Skilled Nursing Care - Intranet UnityPoint Health .2012-04-12 Skilled Nursing Care Skilled...
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Skilled Nursing Care
Skilled Nursing Care may include, but not be limited to:
I. Administration of Medications:
A. Medications are administered by Agency licensed nurses according to Agency policies
and procedures, and within the scope of the State Nurse Practice Act. Medications are
administered only by individuals holding a current license or permit in the state as a
registered nurse or a licensed practical nurse.
B. Agency licensed nurses will administer all FDA approved medications by all
approved routes in accordance with their skills and training with the following
1. IV Aminophylline loading doses
2. IV Pitocin
3. IV Phenothiazine derivatives
4. IV chemotherapy agents which are not included on the Agency=s approved list
5. IV Iron-Dextran Complex
C. Licensed Practical Nurses will not administer IV medications. In addition, licensed
practical nurses may not administer parenteral anticoagulants or parenteral cardiac drugs.
D. The Agency reserves the right to refuse to administer medications if such medication
is determined to be harmful, contraindicated, expired, improperly labeled, contaminated,
or there is no physician=s order. If a medication is withheld, the physician shall be promptly notified and the events documented in the clinical record.
E. No experimental drugs are administered unless the patient has signed a voluntary
consent form. The Agency will consider patients who are part of research, experimental
studies or clinical trials on a case-by-case basis with consideration for staffing and the
Agency=s ability to meet the needs of the patient effectively. For investigational drugs, such as AIDS drugs specifically exempt from FDA review procedures, the Agency will:
1. Obtain a specific physician=s order in accordance with policy
2. Verify that the drug is an acceptable investigational drug for the condition
3. Obtain written literature on the drug action and side effects
4. Obtain specific orders for treatments of reactions or side effects
5. Obtain approval of a subcommittee of the Professional Advisory Committee
physicians, nurses and a pharmacist, if possible
The Administrator is to be made aware of all potential cases in which experimental drugs
may be administered.
Participation of the patient in experimental drug therapy is strictly voluntary and must be
an informed decision by the patient. The physician is responsible for educating the
patient on the specific drug/procedure, benefits and risks, potential outcomes,
consequences, and alternative courses of intervention. Patients admitted to service who
are in the course of experimental drug therapy will be accepted on a case by case basis.
The patient=s physician will be responsible for educating agency staff in the proper care of patient. All items listed above will be included in that education.
F. A written physician=s order must be obtained for all medication administered by Agency personnel. Written physician orders must specify:
1. Patient name
2. Medication name, dose, route, purpose (where appropriate) and frequency
3. Medication start date
4. Medication stop date, if indicated
5. Special instructions or precautions, if indicated
6. Standing orders in case of a drug related adverse reaction, if indicated
7. Laboratory blood work to be routinely collected
G. In the case of an in-home administration of the initial dose of a new medication, the
Agency reserves the right to decide on an individual basis whether or not to administer
the initial dose. If indicated following the administration of any injectable or intravenous
medication, the employee will remain in the home to observe for possible side effects.
H. Medications, dose, route and frequency should be considered generally reasonable and
acceptable therapy for the condition for which they are prescribed. In the event the RN or
LPN has reason to question the orders of the attending physician, such as unusual route or
dosage, Agency guidelines for questioning a physician=s orders will be followed. The physician will be contacted for specific written orders to include drug name, dose,
frequency, route, expected effects, untoward and adverse reactions. The physician will be
requested to participate in patient education and will assist in obtaining informed and
voluntary consent by the patient. A copy of the informed consent and any applicable drug
protocol will be retained in the patient=s clinical record. MMSC pharmacy staff will also be available for additional education as needed.
I. The nurse administering each medication is responsible for researching unfamiliar
3. Side effects
4. Special precautions
5. Usual dose
6. Route of administration
J. The nurse shall routinely monitor all medications to determine their action,
indications, special precautions, patient=s response to therapy, side effects, allergies and contraindications. The RN will be responsible for updating and keeping accurate the
medication profile or medication listing in the patient=s clinical file. This will be done as soon as possible after the order is received. The medication profile will include the name
of the medication, date ordered, dose, route, frequency, duration of therapy if appropriate,
action or effect, side effects, and contraindications. This profile will include over-the-
counter drugs. The profile may also serve as a tool for the purpose of patient/caregiver
education, and/or for drug therapy review by pharmacist(s) as appropriate or required by
policy, regulation or accreditation standards.
K. The Agency may instruct the patient and/or caregiver on the administration of
injectable medications only with a written physician=s order.
L. If the patient expires, all medications become the property of the patient=s family who shall be responsible for their disposal.
M. Injections for the prevention of flu and pneumonia may be given with an order from
the physician at the discretion of the Agency to its home care patients.
N. Controlled Substances. Only RNs and licensed practical nurses are authorized to
handle controlled substances.
1. All controlled substances are to be counted daily or at specified intervals.
2. A controlled substance may be given only with a physician=s order
3. Each medication is to be accounted for according to Agency procedure as it is
removed from the container and before it is administered to the patient
4. If a medication is not given because the patient refused it, a partial dose is
given or the medication is contaminated, documentation is required
5. Any amount of controlled drug that is missing and can not be accounted for
requires an incident report that details particular information regarding the loss of
the drug. A nurse is required to complete the incident report. The incident report
must then be signed by the Supervising Nurse, and reviewed by the Quality
Improvement Committee or other appropriate departments such as pharmacy.
O. A medication error is anything that requires discontinuing the medication, modifying
the dose, hospitalization, treatment with a prescription medication, or an error resulting in
disability, cognitive deterioration or impairment, congenital anomalies, death or is life
threatening. All medication errors will be documented via a variance report.
P. The Agency will attempt to obtain specific orders for treatment of adverse drug
reactions on each patient where such a reaction is possible. The specific orders will be
followed should an incident occur. In the absence of specific orders, the nurse will
implement standing drug reaction/anaphylactic shock orders contained in this policy
manual and remain with the patient until the paramedics arrive. ADR/variance reports
are to be filed with the pharmacy for review by medical staff and appropriate committee.
Adverse Drug Reactions:
Adverse medication reaction is defined as any medication that elicits specific abnormal signs and
symptoms that are not normally or directly associated with the medication. These abnormal signs
and symptoms may include, but are not limited to: headache, tremors, dizziness, muscle spasms,
confusion, nausea, vomiting, diarrhea, cramps, abdominal pain, skin rash or flushing, dizziness,
hypotension, a diffuse feeling of warmth, arrhythmias, tachycardia, bradycardia, shortness of
breath, dyspnea on exertion, and/or respiratory depression.
A significant or severe adverse reaction is defined as those signs/symptoms that are so severe that
the patients requires immediate emergency medical treatment. These may include respiratory
distress, choking sensation, difficulty swallowing, tightness or pain in the chest, wheezing,
dyspnea, respiratory stridor, vascular collapse, cyanosis, imperceptible pulse, or circulatory
A mild adverse reaction may demonstrate the above signs and symptoms but with lesser severity,
and the patient is not in immediate danger. A mild reaction can progress to a significant or
severe reaction and the patient should be mon