Medication Storage Inspection Worksheet

Hillcrest Educational Centers does not allow students to self-administer medication.

1. After the doctor’s order has been reviewed/ verified by the head nurse and consent from parent/guardian has been obtained, the prescribed medication shall be ordered and obtained from the Lenox Integrative Pharmacy. Doctor’s orders may be written, verbal or electronic. They must be complete and include the name of the medication, strength and time to be given. Any questions regarding this information should be clarified with the physician. Standing orders for particular medical conditions are included in the policy and procedures. They are periodically reviewed and approved by the agency Medical Director. Administration of these medications will also follow the guidelines stated below.

2. Medication must be purchased from the contracted pharmacy with these exceptions: STAT medication that is ordered on a weekend, evening or holiday and the contract pharmacy is closed or the medication is not immediately available there. If that is the case, the nurse on duty will order the medication (not more than 3-7 day supply) from a local retail pharmacy.

3. Nursing staff administering medications will adhere to the following guidelines:

a. Nurses will gather all necessary supplies for the medication pass prior to the students arriving
b. Nurses will wash hands with soap and water/ hand sanitizer before each med pass
c. Nurses will not begin medication administration until the students are orderly and attentive
d. Nurses will verify the identity of the student by asking the student their full name, verifying the name with other staff, or referring to the photo in the EMF

e. Nurses will always check the following prior to administering medication:
i. Correct order
ii. Correct medication
iii. Correct dosage
iv. Correct route
v. Correct student
f. Nurses will ensure that the student remains in front of them while receiving medication with both hands visible at all times
g. Nurses will open the packet and place oral medication in water cup; the student will place the medication in their mouth. Water/juice will be poured into the cup so the student may swallow the medication with the fluid provided. The student will be observed as they take and swallow the medication
h. Nurses will perform a standard “mouth check” visualizing the student’s entire mouth for any medication before the student leaves the designated medication area
i. If the nurse is not satisfied that the student has swallowed the medication, the youth will not be permitted to leave the area and staff will perform a search of the youth
4. If the treatment team or physician identifies a student as high risk for med non-compliance, an individualized safety protocol will be initiated by the treatment team. This protocol will include all of the above guidelines in addition to other specifics such as sitting with staff for 5 minutes, drinking multiple glasses of fluid, liquid medication, apple sauce, eating etc. The safety protocol will remain in place until the student has been reassessed as low risk for med non-compliance.

5. All medications will be documented at the time of administration

6. Nurses will utilize the current monthly administration record (MAR) for this documentation
7. Nurses will initial the record for the specific date and time the medication was given. The nurse’s signature will be recorded in the designated signature area of the record
8. Nurses will chart the medication using the following:
a. “H”- Medication held
b. “R”- medication refused
c. “P”- Packed for off campus
d. “Nurse initials”- medication given

i. When charting “H” or “R” the nurse must document the reason and any notifications made on the MAR and electronic progress notes.
ii. If a student refusal reflects a health risk, the nurse will notify the prescribing psychiatrist or physician as well as the head nurse. Documentation of the notification will be noted in the progress notes.

Medication Errors

9. Nurses will accurately and timely report any errors to the appropriate practitioner and immediately to the Head Nurse
10. The Head Nurse will inform the Nursing Coordinator and ensure that a Medication Error Report Form is accurately completed by the nurse discovering the error and forwarded to the Coordinator
a. A review of the error will take place with the Nursing Coordinator and campus Head Nurse

11. The procedure described above will also be followed when dispensing any PRN medications.

12. All trained non-licensed staff certified in medication administration will also follow these procedures.

13. All medication will be kept in a locked, secured cabinet and labeled with the student’s name, the name of the medication and directions for the administration.

14. All medications provided by the pharmacy (one week supply) will be checked by two nurses at time of delivery for accuracy to the current physician orders.

15. Provisions will be made for any medication needing refrigeration when necessary.

Medical Verbal Orders
Medical verbal orders are to be taken only by an authorized nurse who has a current license to practice in the state of Massachusetts.

1. The licensed nurse will identify the caller from whom she/he will take the verbal order.

2. After identifying the caller, the nurse will write the order down as given on the physician order sheet.
3. The nurse will read back the order to the prescriber to verify the order is correct and complete. The order must include the name of the medication, strength and time to be given. Any questions should be clarified by the physician before the call is ended.

4. The nurse taking the verbal order will write the date, prescriber’s name, and his/her name after the order.
5. The nurse will call the parent/guardian for a verbal consent, Witnessed by a nurse on the speakerphone. Only then will the nurse call the pharmacy for the medication to be ordered.

6. Verbal orders will be authenticated by the prescriber during their next visit.

Psychotropic/Antipsychotic Medication

1. Psychotropic/ antipsychotic medication will not be administered to a student without the authorization of the student’s legal guardian and the authorization of the student, if he/she is competent to make such a decision. Guardians will be notified of adjustments of these medications. .
2. Hillcrest does not administer prescription medication to a student without the written order of a physician after review of record, observations by staff and examination by physician.
3. Any change of medication or dosage is authorized by a physician’s new order.
4. A medication record is maintained for each student, and a nurse records every medication administered. . The doctor’s order sheet and medication record are part of the student’s permanent record
5. All students are seen by the psychiatrist as their teams are reviewed on a rotating basis but at a minimum of every eight weeks. At this time, psychotropic medication regimes are reviewed. . A written report in the form of Psychiatric Progress Note will be submitted by the examining physician and become part of the permanent record. This will include details/ rationale of the necessity for the medication, any noted side effects, and the next meeting. Periodic AIMS testing will also be done by the Psychiatrist and documented in the student record.
6. As part of the therapeutic process, all students twelve years of age and older will be informed of the medication treatment, risks and potential side effects. The medications will be discussed and reviewed in all case reviews.
7. Students receiving medications are monitored continuously by the nursing and direct care staff for adverse side effects. Any adverse effects are reported to the psychiatrist or the medical director who then determines an appropriate course of action. All staff will receive additional training on the nature of antipsychotic medications, potential side effects, required monitoring and special precautions. This mandatory training is required annually.
8. No antipsychotic medication will be administered for a period longer than is medically necessary with careful monitoring by the physician. Additional blood tests are ordered on a regular basis to monitor for metabolic side effects.
9. When it is necessary to treat the student with high dose pharmacotherapy or polypharmacy, it may be necessary to increase psychiatric sessions at the discretion of the physician along with increased monitoring as ordered.
10. In an emergency situation where the treating physician determines that antipsychotic medication is necessary for the prevention of substantial and irreversible deterioration of a serious mental illness, such medication may be administered for treatment purposes without parental consent or prior judicial approval as a one-time order. This is if an unforeseen combination of circumstances or need for immediate action is noted and there is no less alternative to the medication. If the treating physician determines that the medication should continue, informed consent or judicial approval must be obtained as required.
11. At the campuses, all medication is administered by a licensed nurse. If a nurse is not available (for example, during off-campus trips), a medication certified staff member will administer prescribed medications to the student. On these occasions, individualized doses are prepared by the pharmacy and checked by the nurse. The certified staff ensures that the correct student receives the medication at the approved time.

Hillcrest Educational Centers utilizes an approved training plan and specified procedures for the certification of staff who will be supervising administration of medication. This plan includes:

Eligibility criteria

Testing criteria

Designated trainers

Recertification requirements

Training curriculum

The Housatonic Academy requires an admission physical exam, health history and immunization record.
Annual updates are required by students’ private physician. Information updated yearly is to include; a physical exam report with the past year, immunization record, current medications (including those given at home), and allergies. Yearly health screenings performed by school nursing staff include: audiological, visual, postural, and growth screenings.

A. Medical Requirements for Admission

The following is a listing of medical information requirements for Hillcrest Educational Centers, Inc., which must be submitted before a new student can be admitted. The information may be submitted on HEC forms or on the placing agency’s own forms.
1. Complete physical exam within past six months documented on Pre placement physical exam form (see attached)
2. Up-to-date medical history including any allergies.
3. Results of most recent laboratory and other indicated testing (i.e. EEG, EKG, etc.).
4. Completed Immunization record (see Attachment E)
Immunization requirements for Massachusetts are on the following page:

5. Report of results of TB testing within 60 days.
6. Reports of most recent vision, hearing and dental examination.
7. Prescription(s) from ordering physician and two-week supply of all medication(s).
8. Valid medical insurance card.
9. Physician’s statement that child is free of communicable and infectious disease.

Management of Community-Associated Staphylococcus Aureus (CA-MRSA) Infections

Purpose: To prevent the spread of MRSA infection from person to person ensuring the health and well-being of all students and staff.
Background: MRSA infections are skin infections that appear as pustules or boils which often are red, swollen, painful or have pus or other drainage. MRSA is typically transmitted by DIRECT skin to skin contact OR contact with shared items or surfaces (e.g. used towels, bandages, shared sports equipment, etc.). It is estimated that 30-50% of the population are carriers of the staphylococcus bacteria on his/her skin or in the nose passages and it can be easily transmitted from one person to another. According to the Centers for Disease Control and Prevention, almost all MRSA infections can be successfully treated with or without antibiotics.
Prevention is the best defense and students and staff should be reminded about the importance of simple hand washing and practicing good personal hygiene overall. All cuts and open draining wounds MUST be covered with a secure bandage.
Actions when a student is infected with MRSA:
1) Staff should notify nursing if a student has any signs of infected skin. (Pustule, redness, swelling, drainage)
2) Nursing staff will assess and treat the area. Cultures of any drainage will be obtained and sent to the lab. Other treatment may include obtaining vital signs, warm packs, application of antibiotic ointment and coverage of any draining area.
3) The nursing department will observe for worsening symptoms and call the physician’s office as necessary. If the culture report is positive for MRSA, physician should be notified. Antibiotic treatment may be instituted.
4) The student should come to the nursing department for dressing changes at least 2-3 times per day or as instructed. Any contaminated dressings should be disposed of properly and the area of examination cleaned with antibacterial wipes.
5) All staff should use universal precautions and barriers when exposed to any drainage. Towels, sheets and clothing coming in contact with the drainage should be washed and dried in the dryer. Students may need assistance with this task.
6) No sharing of personal items
7) Student should be reminded to leave the dressing intact and wash their hands frequently.

Actions when a staff is infected with MRSA:
1) If staff have any type of skin infection which is warm, red, swollen, painful or draining they should seek medical attention from their primary care physician.
2) The draining wound should be covered with a clean, dry bandage that contains the drainage.
3) If the drainage cannot be contained or you have fever greater than 101, you should not be at work.
4) The dressing should remain intact; skin to skin contact should be avoided.
5) Staff should engage in frequent hand washing or sanitizing
6) Report any infection and treatment to HR representative.

Precautions:
• Frequent hand washing is the single most important preventive measure to avoid infection with MRSA. Keep your hands clean by washing thoroughly with soap and water or using an alcohol-based hand sanitizer.
• Keep cuts and scrapes clean and covered with a bandage until healed.
• Avoid contact with other people’s wounds or bandages.
• Avoid sharing personal items such as towels or razors.
• Avoid unnecessary use of antibiotics.
• Additional material on MRSA can be found at the CDC web site: http://www.cdc.gov/Features/MRSAinSchools/

DEFINITION/MANAGEMENT/DISPOSAL STANDARD:
Medical waste is defined as wasted which, because of its infectious nature, may:
A. Cause or significantly contribute to and increase mortality;
B. Cause seriously irreversible or incapacitating reversible illness;
C. Pose a substantial present or potential hazard to human health or the environment.
Therefore, treatment, storage, transportation and disposal of same must be clearly defined.

Areas contributing such wasted include:
Nursing offices

Types of Waste:
A. Sharps
B. Red-bagged waste

Also see Hazardous Materials and Waste Management (EOC) Plan

POLICY AND PROCEDURE FOR HANDLING MEDICAL WASTE
Purpose: To safely transfer medical waste from place of origin to off-site disposal.
Equipment: Biohazard approved red plastic bags .
White biohazard disposal box
Sharps containers provided by the Nursing Department.
Locations: Hillcrest Center Nursing Office
High Point Nursing Office
Brookside ITU Nursing Office
Housatonic Academy Nursing Office
Medical Waste Storage Location:
Hillcrest Dental Care, 788 South St., Pittsfield Ma.

Procedure:
1. Medical waste (as defined) will be placed into appropriate sharps containers in the nursing offices, or approved red plastic bags.
2. When sharps containers are filled and in need of disposal, the nurse manager at the location will call the Housekeeping Office at Administration, phone # 413-499-7924 ext. 114, to arrange for a pick-up.
3. The housekeeper will place the sharps container in the biohazard disposal box located at the Dental Clinic.
4. When the biohazard storage box is full the dental Manager will call for a pck-up.
5. All housekeeping staff will be trained regarding Universal Precautions and disposal of medical waste
6. In the event an exposure occurs during transport, the staff will notify their supervisor immediately and be evaluated by Occupational Health
7. In the event an accidental needle/ sharps exposure occurs the Exposure Incident Report contained in the Infection Control Manual should also be completed.

Purpose:
To place linen into proper containers for transport to laundry.
To contain linen and prevent contamination to Student/Staff/Environment.

Equipment:
Appropriate bag – linen or plastic.
Procedure:
1. Place bag in easy-to-use position.
2. Linen removed from Student is placed into bag.
a. Dry clothes – Linen Bag
b. Visibly wet/soiled clothes and/or linens with (stool, urine, blood/body fluids) – plastic bag
3. Close bag (bags) securely – and take to Laundry.

Care needs to be taken NOT to aerosolize particles, as linen/clothes are being removed. Use a minimum of agitation, handle as little as possible. Use UNIVERSAL PRECAUTIONS when handling ALL soiled linen.

Standard:
1. Staff are advised to keep a change of clothing available in their car or locker.
2. Staff may wash their soiled clothes in an on-campus machine or at home.
3. When clothing is soiled with Blood/body fluids, Remove and place into a plastic bag.

Purpose:
To protect both personnel and student from infection.
Equipment:
Foam Soap (Provided in wall dispensers)
Water
Paper Towels

NOTE: ALL Employees and Students hands are to be washed:
a. Prior to and at End of work period.
b. Between direct Student contact (Student and/or Body Fluids)
c. After handling any contaminated articles or waste
d. Before and after handling food
e. Following each use of bathroom
f. When gloves are removed

Procedure:
1. Dispense paper towels first
2. Turn on faucet, adjust temperature and force of water. Stand well away from sink to avoid splashing.
3. Wet hands
4. Soap hands, work up lather using vigorous friction. Include the areas between the Fingers and around Nails. Wash for at least 20 seconds.
5. Rinse thoroughly. Hold hands DOWNWARD for water to fall from ends of Fingers.
6. Dry hands thoroughly with sufficient paper toweling
7. Use paper towels to turn off faucet, to maintain clean hands.
8. Discard paper towels in waste basket, plastic lined.