUCCINATE E.R. 50MG – TAKE 1 TAB EVERY MORNING AUDIENCE PARTICIPATION How do you document these medications? Refill or new medication? Which sheet do you use to document these medications? Countable MOR or NonCountable? P.B.’s CURRENT MEDICATIONS: METROPROLOL SUCCINATE E.R. 50MG – TAKE 1 TAB EVERY MORNING AUDIENCE PARTICIPATION Paul Blart 10/1/23 Metoprolol E.R. CP 50 mg Take 1 tablet by every morning 10/1/23 8:01 am 10/1/23 11:05 am 1 JK 30 CP CP AUDIENCE PARTICIPATION Paul Blart Zolpidem Take 1 tablet by every morning 11/14/23 10mg CP 30 Medication Return Form Used to document the return of medications to the resident when discharging Medications left behind are kept for 14 days to allow for the resident to pick them up. If not picked up, the medications are then disposed Document all medications being returned to the resident Active medications Inactive held medications brought by the resident on intake Resident OTC’s Refrigerated items Medication Return Form 1. Write the resident’s full name, name of staff member completing the form, and the date 2. Disposal date will be 14 days after resident discharge. Calculate the disposal date and document it 3. Staff writes their initials and acknowledge they checked all medication storage areas and ensured no resident medications were left behind 4. Write the name and strength of each medication being returned to the resident. For Countable Medications count and write the quantity returned Medication Return Form 5. 6. 7. 8. 9. Medication is returned only to the patient, or an authorized representative The patient or their representative signs and dates the form Staff member signs and dates the form If the patient refuses to sign, then a second staff member who witnesses the medication return process to the resident, signs the form Medication cannot be returned to a resident representative who refuses to sign the form Thank you