NewBridge Services, Inc.
Policies and Procedures
TITLE:
Supervised Self-Medication Process in Community Residences
EFFECTIVE DATE:
CODE: RES 206
2015
POLICY:
The NewBridge Residence Program provides complete and careful monitoring of
medications prescribed to individuals living in the community residences, as well
as supporting their educated participation in the process.
PURPOSE:
To ensure the safe and effective distribution of medications to individuals living
in the NewBridge community residences to support their recovery efforts.
PROCEDURE:
A. All community residence participants who store their medications within the organization
will be assisted with medication self-administration.
B. All distributed doses will be observed by designated and authorized staff.
1. Medications are managed in designated medication areas in order to address the
right to privacy during such encounters.
2. The resident will identify the medication packaging as having their name, current
date and current administration time on it.
3. The resident will remove prescribed medications for designated staff to verify.
4. The resident will be encouraged to identify medication and their understanding of
its use at this time.
a. Staff may help the resident identify any positive or negative effects that it
may have as the resident understands them and as directed by the
residence nurse, clinician, or psychiatrist.
b. Staff may help the resident articulate the reason for the medication and its
intended benefit.
5. The resident will ingest medication in the presence of the staff member.
a. Staff will provide and encourage the use of appropriate fluid.
b. Staff may request that the resident open his/her mouth to demonstrate
completed ingestion.
c. Staff may request that the resident remain with staff for up to ten (10)
minutes and drink more appropriate fluid to ensure ingestion if determined
appropriate by the treatment team.
C. Medication distribution is documented with each dose, with added focus and
documentation of any dose omitted, held, refused, or not available.
1. A medication log book is kept in the medication area.
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Policies and Procedures
Supervised Self-Medication Process in Community Residences
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a. Each resident has a designated medication administration record (MAR),
designating prescribed and physician approved medications, their dosages,
and prescribed time of day in the log book.
b. The MARs will be separated by resident and will be clearly marked with
the resident’s name, prescribing physician, and known allergies.
c. Staff members supervising medication self-administration will enter their
initials, signature, and title on the reverse side of each resident’s MAR.
d. The supervising staff member will initial the MAR in the box
corresponding with the medication, day, and time when medications have
been observes as taken.
e. The supervising staff member will label the appropriate box on the MAR
with the letter “P” if the medication is packed and given to the resident for
later self-administration.
I.
The staff may provide medication education to any parties who
will be with the resident during the administration time.
II.
The resident will be instructed to return any unused medications at
the time of their return.
f. If the medication is observed as not taken, the staff will circle their initials
and provide a written explanation on the reverse side of the MAR sheet.
g. If the packed medication is returned before the administration time, staff
will return the dose to the resident’s box and enter their initials below the
“P” on the MAR when the medication is taken. A corresponding note will
be entered on the reverse side that packed medication have been returned
and taken.
h. If the packed medication is returned after the time that it could be
ingested, the staff will circle the letter “P” that was input for that
medication time and write a note on the reverse side that the packed
medications have been returned and not taken.
i. If a resident takes a PRN medication, staff will enter the selfadministration time and initials in the corresponding box within the
appropriate date, and will enter a note on the reverse side indicating the
reason for use as described by the resident and any regulated outcomes.
j. All returned doses will be recorded in the staff log.
k. All missed doses, and related resident’s statements and staff’s
interventions, will be recorded in the staff log.
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Supervised Self-Medication Process in Community Residences
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l. Efforts to educate the resident on the role of medications as it relates to
their illness management will be documented in the progress notes weekly
by the assigned staff.
m. The residence nurse and clinician will document medication education,
counseling, and issues in the resident’s chart monthly.
2. Medications started, stopped, or changed mid-month should have the unused
section of the medication sheet highlighted with yellow marker with the date of
the start/stop/change and prescriber’s name.
a. Medication changes should appear in the resident’s chart, residence log
book, and resident’s progress note.
b. All medication changes should be communicated to the pharmacy and are
stored in a separate file, called the prescription log book, at the facility.
c. The residence staff may change the medication label to reflect prescriber
changes under the supervision of the residence nurse.
D. Medications are to be taken within a two hour window of the time prescribed by the
physician (two hour window means two hours before or after the prescribed time).
1. If a resident does not present him or herself at medication time, and is known to
be in the residence, staff may find the resident and prompt him or her to take
medications up to three times.
2. If medications are not taken on schedule, the missed dose and reason should be
documented on the resident’s MAR by the assigned staff who will circle their
initials and document the reason for the missed dose on the reverse side of the
MAR.
3. If missing a dose is unusual for the resident, the staff should report it to the
clinician.
4. If missing the dose poses a medical risk to the resident (e.g.: an anticonvulsant)
the staff should report it to the residence nurse.
5. All missed doses are recorded in the staff log.
6. Missed medications will be communicated to the prescriber as determined
clinically appropriate by the residence nurse or clinician.
E. Medications shall not be shared between residents.
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F. Discontinued, expired, and untaken medications shall not be available to residents, and
will be removed from the resident’s bin into a designated discard container as per policy
Med 105.
G. Discontinued and expired medications will be removed from the residence as per policy
Med 105.
H. Medication education and counseling is integral to supporting resident efforts toward
wellness and recovery. During medication counseling the prescriber or nurse may
provide written information to the consumer regarding the risks and benefits of the
prescribed medication.
1. At the time that a new medication is prescribed by a NewBridge prescriber, the
prescriber will provide written information about the medication’s risks and
benefits.
2. Under the direction of the residence nurse or clinician, the direct care staff may
utilize the provided information to support the resident’s understanding of the role
of medications in his or her recovery.
3. The resident will be referred to the residence nurse or prescriber for medically
technical questions, or to the residence clinician if needed.
4. The staff will respect the resident’s right to decide if medications should have a
role in his or her recovery, and should help the resident evaluate the results of his
or her decision on an ongoing basis.
I. Each consumer is encouraged to be ultimately responsible for taking medications as they
are ordered by the prescriber.
J. If it is suspected that a consumer is under the influence of drugs or alcohol and/or informs
staff of recent substance use, then the residence nurse or psychiatrist will be contacted for
further direction regarding the next medication dose.
1. If the staff is instructed to withhold the dose, it will be documented in the MAR as
a missed does and a detailed explanation will be entered on the reverse side as
described in section C, item 1k, section D items 5 and 6, and section F.
a. All reasonable efforts will be made to obtain information on the substance
used and the amount used.
b. All information related to substance use and held medications will be
documented in the staff log and resident progress notes.
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K. The resident’s medication use pattern will be reported to the prescriber during follow up
visits.
L. Staff responsible for observing self-medication and medication education will receive
annual medication training authorized by the Pharmacy committee.
REFERENCES:
A. N.J.A.C. 10:77A
B. N.J.A.C. 10:37A
Revised: 3/2015 C. Dean