Determining Medication Self-Administration
The philosophy of Assisted Living Facilities (ALF) is one of individualizing and maximizing consumer independence, choice, privacy and dignity, all while minimizing risk. Every state varies in its definitions and regulations concerning medication administration. It is extremely important for providers to know and follow the medication administration expectations within their state. The following are some common trends and safeguards that can be adapted by your facility, as applicable.
Facilities often consider medication administration their responsibility and are hesitant to relinquish control. However, it is expected that assisted living residents are encouraged and allowed to maintain as much independence as possible, including the right to retain control of their medications. In most states, the resident determines which medications (prescription and non-prescription) will be administered by the facility’s program. Residents are allowed to self-administer medications, unless the prescription explicitly states the resident is not to self-administer or the resident delegates administration to the assisted living program by an occupancy agreement or signed service plan. Moreover, some residents who give the program responsibility for administering prescription medications may choose to administer their own over-the-counter (OTC) and as needed (PRN) medications.
A resident with the mental and physical capacity to develop increased independence in medication administration should be supported with self-administration instruction. Self-administration suggests that individuals are functionally and cognitively competent to take and manage their own medications independently. Residents who wish to self-administer medications must be assessed to determine if they have the ability to do so safely. A thorough assessment may include such factors as dexterity, comprehension, recall and visual acuity.
Residents should be re-assessed at least annually, and whenever there is a change in their physical, cognitive, functional status or desire to self-administer medications. Each state has specific regulations regarding who can "assess" and "assist" with medications. Both licensed and non-licensed staff are often involved in medication management with a resident.
There are three basic areas to evaluate:
What a person knows about their medications;
How to take their medications; and
How to obtain (re-order) their medications.
The evaluation also should include:
OTC and PRN medications that may cause interactions with prescribed medications;
Review of storage and security of the medications in a resident’s room, especially if there is a roommate; and
Disposal of discontinued medications.
There are many forms available to document a resident’s assessment, including:
Residents Requiring More Assistance
The first 30-days of tenancy is usually an adjustment period. One option for residents who think they may need help with some, but not all of their medications is to include medication administration in the preliminary service plan. Providers could assess the resident’s ability to remember and take medications (as previously discussed) during that 30-day period, and then adjust the service plan accordingly when it is rewritten at 30 days.
If a staff person becomes aware that the resident may be inappropriately utilizing their OTC, PRN or other medications, they should attempt to discuss the issue with the resident and provide education on the risks of misuse of medications. If the resident refuses to heed the staff person’s advice, he or she can trigger a 90-day review and execute a negotiated risk agreement with the resident that clearly spells out the dangers of continued misuse.
Sometimes a family member will ask the program to "keep an eye on Mom to make sure she takes her meds," out of concern or simply not wanting to pay for additional services. Residents and families should understand that there should be no "gray area" in medication administration. That is to say, there is a danger in providing reminders without including and documenting medication administration on the service plan because the resident and family will expect the reminder. If the caregiver forgets, the resident and family may feel the program has failed to provide proper care, especially if an adverse effect or decline occurs to the resident as a result.
To the extent possible, it is best for the program to take full responsibility for medication oversight, or the resident retains autonomy in managing their own medications. In the latter case, a better solution might be for the family member to call the resident and remind them to take medications, just as they might have done when the resident was living independently. Providing a clear explanation of the roles, responsibilities and costs regarding medication administration prior to move-in will help to offset any unrealistic expectations residents and family members might have.
Some residents have purchased, or brought with them, a pill box that dispenses medications and provides a verbal reminder to "take your medications now." In general, if the program sets the meds up in the talking pill box, they are taking responsibility for medication administration. However, if the pharmacy or a family member sets the pills up in the box, the resident is self-administering medications.
In general, residents may keep their own medications in their possession unless the prescription states that the medication is to be stored by the assisted living program, or if the resident delegates control of medications to the program by occupancy agreement or signed service plan.
A resident who takes responsibility for their own medications may be offered the option to have a locked box or drawer to secure their medications. In many states, when the resident does not delegate responsibility for medication administration to the program, they have the right to store medications within their own apartment as they see fit. However, the medications should not be easily accessible to other tenants, as a confused resident may pick the bottles up and carry them out of the unit. If staff witness medications stored in an unsafe manner (on a table, next to a door left open through-out the day), they should counsel the resident about the safe storage of their medications.
If the program takes responsibility for all or part of the resident’s meds, they should be locked in a box or drawer in the resident’s room, and only employees who will be assisting with med distribution should have a key. The medications should be labeled and maintained in compliance with label instructions and state and federal laws. The program should list in a resident’s record any medications to be stored or administered by the program. Staff should document, by exception, any medication the program has agreed to administer or supervise that is not taken by the resident.
Staff should be aware of potential adverse effects of all medications, including self-administered meds, and know how to report and investigate a medication error. If the resident is ill or refuses meds, responsibility exists for the facility to provide follow-up oversight.