Assisted Living Nursing Practice: Medication Management: Part 2 Supervision and Monitoring of Medication Administration by Unlicensed Assistive Personnel

Article Outline

• Abstract
• Background
• Readiness for Medication Assistance/Administration
• Legal Issues
• Performance Evaluation
• Culture of Safety
• Conclusion
• Acknowledgment
• References
• Biography
• Copyright

More than half the states permit assistance with or administration of medications by unlicensed assistive personnel or med techs. Authorization of this nursing activity (or task) is more likely because of state assisted living regulation than by support and approval of the state Board of Nursing. In many states, the definition of “assistance with” reads exactly like “administration of” thereby raising concern with regard to delegation, accountability, and liability for practice. It is, as well, a hazardous path for the assisted living nurse who must monitor and evaluate the performance of the individual performing this nursing task. This article, the second in a series on medication management, addresses delegation, standards of practice of medication administration, types of medication errors, the components of a performance evaluation tool, and a culture of safety. Maintaining professional standards of assisted living nursing practice courses throughout the suggested recommendations.

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• Ethel Mitty

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• Sandi Flores

This is the second of a two-part series on medication management in assisted living residences and communities. The first part, which was published in the March/April issue, focused on assessment of the resident for self-medication ability. Inasmuch as more than half the states permit unlicensed assistive personnel (UAP; an unfortunate term) to “assist” with—if not “administer”—medications to residents, it is important to understand the context and the professional and legal ramifications of medication assistance and administration by nonlicensed staff. This article suggests specific elements to include in a performance evaluation of medication assisting/administration by UAP/med techs.

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Background 

Assisted living (AL) residents tend to receive more prescription medications and more antidepressant and antipsychotic medications than nursing home residents.¹, ² An analysis based on the Beers criteria (i.e., a list of medications to avoid completely or titrate carefully when prescribing for older adults with specific conditions) reported that 25% of AL residents are receiving inappropriate medications.³ Medications are being prescribed (and administered) in the absence of a documented diagnosis or rationale.⁴ The incidence of medication errors is poorly reported, although their occurrence seems to be increasing.⁵ Some but not all states require that AL facilities have a medication review by a consulting pharmacist or an RN (or both).⁵ Given the increasing acuity of AL residents, medication management can no longer be viewed simply as part of a service plan; it is an integral component of the health care supervision and monitoring offered by an AL facility—a component for which the facility and its professional staff are accountable. Although various states (e.g., Maryland, North Carolina) are addressing the education and training of UAP and med techs, few have promulgated—or required—an evidence-based systematic performance monitoring system. North Carolina’s Adult Care Licensing Section is an exception to this and was a source of some of the recommendations contained in this article.

The difference between “assisting with” and “administration of” medications is often based on what a regulation or statute says it is. As recently as 2001, in a review of state AL regulations regarding medication management conducted by one of the authors (E.M.), “assisting” was defined 17 ways in as many states. Most frequently, assisting meant reminding the resident, opening the container or otherwise obtaining the medication, pouring the medication, handing the medication to the resident, and guiding the resident’s hand to bring the medication to his or her mouth. Less commonly, assisting included observing ingestion or swallowing the medication and returning it to safe storage. It is interesting to note that no definition was found among the state regulations for “monitoring” and “reminding.” In 1 state, administration of medications was defined as “read label for resident, check dose, remove from container, observe.” Given these permutations, it is difficult to identify and differentiate medication assistance from administration and more difficult still for the AL nurse to determine whether it is a delegated activity requiring a certain kind of preparation for the task, supervision, and monitoring. If for no other reason, the state regulation that describes who and what is involved in medication assistance should be part of the AL facility’s medication management policy and the job description of the persons involved. AL nurses should seek (if not demand) clarity of this function, responsibility, and accountability.

Every state’s Nurse Practice Act (NPA) stipulates what level of licensed nurse (i.e., RN or LPN/LVN) is authorized to delegate, what can be delegated, and to whom. Many states’ NPAs only permit RNs to delegate skilled nursing acts, such as medication administration (e.g., Maryland, New Jersey, North Carolina, Oregon, Washington).⁶ Oregon differentiates between “basic tasks” (tasks that do not require an RN’s level of education)—and can therefore be “assigned’ by an LPN/LVN or RN—and “special tasks” that can only be delegated by an RN (because they require an RN level of education and training).⁶ It is tempting to conjecture that medication assisting is a basic task and administration is a special task, but the field lacks such discrimination and guidance.

The Maryland Board of Nursing approves the “medication technician” (formerly, “medication assistant”) training program and requires that such individuals register with the Board.⁷ In specified community settings, such as assisted living, residential placement programs for juveniles, and alternative living units for developmentally disabled, the med tech can administer medications when delegated to do so by an RN and there is an RN available to supervise and monitor. In most states, however, the nursing board is silent on the issue of medication administration by nonlicensed staff. In addition, most state nursing boards are, unfortunately for AL nurses, uninvolved and uninformed about the nature of AL nursing practice.

The AL regulations in many states (e.g., North Carolina) trump the authority of the nursing board with regard to medication administration by others; the regulations authorize nonlicensed staff to perform this task. Whether by nursing board delegation or state fiat, however, accountability for safe practice resides with the nurse (RN or LPN). Responsibilities associated with medication assistance/administration should be part of the job description of staff involved in this service. The medication management policy should address continuing education for these staff, the monitoring and performance evaluation methods, and the medication error reporting system.

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Readiness for Medication Assistance/Administration 

Whether medication assistance/administration by nonlicensed staff (i.e., unlicensed assistive personnel or UAP) is authorized by state regulation or nursing board approval—and whether or not it is called delegation—the UAP’s readiness to assist with or administer medication can be estimated as well as reinforced by following the steps of delegation. Delegation is the transfer of authority “to a competent individual” for the performance of a specific act or function.⁸ The context of delegation assumes that the “client” is stable and his or her care needs are known. This requires, then, at a minimum, that the resident’s plan of care or service plan describes the resident’s medical condition(s), nursing needs, and the rationale for every medication that has been prescribed for the resident.

The Five Rights of Delegation delineate the accountability and decision-making steps associated with safe delegation.⁹ Given the significant variation between states with regard to the breadth and depth of UAP education in medication assistance/administration (i.e., “med tech” preparation), the assumption is made in this article that staff involved with medication assisting or administration have had some education/training.

A “Delegation Decision-Making Grid,” developed in conjunction with the Five Rights, might be useful in supporting an AL nurse’s decision whether to permit or forbid a UAP or med tech from assisting with or administering medications.¹⁰ The grid is a scored assessment of items regarding the degree of monitoring needed, client stability, UAP or med tech competency, level of decision making associated with the delegated activity, and potential risk. For example, a “frequency” score speaks to how many times the UAP has performed the specific activity, in this case, medication assistance or administration. Level of competency is characterized as UAP or med techs’ degree of expertise in the specific activity (i.e., medication assistance or administration) and their familiarity with the specific patient population.

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Legal Issues 

A nurse who has delegated a task to another is accountable for the delegation. The person accepting the task, the UAP or med tech, for example, is accountable by virtue of having accepted the delegation and for carrying out the task.¹¹ As stated in a variety of ways in Nurse Practice Acts, the nursing functions of assessment, evaluation, and nursing judgment cannot be delegated. Yet it is patently obvious that medication administration by a UAP or med tech often requires assessment and judgment (e.g., implications of vital signs data; glucometer reading).

Although the terms “malpractice” and “negligence” are often used synonymously, negligence implies deviation from a standard of care in a particular situation by a reasonable person. Malpractice is a deviation from a professional standard of care; it is a specific kind of negligence.¹² Yet the rules, regulations, and guidelines associated with medication assisting, administering, and delegating lack clarity. Unlike the nursing home nurse, the AL nurse is at some degree of risk with regard to a state’s requirement of nursing supervision and monitoring of UAP or med tech’s medication management activities—particularly if the RN is not on site during the “med pass.” The courts hold that workers are individually and personally liable for their acts of negligence and malpractice; this applies to UAP as well.¹¹ It has been successfully argued in law courts that a nurse can be held legally liable for failure to identify (and report) the violation of a reasonable standard of care. If a presumably competent UAP or med tech is making repeated errors, even after retraining, a prudent nurse must remove that person from medication assistance and administration. The best justification is a valid and reliable performance evaluation tool.

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Performance Evaluation 

North Carolina has an extensive and intensive program for training and monitoring of unlicensed staff who will administer medications in adult care homes (i.e., assisted living). In addition to a written competency test administered under the aegis of the Department of Health, there is also a clinical skills observation or checklist.¹³ Guidelines for administration of the checklist, the checklist itself, and a medication study guide are available on the Web site.¹³ Performance observation must be conducted by a pharmacist or an RN. Each of 13 sections on the checklist require verbal feedback or actual demonstration (or both) of an activity by the UAP or med tech. It is unclear whether use of this document by an AL nurse or residence outside North Carolina requires permission or if, given that it is available on the Internet, it can be used with attribution. Table 1, Performance Evaluation: Criteria and Components, is an adaptation of the North Carolina checklist sections that suggests the requisite knowledge or skill that might be evaluated in performance monitoring.

Table 1. Performance Evaluation: Criteria and Components

Data from Medication Administration Clinical Skills Checklist. North Carolina Division of Facility Services, Adult Care Licensure Section.¹³

PRN = pro re nata; VS = vital signs; MAR = medication administration record; ac = before meals; sl = sublingual; GT = gastrostomy tube.

Another approach to performance evaluation of medication assistance and administration competency is utilizing the “6 rights” of medication administration. These are generic standards of practice that apply across settings and worker. Table 2 provides some selected observations for each “right” and in some cases suggests observation related to particular medications. It is strongly recommended that UAP and med techs are key participants in the construction of a tool that will evaluate their performance.

Table 2. The Six Rights of Medication Administration: Observation for Performance Evaluation

VS = vital signs; gtts = drops; ac = before meals; pc = after meals; PRN = pro re nata; ALR = assisted living residence; OOS = out of stock.

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Culture of Safety 

Since the late 1990s, a “culture of safety” in health care organizations is slowly changing how a medication (or treatment) error is handled. Three aspects are noteworthy. First, there is movement away from “name and blame” with regard to an error toward a systems-oriented or cognitive science approach as to why an error occurred. Second, there is as much interest in actual errors as in potential errors—the “near miss.” Nurses in particular, being most involved with medications, are encouraged to describe the near miss; how they caught and stopped the error from happening—a different smelling liquid, a misplaced “0,” a different color pill (a major hazard with generics). Third, the ethical principle of respect for persons is invoked by the requirement that the patient or significant other (or both) must be advised that an error has occurred. Initial fears that this would engender more lawsuits has not proved to be the case. When patients are told that a medication error has occurred, they should also be told what to expect as a result of the wrong medication (or dosage), what will be given to them to mitigate the effect of the medication error, how they will be monitored for any adverse effect, and the likelihood of certain outcomes. Apologizing for the error, in addition to explaining how it will be handled, maintains patients’ sense of self-esteem. It is important that the individual(s) most associated with the error speak to the patient; this is not the time for a messenger.

Medication errors (and near misses) come in various guises. Empowering the licensed AL nurses and UAP/med tech staff to develop a medication error reporting system exemplifies professional standards of practice and nursing governance. Minimum components of a medication error report include relevant attachments (e.g., the medication order, medication administration record (MAR), relevant nurses and physician notes), the type of error, associated facts and information, notification and actions taken. Types of errors include the following:

If not on the error report itself, the continuing care or progress notes should describe the effect of the error on the resident, how the resident was advised of the error and by whom, what the resident was told, and follow-up. The AL facility policy must address the consequences of repeated medication error by a staff member, but this should not preclude a system or “root cause” analysis of the error. It could be a packaging or labeling issue.

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Conclusion 

A culture of safety requires monitoring and performance evaluation systems as well as meaningful reporting and data collection (i.e., quality improvement). There is a paucity of research regarding assistance and administration of medication by UAP and med techs. With regard to medication knowledge, almost 75% of UAP administering medications knew about taking the pulse of a resident receiving digoxin/lanoxin and understood metric measures.¹⁴ Yet less than half were knowledgeable about the side effects of psychotropic and antipsychotic drugs or which symptoms needed to be reported.¹⁴ On a reassuring note, two studies reported no increase in medication errors or adverse outcomes associated with medication administration by UAP.¹⁵, ¹⁶

Research is needed on the kind and quality of education, training, and monitoring for the safest UAP and med tech practice and on errors and adverse outcomes. The American Assisted Living Nurses Association is a member of the Research Advisory Group on a project to improve medication management in assisted living: the Center for Excellence in Assisted Living and the University of North Carolina Community-Based Participatory Research Partnership, funded by the federal government Agency for Health Research and Quality.

Just as there is no gold standard tool to determine the capacity of a resident to self-administer medication, there is no gold standard performance evaluation tool. Robust quality improvement methods, effective medication management policies, and networking among AL facilities can create useful evaluation tools that might be applicable across facilities and across states. State and national conferences of AL nurses are an excellent opportunity to share performance evaluation tools and even move to a rigorous scientific evaluation of their validity, reliability, and usefulness. The role, responsibility, and contribution of the UAP and med tech to an AL facility’s culture of safety and creation of a useful competency and performance evaluation process is a critical factor in workforce stability. It speaks as well to other ways of “doing nursing” with a keen appreciation of the moral accountability—and contribution—of assisted living nursing in the long-term care continuum.

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The authors thank Jan Brickley, BS, RPh, lead pharmacy consultant, Adult Care Licensure Section, Division of Facility Services, North Carolina Department of Health and Human Services.

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References 

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