November 15, 2000
MEDICATION ADMINISTRATION IN NURSING HOMES
By: Susan Price-Livingston, Associate Attorney
You asked about other states' laws, regulations, or policies permitting people who are not licensed as registered or practical nurses to give medicines to nursing home residents. This is an update of OLR Report 2000-R-0123, which describes nine states' (Indiana, Iowa, Kansas, Maryland, Minnesota, Nebraska, Rhode Island, South Dakota, and Texas) rules.
We asked this question of nursing boards, nurses associations, and nursing assistant organizations in all 50 states. Of the 27 states that responded, 16 permit unlicensed people to give medication to nursing home residents and 11 (Alabama, Delaware, Michigan, Montana, New Hampshire, New Jersey, New York, Ohio, Vermont, and Wyoming) do not. We also confirmed by computer search that 17 other states (Arkansas, Arizona, Alaska, Colorado, California, Georgia, Illinois, Idaho, Louisiana, Massachusetts, Mississippi, Pennsylvania, South Carolina, Tennessee, Utah, Virginia, and Washington) prohibit unlicensed people from giving medications in nursing homes by statute, regulation, rule, or attorney general opinion.
Following are brief summaries of who can become a nursing home medication aide in seven states that were not described in our earlier report. The new states are: Florida, Missouri, North Carolina, North Dakota, Oklahoma, Oregon, and Wisconsin. We have included relevant statutes, regulations, and other materials describing these programs.
REQUIREMENTS IN OTHER STATES
Two attorney general opinions interpret Florida's Nurse Practice Act as permitting certified nursing assistants to give topical, eye, ear, and nasal medications; rectal and vaginal suppositories, ointments, and creams; and prescribed, premeasured and prepackaged oral medications under the direct supervision of a nurse or doctor (1981 Op. Atty. Gen. 171; 1975 Op. Atty. Gen. 218). The Board of Nursing did not respond to our request for information about medication training and competency requirements, if any, for these nursing assistants.
Missouri permits technicians, nurses' aides, or their equivalent who are trained and employed in licensed nursing homes to administer non-injectable medication and insulin (Mo. Rev. Stat. §335.081). They must first successfully complete a medication administration training program approved by the state's Division of Aging.
The training must include at least 60 hours of classroom instruction; eight hours of clinical practice under the direct supervision of an instructor or nurse, including a two-hour final practicum in a licensed intermediate care or skilled nursing facility; and a final written examination. The curriculum must include:
1. basic review of body systems and drug effect on each;
2. medical terminology;
3. infection control;
4. drug classifications;
5. dosage, measurements, and forms;
6. storage and accountability;
7. problems of observations in drug therapy;
8. oral, rectal, vaginal, otic (ear), ophthalmic (eye), nasal, skin, topical, transdermal patch, and oral metered dose inhaler administration techniques; and
9. special categories.
Medication technicians, as they are called, must also have a high school diploma or GED, pass an adult basic education test, be listed on the state's nurse assistant registry, and have worked as a certified nurse assistant for at least six months.
North Carolina's nursing regulations permit unlicensed people to administer nutritional supplements, non-systemic topical skin preparations, and commonly used cleansing enemas or suppositories with local effects only (21 N.C.A.C. §36.0221). We found no law or regulation excepting nursing homes from this rule. In addition, an attorney general opinion has interpreted the state's Nurse Practice Act as permitting unlicensed employees to perform “mechanical acts” which do not require the knowledge of a registered nurse or licensed practical nurse, including taking a pill out of a bottle and giving the pill to a patient. The bottle must specify the patient's name and the medication, its dosage, and how often it should be taken (47 N.C. Op. Atty. Gen'l 253). The Nursing Board did not respond to our request for information about medication administration in nursing home settings and special training or competency requirements.
North Dakota has permitted nursing homes to use registered medication assistants since 1994, reports Sharon Moos of the state nurses' association. The Nursing Board approves state universities' basic and advanced medication administration courses for students already holding nurse assistant certifications.
The advanced course must include 40 hours of classroom instruction, eight hours of laboratory, and 32 hours of clinical experience. It must cover concepts similar to Missouri's curriculum, described above. Those who successfully complete it with a score of at least 85 on each unit test can register with the board and give medication to nursing home residents under the direct supervision of a nurse or other licensed professional (N.D.B.O.N. Regs. §54-07-07).
The board's rules also allow nurses to delegate specific medication assignments for specific patients to nursing assistants who are not certified medication assistants. The nurse must first give the assistant verbal and written instructions, observe her correctly giving the medication to the client, and verify her competency using quizzes, tests, and personal observation (N.D.B.O.N. Regs. §54-07-08-01).
Medication aides can give regularly scheduled, non-injectable medications in Oklahoma's nursing homes, reports Barbara Acello, R.N. By law, an “advanced unlicensed assistive person” who has completed a certified training program can assist licensed nurses as permitted by the Board of Nursing (OK Stat. §567.3a(13)). The board did not respond to our request for additional information.
Experienced certified nursing assistants may complete a state-approved training program and become medication aides in Oregon. By regulation, they can, under the supervision of a licensed nurse, administer:
1. oral, sublingual (under the tongue), and buccal (cheek) medications, including regularly scheduled controlled substances (narcotics);
2. eye medications, except to new post-operative eye clients;
3. ear, nose, rectal, and vaginal medications;
4. skin ointments, and topical medications including patches and transdermal medications;
5. medications by gastrostomy or jejunostomy (types of feeding tubes); and
6. dosage controlled aerosol/Nebulizer therapies.
They may also give “PRN” (as needed) medications, including controlled substances, to stable clients if ordered by a physician or nurse practitioner in response to a client's or nurse's request, so long as a nurse assesses or monitors the client's response to the medication.
Medication aides must successfully complete a training course approved by the state Nursing Board. The course must provide 40 hours of classroom training and at least 40 hours of supervised clinical experience in medication administration and related activities. Twenty of the clinical hours must take place in a licensed nursing home.
Before enrolling in the medication aide program, applicants must have completed the 150 hours of training required for nursing assistants, be listed on the state's registry, and have worked as a certified nursing assistant for at least six months.
Wisconsin nursing home regulations permit people who have passed a state-approved course to give medication to residents. The course must consist of 60 hours of classroom instruction and 40 hours of clinical experience. To be eligible, applicants must (1) be at least age 18, (2) have a high school degree or GED, (3) be listed on the Wisconsin Nurse Aide Directory, (4) have provided at least 2,000 hours of direct patient care in the past three years, (5) have worked at least 40 hours within the last 90 days (or by the time the course clinical experience begins) caring for the same residents they will be working with during the clinical phase of the training; and (6) receive written recommendations from the nursing director and the administrator of the facility in which they will be working and from two licensed charge nurses.
To maintain their certification, medication aides must keep their nurse aide certification current and attend four hours of continuing education on medication and medication administration annually. (The nurse aide certification requires an additional 12 hours of in-service training every year.)