School Nursing Courage Conviction Compassion 1 2/1/2018 - - PDF document

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Massachusetts Department of Public Health

Medication Administration in Schools: What School Nurse Managers Need to Know

Mary Ann Gapinski, MSN, RN, NCSN Director of School Health Services

School Nursing

Courage Conviction Compassion

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Prerequisite for this workshop

Completion of SHIELD online course

Course Objectives

• Describe the role and responsibilities of the school nurse manager in

the medication administration program in schools

• Collaborate with school district administration and school physician

to assess, develop, revise and implement medication administration program policies and procedures that meet federal, state, and local laws and regulations.

• Establish systems to evaluate, verify, and communicate ongoing

competence in medication administration and delegation for RNs and delegates.

• Explain and implement the process for registration with MDPH of the

school’s or school district’s medication administration program

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MEDICATION ADMINISTRATION IN THE SCHOOL SETTING

Overview

Massachusetts Laws and Regulations Affecting Medication Administration and Delegation

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Massachusetts Laws and Regulations Affecting Medication Administration and Delegation

MGL 94 C MGL C112 Section 80B MGL C71 S54B

BORN: 244 CMR 3.00 (Nurse Practice Act and Regulations)

BORN 244 CMR 9.00 (Standards of Conduct) 105 CMR 210.000 http://www.mass.gov/legis/laws/mgl/index.htm

Purpose of the Regulations

“…to provide minimum standards for the safe and proper administration of

prescription medications to students in the Commonwealth’s public and private

primary and secondary schools. The regulations permit school nurses to delegate responsibility for administration of prescription medications to trained, nursing- supervised school personnel, provided the school district or private school registers with the Department of Public Health. The aim of 105.CMR 210.000 is to ensure that students requiring prescription medication during the school day will be able to attend school and to ensure that prescription medications are safely administered in

• schools. 105 CMR 210.000 encourages collaboration between parents and guardians

and the school in this effort.”

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Definition of the School Day per 105 CMR 210.001 Purpose:

The purpose of 105 CMR 210.000 is to…… ensure that students requiring prescription medication administration during the school day will be able to attend school and to ensure that prescription medications are safely administered in schools…

The School Day

The “school day” as defined for the purpose of 105 CMR 210.000 is any part of a day, including a partial day that students are in custody of the school, whereby the school has the authority and duty to provide care and protection of students.

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Options For Medication Administration in the School Setting Permitted by Law and Regulations

 All medication administered by licensed

personnel  Registration for Delegation to unlicensed school staff by the school nurse:  Residential Schools  Public and Private Day Schools  Self administration with parental permission and approval by the school nurse Options (continued)

 Training of unlicensed personnel in the administration of epinephrine via an auto-injector to those with a prescription (requires registration)

Requires:

• Agreement at the school district level by the School

Nurse, School Physician, Superintendent (Administrator) and School Committee (Directors).

• Registration with the Department of Public Health

after certain conditions are met.

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Medication Administration Program: Management

All public school systems/non-public schools in the Commonwealth are required to comply with regulations 105 CMR 210.00: The Administration of Prescription Medications in Public and Private Schools.

Management (continued)

Only certain licensed professionals such as School Nurses (RNs), described n M.G.L. Chapter 94C, may administer prescription medications in Massachusetts public school systems/non-public schools unless the school is approved for registration with the Massachusetts Department of Public Health (MDPH) School Health Unit and MPDH Drug Control Program (DCP) for the handling and storage of medications by unlicensed school personnel.

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The School Nurse Manager is responsible for the management of the medication administration program in all public/non-public schools.

Management (continued)

School Nurse Manager Roles and Responsibilities

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School Nurse Manager Responsibilities for the Administration of Medications Within the School System

• Collaborates with school committee/

administrators/ school physician to establish policies that:

• Establishes protocols for administration of all

medication in the school setting;

• Defines which medications may be delegated;

School Nurse Manager Responsibilities (continued)

• Designates who may administer;
• Ensures training of designees;
• Supervises and evaluates total program
• Establishes record-keeping system.

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BORN Advisory: Verification of Orders Nurse Manager The School Nurse Manager must develop and implement the necessary measures to promote the delivery of safe nursing care in accordance with accepted standards of care. BORN Advisory: Verification of Orders

The School Nurse Manager must ensure:

• Infrastructure that is consistent with current

standards of care to minimize errors

• School policies reflect student safety concerns
• Orders are obtained in an acceptable method

(whether verbal, electronic, written or standing) and in what circumstances which method can be used.

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School Nurse Manager Responsibilities for Delegation

The School Nurse Manager (Leader/Contact Nurse) is accountable for:

• Establishing systems to evaluate ongoing

competence of all nursing and UAP staff

• Developing policies and protocols
• Ensuring standards of practice are established

and maintained

(NCSBN 2009)

School Nurse Responsibilities

For each individual student the School Nurse:

• Completes the IHCP including medication

administration plan (MAP) in collaboration with student’s prescriber;

• Gives first dose of medication/ first treatment

(medication or treatment that has not been initially administered in another setting should not be administered in the school setting);

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School Nurse Responsibilities (continued)

• Determines whether to delegate

administration and/ or treatments and to whom.

• Evaluates student ability to determine

readiness for self-administration in the school setting. BORN Advisory: Verification of Orders School Nurse The School Nurse is accountable to ensure that the order:

• Originated from an authorized prescriber
• Is reasonable, based on nurse’s knowledge and

student needs

• Is compliant with school policy and protocols

(putting student safety first)

• Is current and evidence-based
• Reflects student allergy concerns

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School or District Responsibilities for Delegation

The School District is accountable for providing:

• Sufficient resources
• Sufficient staffing
• Documentation of employee competencies
• District policies on medication administration

and delegation

(NCSBN 2009)

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Policies Discussion SELF ADMINISTRATION IN THE SCHOOL SETTING

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210.006: Self-Administration of Medications by Students

DELEGATION IN THE SCHOOL SETTING

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FIELD TRIPS AND OTHER SHORT TERM EVENTS

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TRAINING OF UNLICENSED PERSONNEL

The training of unlicensed school personnel in the handling, storage, administration and disposal of medications shall be provided under the direction

• f the School Nurse Manager (RN). The training

must follow the content outline, and use the competency test provided by the School Health

• Institute. There must be plans for an annual review

and update for unlicensed school personnel.

TRAINING (continued)

Must indicate which category(s) of unlicensed school personnel may be delegated the responsibility for medication administration in your school system /school as approved by the School Committee or Board of Trustees and in accordance with 105 CMR 210.004, (B), (1), (2):

• Administrative Staff
• Health Aides
• Teaching Staff
• Secretaries

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TRAINING (continued)

A current listing of all unlicensed school personnel who have been trained by the School Nurse in the administration of medications shall be maintained in each school. Upon request, a parent shall be provided with the name(s) of school personnel authorized to administer medications.

Medication Administration Training Manual Available on SHIELD Website

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Delegation and Supervision of Medication Administration

• School must be registered with the

Massachusetts Department of Public Health

• Unlicensed personnel are under the

supervision of the School Nurse 105 CMR 210.004 (B) (3) states “A school nurse shall be

• n duty in the school system/school while prescription

medications are being administered by designated unlicensed school personnel and available by telephone should consultation be required.”

Delegation and Supervision (continued)

• School Nurse selects, trains, supervises unlicensed

staff to whom she will delegate

• On-site supervision required for the first time an

unlicensed person administers medication

• Amount of on-going supervision varies according

to condition of student, ability of unlicensed person, type of medication

• Be sure documentation procedures are in place.

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Regulatory Guidance

105 CMR 210.004 (B) (3) states “A school nurse shall be on duty in the school system/school while prescription medications are being administered by designated unlicensed school personnel and available by telephone should consultation be required.

Regulatory Guidance (continued)

105 CMR 210.005 (G) states: “…The School Committee or Board of Trustees in consultation with the Board of Health where appropriate, shall provide assurance that sufficient school nurse(s) are available to provide proper supervision of unlicensed school personnel…”

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The Application Process

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APPLICATION PROCESS OVERVIEW

1. Request Application (new and/or renewal) by fax

• r mail (no email). PLEASE SPECIFY:

a. Residential b. Public or Private Day School c. Training of unlicensed school staff in epinephrine administration. 2. Complete Application including all required signatures.

APPLICATION PROCESS (continued)

• 3. Mail to MDPH School Health Unit (ATTN: Janet

Burke) along with SHI attendance certification/ RN license of school nurse manager if required. 4. MDPH SHU reviews application. 5. If need for MCSR: forwarded to DCP for additional approval. 6. NOTE: Registration mailed to address indicated

• n application

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MDPH Registration Process

Step #1 School Nurse Manager Mail or Fax Request for an Application on School Letterhead

(NO email requests accepted)

School Health Unit MA Department of Public Health 250 Washington Street, 5th Floor Boston, MA 02108 Fax: 617-624-6062 To review Regulations visit: http://www.mass.gov/eohhs/docs/dph/regs/105cmr210.pdf

Completing the Application

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APPLICATION FOR PUBLIC AND PRIVATE DAY SCHOOLS Essential to check off when delegation is

• ccurring:

APPLICATION FOR RESIDENTIAL SCHOOLS Essential to check off when delegation is

• ccurring:

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Please Note:

School Building Profile

• 1. Must reflect the School / District nursing coverage

to assure adequate nursing staff for appropriate delegation (national (not state) standard is considered)

• 2. Delegation is not intended to substitute for school

nurses but to add flexibility to the nurse’s daily practice

• 3. School nurse must be available for consultation

whenever delegation occurs.

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Please Note:

MA Standards of School Nursing Ratios

1998 legislative report defined recommended school nursing ratios: Options for Developing School Health Services in Massachusetts

1 FTE: 250-500 students; More than 500: 0.1 FTE for each additional 50 students; Fewer than 250 students 0.1 FTE: 25 students *Note this was 20 years ago. Nurse Manager must communicate what’s appropriate to administration.

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Signatures Required

• School Nurse Manager responsible for management
• f the medication administration program
• School Physician
• School Superintendent/ Administrator
• Chair, School Committee or Board of Trustees

All who need to collaborate and approve the adoption

• f the school / district medication policy.

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Changes to Signatories

• IF THE SCHOOL NURSE MANAGER CHANGES,

A NEW APPLICATION MUST BE COMPLETED AND APPROVED!

If the School Physician, Superintendent (or School Administrator), or Chair of the School Committee (or Board of Trustees) changes, must send a signed letter informing of change and agreement to the requirements of regulations 105 CMR 210.000

Please Note: Signatures Required for Assurances

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Drug Control Program

Massachusetts Controlled Substances Registration (MCSR)

• Required of all Residential Schools due to

requirements for dispensing and storage of medication

• Must have initial approval of the MDPH

School Health Unit

• Additional application and fee
• Renewed Annually

Massachusetts Controlled Substances Registration (MCSR)

• MCSRs are issued to health care

facilities, community-based programs and other entities as well as to individual health care providers and researchers.

• The MCSR provides accountability

for the manufacture, distribution, dispensing, possession, prescribing and administering of controlled substances which, in Massachusetts, includes all prescription drugs.

• Required of

Residential Schools

• Not required

for Day Schools

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MDPH Registration Process

Copy of License of the Registered Nurse (RN) Manager must be included with application

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Two Certificates of Participation

• TWO courses: online Medication in Schools AND live

program for Nurse Managers

• Contact Hours/PDPs/CEUs/CNEs
• Write name of participant and name of school/district on

certificate

• Send to MDPH when registering for medication delegation
• Attendance required every five years for

continued approval of registration

Process Recap:

 Read instructions carefully  Be sure the application is complete, including all signatures, attachments, and fees  Review process takes about 2 months

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Managing Life Threatening Allergies in the School Setting

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Additional Issues of Medication Administration in the School Setting

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Medication Errors

• Notify parent/guardian immediately
• If harm possible notify provider
• If harm, notify MDPH SHU SHA and

complete form provided (recommended to be completed for all medication errors)

• Diversion/Drug Loss – Notify MDPH DCP &

Local Authorities.

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Medication Errors (continued)

• Document on district accident /incident form
• Review reports of errors to reduce chance of

repeat

• A missed dose is a medication error!
• As number of distractions increases, so do the

number of medication errors and the risk to patient safety. (Executive Health, 2010).

• Recommendations include establishing a

“protected hour” for medication administration.

Medication Emergencies

• Do not give initial dose of new medication

in the school setting

• Follow established school policies related

to all health emergencies

• Local EMS telephone number – with

directions on how to access to outside phone line

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Medication Emergencies (continued)

• Individuals to be notified (parents, principal,

physician, etc.)

• List of CPR trained school personnel
• Provision of needed supplies and equipments
• Reporting Requirements: DCP or School Health

Unit

Duty to Report

244 CMR 0.03 (26) Duty to Report to the Board. A nurse who holds a valid license and who directly

• bserves another nurse engaged in any of the

following shall report that nurse to the Board in accordance with Board guidelines: (a) abuse of a patient; (b) practice of nursing while impaired by substance abuse; (c) diversion of controlled substances.

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Risk Management for Medication Administration in Schools

• 1. Know your Scope of

Practice! (regulations/ job description, etc.)

• 2. Maintain nursing

competencies through continuing professional development

• 3. Document often and well

and ASAP!

Risk Management (continued)

• 4. Recognize that the nurse is the final GATEKEEPER

in Medication Administration:

• a. Document allergies in a conspicuous manner
• b. Indicate current and past medications and any

deviations

• c. Record student’s response as necessary

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Risk Management (continued)

• d. Recognize the appropriate medication

indications, dosage, route, side effects of any new or unfamiliar drug

• e. Document any wasted, destroyed, returned

medication in compliance with school policy and local and state laws f. Follow the EIGHT rights of medication administration

References

BORN: https://www.mass.gov/orgs/board-

• f-registration-in-nursing

ANA: http://nursingworld.org National Council of State Boards of Nursing: www.ncsbn.org NASN: https://www.nasn.org

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Resources

MDPH School Health Services: http://mass.gov/dph/fch/schoolhealth MA Comprehensive School Health Manual (2007): http://bucme.org/node/1098#1 Boston University School Health Institute for Education and Leadership Development (SHIELD) http://www.shield-bu.org

Resources

http://reference.medscape.com/pill-identifier/ http://www.rxlist.com/script/main/hp.asp http://www.drugs.com http://health.nih.gov/topic/AboutYourMedicines

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Available for Review New Resource Available

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EOHHS Region Name Office Phone Cell Phone Email Central Kate Maher 978-567-6190, ext. 21123 774-230-3868 kmaher@hudson.k12.ma.us Metrowest Jean Afzali 781-848-4000, ext. 7841 781-724-4018 jafzali@braintreema.gov Northeast Shanyn Toulouse 978-420-1919 978-761-2307 shanyn.toulouse@haverhill-ps.org Southeast Ann Klaver 508-580-7363 annmarieklaver@bpsma.org West Diane Colucci 413-750-2511 colucci-hechtd@springfieldpublicschools.com Therese Blain 413-750-2007 blaint@springfieldpublicschools.com

Regional Consultant Staff

MDPH School Health Unit Staff

Mary Ann Gapinski, MSN, RN, NCSN Director of School Health Services Mary.Gapinski@state.ma.us Janet Burke Program Coordinator Janet.Burke@state.ma.us

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Let whoever is in charge keep this simple question in her head – How can I provide for the right thing to always be done?

Florence Nightingale

Thank You

Policy Review Document

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QUESTIONS FOR DISCUSSION

If you’re not the nursing director…. Working with nursing assistants No full-time nurse available When is a nurse needed on a field trip or other school-sponsored events Delegation versus training SPED Director supervising one-on-one nurses Other?

Case Study

You are the new nurse manager in a small regional school district. In doing a walk- through of your school nurses’ offices, one of the nurses, Pat, reports that there is a new student, Taylor, within the district. Taylor’s mom has requested that Pat administer a homeopathic medication ordered by a homeopathic physician to Taylor at noon each day for ADHD to “help them concentrate.” You have a letter from the homeopathic physician, Dr. Lynda Smith, PhD, MS, MBA, BSN. The letter explains that Dr. Smith, is a certified homeopathic provider. The letter also contains the name of the medication, Anger-Soothe, as well as instructions to “give 1/2 teaspoon at noon each day for ADHD.” Taylor’s mother gives you an unopened bottle of medication which came from the homeopathic pharmacy. It is factory labeled, with the following: Homeopathic Formula, NativeRemedies, The Natural Choice, Anger-Soothe (reduces angry feelings & emotional outbursts) 4 oz. The principal is aware of the situation and has told the mother the nurse will give the medication. You reviewed the district policy which was in effect prior to your hire and it states that nurses are able to give homeopathic medication in the school setting.

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Case Study Discussion

What are your concerns, if any? Are there any issues with giving this medication? What guidance would you give your nurse -give this medication or not? Why or why not? What guidance would you give to your nurse to work with Taylor’s mom to assist her wishes that Taylor receives the medication? What information do you need to provide to the principal? How and when would you involve the school superintendent or the school physician? Are there other “red flags” that this raises for you as the school nurse manager concerning the medication administration program in this school? In the district?