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Hot Topic of Medication Management in Residential Care/Assisted Living Facilities

By Wendy Simons



   Isn’t it interesting how things roll along smoothly for years then all chaos breaks loose?


   During the past 18 months, 5% of the licensed larger Residential Care/Assisted Living  facilities (RCF/AL) in the state have experienced significant issues with regard to medication management and 50% of the smaller RCF/group homes have had similar issues.  Some of these issues have resulted in fines in excess of $100,000 by the licensing entity, the Bureau of Health Care Quality and Compliance, most specifically for “failure to administer medication as prescribed”. But first, a bit of history might be in order.


   About 16 years ago, the state of Nevada crafted law and regulations that allowed staff in a Residential Care/Assisted Living Facility (RCF/ALF) to assist residents with their daily medication.  Prior to that time, it was assumed that if a resident could not manage their own medications, perhaps they should be in a skilled nursing facility.  It actually took an action of the legislature, and a group effort of the Board of Nursing, Board of Pharmacy, Bureau of Licensure and Certification (of the Nevada State Health Division) and residential care industry professionals, to craft that law and subsequent regulations to establish procedures and protocols for such assistance or “administration” of medication.


   Over the past 16 years, several modifications have occurred, some of which prove confusing to the family members as well as the senior residing in the facility.   However, the purpose has been to assure that each senior residing in a residential care/assisted living facility has the utmost protection with regard to medication management and assistance.


   Initially, guidelines were established for the receipt, storage and administration of medications. Documentation in the form of a Medication Administration Record (MAR) is required and medication must be given as prescribed by the physician for routine or scheduled medications and those given “as needed or PRN” (usually for pain management).


   Additional criteria have been established that required caregivers assisting with the administration of medication attend a state approved training and pass a state approved testing process.  Subsequent regulations were adopted requiring those caregivers to have training updates every 3 years and pass an additional state approved exam. A newly developed recertification exam was developed by the state and was implemented in January of 2009.


   Now, let’s return back to the current issues.  Standards and regulations require medication must be administered as prescribed by the resident’s physician. This also includes over the counter (OTC) and supplements. 


   Where is the breakdown in this process that is causing all the fuss, media coverage and fines?  The top issues are:

  • Facilities are failing to obtain refills for medication prior to the resident’s running out; therefore the medication is not available to give.
  • Facilities are not securing physician approvals in a timely manner to assure refills are obtained before the resident runs out.
  • Pharmacies report insurance companies are not authorizing refills in a timely manner.
  • Family members or responsible parties are refusing to pay for costly medication and again, medication is not available to give.
  • Family members are not bringing the proper medication and OTC/Supplements as written in the physician orders (Example: “Calcium with vitamin D” may be the order and family brings plain “Calcium”).
  • Facility operators and caregivers who assist with medication are not being diligent in their systems management to properly give or document medication administration.


   From a regulatory oversight perspective, when a facility is cited at time of survey or following a complaint investigation, the facility is given a clear understanding of the regulatory deficiency.  It responds with a plan of correction that it has taken steps to correct the problem and how to prevent it occurring in the future. When the regulatory authority ( HCQC) goes back to follow-up and finds that the problem still exists, fines or sanctions may be imposed.


   So what has happened in the cases that have become newsworthy?  The facilities, their ownership, management and staff just “didn’t get it” and failed to correct the problem quickly.  In some cases in the Las Vegas area, the HCQC was able to substantiate that harm had occurred to a few residents due to the failure to give medications as prescribed and tougher sanctions were imposed. 


   Facilities must remain mindful that one bad story shakes public confidence and all other facilities come under scrutiny.  Facilities that betray that confidence have already suffered financial penalties and long term damage to their reputations, but the fall out of bad practices has an effect on  other providers in the industry.


   I leave you with this final thought. There is tremendous benefit to our seniors who settle happily into a supportive environment with caring staff.  It goes without saying that many facilities operate with exceptional dedication to their seniors and minimal issues; but sadly, bad news casts doubt. (Look at Toyota and their recent news, great company, now in doubt). 


   If you discover the need to have a loved one in a Residential Care/Assisted Living facility, just ask the tough questions, continue to be on top of issues of concern, advocate for the well being of that person, and be a partner in the care and services planning for that person.  It takes a team (family, doctor, care facility, pharmacy) to assure that medication management and administration remain successful.


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