Medication Management

Table of Contents:

1. Medication Management
2. Med Set
3. Complex Medications
4. Reordering Medications
5. Receive Medications and Medication Disposition
6. Medication Setup/Reviewed by Nurse
7. Managing Late or Missed Medications
8. Controlled Medication - FAQ

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Medication Management

Schedule a Medication for a Resident

Navigate to Residents > Select a Resident > Medications > Add New Medication
If you have a pharmacy interface, you may enter medications through the Pharmacy Connect process.

Medication Entry

• Start typing the name of the medication, if it appears in the dropdown list, hover over it and click on it. This will auto-fill the rest of the name for you and prevent adding an additional same-name medication to your Global Medications List.
• If the medication you are adding does not appear in the dropdown list, verify the spelling is correct and complete the entry of the name (this will automatically add this medication name to your Global Medications List).
• Matching the name on the pharmacy label is best practice, especially when this label is used by the med passer when verifying the medication at the time of administration.
  
  
• Strength
  • The strength is entered with both quantity and unit (i.e. 325 mg, 20mg/5mL, 25 mcg, etc.).
  • For best practice, the strength should match the pharmacy label and allow for the medication passer to clearly verify 'right dose' at the time of administration.
• Route
  • Administration route. For an order that has more than 1 prescribed route, add the additional route options to the Administration Instructions
• Scheduled or PRN
  • Different scheduling fields will appear depending on this selection. Medications with both a scheduled and PRN component will need to be entered twice, once for each schedule type.
• Indications
  • Type out the indication(s) for the medication, and/or select one of the resident's diagnoses from the dropdown list.

Schedule

• Active Date & Active Time
  These will determine when the first administration of this medication will appear in the eMAR.
  • Today's date & current time will default in, but can be edited for a medication order of a future date if the medication will not be administered right away.
  • When scheduling a medication for a future date, be mindful of the active time so that it falls before the scheduled time. You can run the report Simplified Schedules to determine the sort time if using simplified times.
  • If a resident is on Reserved or Hold status, you do not need to match the start date & time to their return; the medication will not appear for administration in the eMAR until the resident is active.
• End Date/Time
  When the last medication administration for this medication will appear in the eMAR.
  • Common for short-term medications such as antibiotics, pre-procedural medications, and tapers.
  • If not all doses will be given on that last day, then you will edit the time to be after the last dose. The most common would be the antibiotic that is 2 x daily for 7 days with the first dose being given at the time of 2nd daily dose (meaning the last dose will be a morning dose).
• Medication will be provided
  The Frequency of scheduling for scheduled medications including daily or less frequently. For PRN medications, fields will allow you to set limits on frequency. Some Examples:
  • Daily: Used anytime a medication is scheduled daily, whether it is 1 x day, 2 x day, 3 x day, etc
  • Every X Days: Used for medications scheduled with a set amount of days in between. Ex: Every other day would be Every 2 days
  • Even Days / Odd Days: NOTE: We recommend to update order to Every X days (2) in the place of Even / Odd days due to potentially 2 even or odd dates at month-end/start
  • X Days On / Y Days Off: Can be used for medications with a defined number of days of administration followed by a defined set of 'hold' days Ex: Give the med for 7 days, then hold for 14 days
  • Weekly (Specific Days): Orders for specific days of the week. Ex: M, W, F
  • Monthly: Can be used for medications ordered for a specific date of the month (15th) or day of the month (1st Friday).
• Time
  • Enter the time of administration for scheduled medications.
  • Click Show current schedule to see the times this resident is already receiving medications.
  • Specific is the most common option for medication administration times that specifies the hour and minute it is due. There is still the traditional grace period to administer and chart it before or after the specific scheduled time.
  • Simplified is a broader scheduled time, such as AM, Midday, PM, and Bedtime. This is not encouraged to be used for medications administered more than 1 x in a day.
  • Use the dropdown to choose the hour, minute, and AM/PM or a simplified option.
  • Add new time for medications administered more than 1 x in a day.
  • If a medication is to be given 3 x daily and you want to schedule it for 7:30 AM, 2 PM, and Bedtime, then you will need to enter the medication twice (once to schedule it for the 2 specific times & again to schedule it for the simplified time).
  • Parameters: if a blood sugar or other vital sign is needed for determining if this medication should be held or administered, schedule that service for the same time and to the same assignment as the medication.
  • Tip: The blue box below the 'Time' field will display the date and time of the first scheduled dose to be administered based on the schedule active time and medication administration time.
• Assignments
  • Using the dropdown options, choose which assignment list to add this service to.
  • Assignments in this list will only appear if that assignment shift is during the administration time (this prevents errors such as accidentally assigning a midday medication to an overnight assignment).
  • If any other medications are assigned for the time already, then you will be limited to that option (this is a safeguard to prevent multiple staff from being tasked with administering medications to the same client at the same time and helps to prevent medication errors). Simply change the administration time (even if only by 5 minutes) if this needs accommodated.

Administration

• Setup
  • Family: use when a personal contact for the resident sets up his/her medications (This medication will not be available on the Setup/Review medication screen)
  • Nurse: use when you or any nurse at your facility is setting up a resident's medications (typically used for medications that are not in a single-dose package or from the pharmacy).
  • Pharmacy: use this when the pharmacy sets up medications in a single-dose packaging by time or medication and time.
  • Self: use when the resident sets up his/her own dose for administration.
    Note: Medications that are set up by "Self", "Family", or "Other" will not appear in the Med Setup screen for documentation of setup.(This medication will not be available on the Setup/Review medication screen)
• Assist
  • Family, Home Care Agency, Self, and Other are non-facility staff and will not generate a Medication Administration Service for staff to sign off completion of.
  • Facility staff, such as HHA/RA and Nurse will generate a Medication Administration Service on the electronic MAR & are used with their hierarchy in mind.
  • HHA/RA: use this if the lowest hierarchy type for medication administration is permitted to administer this medication. It will allow you to schedule to provider types of both HHA/RA and Nurses since HHA/RA is lower in heirarchy.
  • Nurse: use this when the medication will only be assigned to a Licensed Practical/Vocational Nurse (LPN/LVN) or Registered Nurse (RN) that is part of your facility staff. If the medication is being assigned to a nurse simply because of the time it is scheduled and not related to scope of practice or policy, we recommended choosing HHA/RA to prevent problems in the future from staff schedule changes.

Administration Note
Notes can always be entered during the med pass, but are not required for most medications. If you do require a note for a medication administration to be complete, select the type of note (the note type will reflect which Snippet options are available for the med passer to choose, and additional free-text notes is always an option at administration time as well)

• Checkboxes
  • HHA Verify: this is a place for the med passer to indicate Medication Administration Rights have been verified as correct at the time of the med pass. It places an extra checkbox under this medication in the Medication Administration Service. (For those nurses familiar with paper MARs, this is equivalent to putting a dot in the initial box to keep track that the medication dose is in the med cup but not yet administered as your initials would otherwise indicate.)
  • Psychotropic and Antibiotic: appropriately indicating if a medication is in one of these categories will assist you later with proper reports and quality assurance.
  • Standing Order: identifies if the medication is part of routine standing orders.
  • Hide on MAR: this box will prevent this item from showing up in the Medication Administration Service. This is wonderful for those prescription items that you don't want to lose track of but don't need anyone to sign off as administering, but you still need all of the information for re-ordering and medication management tasks (lancets, pen needles, or even incontinent products for those using a Veterans Affairs Pharmacy!)
  • Crushable: this is to indicate if it is approved to crush this medication for this resident
  • Controlled: this will add this medication to the "Medication Counting" list and require the med passer to enter the quantity administered & the quantity remaining each time the medication is administered. This is for your "double-locked" medications. Only a facility staff person with the Administrator (Role 411) is able to edit this checkbox if it is incorrect.
• Administration Instructions
  Individualized instructions for the medication pass (e.g. give "2 tablets by mouth three times daily," "give 1.5 teaspoons by mouth two times daily -- okay to mix in 2 ounces of apple juice and watch to ensure she drinks all of it.", "give 1 tablet by mouth every morning (do not give if pulse is less than 60).")
• Pharmacy, Rx Number and Prescriber
  The final fields allow you to select the appropriate pharmacy and prescriber. The Rx Number is not a required field and need not be entered on medicaton entry. The number will automatically populate if imported using Pharmacy Connect, OR if entered on controlled medications when documenting as received under Clinical > Received Medications.

Medication Editing, Rescheduling, Hold, & Discontinuation

To make changes to a medication, navigate to the resident profile > Medications > select medication.

• The Edit button will allow you to update strength, route, indications, and administration details for a medication. Changes that are more than minor edits or additional details will alert you to the need for a discontinue and restart of the medication to preserve an accurate history. You can chose to confirm the change by clicking Save or cancel.
• The Reschedule button will allow you to change when a medication administration is scheduled.

Note: If a controlled medication warrants a discontinue and restart or is rescheduled, the count will transfer from the old record to the new record.

Troubleshooting Med Scheduling

Residex only allows 1 assignment for each med time. If you are not seeing the assignment you need when rescheduling/assigning a med assist from a single medication, you will need to use a different time OR reschedule En Masse from the Schedule tab.

Definite Hold

If the prescriber specifies a set time frame for which a medication should be held, use the 'Reschedule' option to enter an end date and time for the medication, and then the date and time the medication is to be restarted. This creates a gap in time during which the medication will not be able to be marked as administered. The advantage to this method is that the medication will restart automatically at the selected date and time without additional action.

Indefinite Hold

The Hold button will immediately put the medication on hold indefinitely, after a second confirmation step. The medication will then display in the current medication list and eMAR as being on hold, and staff will not be able to record administrations.

To remove a Hold, simply reverse the process - select the medication from the resident medications screen, and press the Remove Hold button.

The Dashboard/Login Report, Meds on Hold, can help remind nurses of meds that are in this temporary hold status.

Discontinue

The Discontinue button will end the medication after a confirmation step where you specify the End Date & Time, & optionally a reason.

Note: When discontinuing a controlled medication, the medication will remain on the Medication Counting screen until the count remaining is 0. Navigate to Clinical > Medication Disposition to dispose of the discontinued medication.

Reschedule Med Administrations En Masse

You can reschedule groups of medications to a new administration time and/or a new assignment very easily. From the resident Profile > Medications screen, select the Schedule tab; this will show you all medication administrations for a resident grouped by time.

Press the Reschedule button to reschedule/reassign all medications for a given time and assignment.

Medication Assessments

The first step to managing medications for a resident is to determine what his/her needs are regarding all medications. Reports such as the Individualized Medication Management Plan (IMMP) and Self Administered Medication Management (SAMM) Plan are created from information entered in the resident's assessment.

Med Set

Med Sets simplify adding a standard group of PRN meds, such as Standing House Orders or Hospice PRN Orders.

Complex Medications

Some medications require additional entry considerations (e.g. sliding scale insulins, steroid tapers, and transdermal patch removal)

Reordering Medications

Medication Setup/Reviewed by Nurse

This optional step allows the nurse to document either that the meds have been setup in a dosage box OR that cards/containers sent by the pharmacy have been reviewed by the nurse prior to making those meds available to staff to administer.

Managing Late or Missed Medications

Administering Meds 'as ordered' and on-time is the goal. We offer strategies and tools to minimize and manage late or missed medications.

Chart in Real Time

Provide your staff the tools they need to chart on time. Residex can be accessed on smart phones, Ipads, Chromebooks, computers. Portable devices allow staff to carry the device with them, read the instructions for each service, and document their actions at the point of service. Charting is accurate and complete!

If staff are sharing a single stationary computer, they are likely to scan their assignment, possibly work from memory, and chart at a later time. Accuracy is compromised, and the chance of errors - including med errors, late or missed charting - is increased.

Med Scheduling Considerations

Residex allows you to use either a Specific Time (8:00 AM) or a Simplified Time (AM) when scheduling medications. What is the difference?

• Specific Times convey to staff that the med should be given as close to that scheduled time as possible. Charting restrictions for a HHA will allow them to chart Scheduled meds up to 2 hours early or 4 hours late. If charting over 1 hour late, they can mark it as administered but will need to enter a note as to why it was late. A red 'late' flag will appear next to a service that is more than 1 hour late. This is meant to simply grab the attention of the staff and perhaps suggest that they give that service priority.
• Simplified Times give the staff more wiggle room. While best nursing practice suggests that specific times are best for most medications, there are times that a resident has an erratic schedule (a memory care client who may wake up at 5 am some days or 10am others). In this case, assigning meds a simplified time will allow the staff to mark it complete any time on the same calendar day it was scheduled. The nurse may choose to enter additional administration instructions to guide the staff.

Tracking Late or Missed Meds

The Login Report or Alerts can keep staff aware of missed and late meds.

Examples of Alert or Login Report options:

• Late Medications
• Late Medications All Campuses (for supervisors of multi-campus databases)
• Meds Late 3 hours or more
• Meds Late 4 hours or more
• Missing Med Recap - Last 24 hours (meds 2 hours late or missing)
• Missing Med Recap - Last 72 hours
• Missing Med Recap - All Campuses (for supervisors or multi-campus databases)

Adjust report permissions so late or missed medication information can be visible to unlicensed staff as they login. Make review of the login report part of the change-of-shift process.

How to Chart Late or Missed Meds

Meds that are late, whether they were scheduled as specific or simplified times, can be charted by the nurse even when unlicensed staff can no longer chart. Nurses, Supervisors, & Managers can chart care services up to 3 days early or up to 14 days late. Nurses have a much broader time frame in which to chart (up to 12 hours early or 14 days late for medications). So the nurse can:

• Navigate to the Today screen, select the calendar date and the assignment, locate the medication service, and mark meds as administered or declined, with a note of explanation.
• Alternatively, you can go to Clinical > Med Charting History > select the resident and the med > enter a Nursing comment. Entering a comment here will remove the 'missed' flag from this medication.

Pharmacy Connect

Controlled Medication - FAQ

Why isn’t there a count for a medication I know is controlled?
Pill counts will only be available for medications marked as ‘controlled’. Once a new medication has been added into Residex, changing the controlled option can only be completed by a user with the 411 or 410 role. This can be done 1 of 2 ways:

• Navigating to Admin > Global Medications > Select the medication > Check the Controlled box.
• Navigating to Residents > Residents > Select the appropriate resident > Medications > Select the appropriate medication > Click edit > Check the ‘controlled’ box.

How do discrepancies occur and how do I fix them?
If a controlled medication is charted, but the medication administration service is not marked ‘complete’ until after the medication is fully charted again, the count will not be in order. This will be indicated as a discrepancy.

Example: I charted the 8 AM pass and count, but did not mark the med pass “complete”. You fully charted the noon pass and count, and marked the med pass “complete”. When I finally mark the 8 AM as “complete”, it will show a discrepancy because the noon med pass was fully charted first. The med passes were charted/saved out of order.

While these counts cannot be edited nor the timestamps changed, it is appropriate to add a note to the count to indicate there was not a missing or extra dose.

• Navigate to Clinical > Medication Counting > Choose the resident > Select the correct medication > Enter the current medication count and appropriate note > Save.
  If the most recent count is a discrepancy and entered in error where the entry is incorrect but the true count is as it should be, you can correct this by navigating to Clinical > Receive Medications > Select the Resident > Select the medication with the error > enter the difference as the Count/quantity received > enter the true count as the Total count/quantity remaining > Enter explaining correction (i.e. No additional tablets received to facility; count was adjusted related to a count miss-entry). A negative number can be entered in the Count/quantity received field, when necessary. We recommend having a witness verify these corrections and notes when they occur.

How do I enter tapered dosing for a controlled medication?
Each entry of a controlled medication via Residents > Medications will have it’s own count; thus, needing its own allotted inventory/supply.

• Ensure you have entered the correct Active and End dates and times for the duration of each dose.
• If each dosing was delivered in its own package, remind the med passers that each has it’s own count and timeframe to be given. Consider writing the dates of administration on each package as well as in the medication instruction for clarity and verification.
• If all varying doseages are in one package but with the appropriate number of tablets in each single-dose bubble for the tapering, you might consider visually separating them by sectioning off each group with a pen or marker on the card. You will then need to decide the best way for your team to count them.

Example scenario: 1 tablet 1 x daily x 7 days, then 1.5 tablets 1 x daily x 7 days, and then 2 tablets daily for all future days. You have received a 28-day supply from the pharmacy, equaling 45.5 tablets.

Option 1
Enter each of the 3 doses separately in the resident’s medications.

• 1 tablet 1 x daily to be Active on 7/1/22 at 6 AM - Administration at 8 AM; End date of 7/7/22 at 11:59 PM
• 1.5 tablets 1 x daily to be Active on 7/8/22 at 6 AM - Administration at 8 AM; End date of 7/14/22 at 11:59 PM
• 2 tablets 1 x daily to be Active on 7/15/22 at 6 AM - Administration at 8 AM; No end date
• Navigate to Clinical > Receive Medications, and record the quantity received under medication ‘a’ as 45.5
• On 7/7/22, after the last administration of 1 tablet, navigate to Clinical > Medication Disposition and record the disposition of the remaining 38.5 tablets. Include a note that these were not discarded but transferred to the new order that starts on 7/8/22.
• Navigate to Clinical > Receive Medications, and record the quantity received under medication ‘b’ as 38.5. Include a note that these were transferred from the discontinued/completed order of 1 tablet, 1 x daily.
• On 7/14/22, after the last administration of 1.5 tablets, navigate to Clinical > Medication Disposition and record the disposition of the remaining 28 tablets. Include a note that these were not discarded but transferred to the new order that starts on 7/15/22.
• Navigate to Clinical > Receive Medications, and record the quantity received under medication ‘c’ as 28. Include a note that these were transferred from the discontinued/completed order of 1.5 tablets, 1 x daily.

OR

Option 2
Enter each of the 3 separately in the resident’s medications.

• 1 tablet 1 x daily to be Active on 7/1/22 at 6 AM - Administration at 8 AM; End date of 7/7/22 at 11:59 PM
• 1.5 tablets 1 x daily to be Active on 7/8/22 at 6 AM - Administration at 8 AM; End date of 7/14/22 at 11:59 PM
• 2 tablets 1 x daily to be Active on 7/15/22 at 6 AM - Administration at 8 AM; No end date
• Navigate to Clinical > Receive Medications, and:

1. Record the quantity received under medication ‘a’ as 7
2. Record the quantity received under medication ‘b’ as 10.5
3. Record the quantity received under medication ‘c’ as 28
   Indicate on the card the 3 separate counts

How do I count a PRN and Scheduled controlled medication as 1 count?
This cannot be done at this time. Each entry of a controlled medication will have its own count in Residex and will need its own dedicated inventory/supply for counting.

A resident gets the same controlled medication 3 times a day, but the midday dose is 0.5 tablets instead of one. The medication list has this entered twice as it is 2 different instructions: 1 tablet 2 x daily & 0.5 tabs 1 x daily. How do these get counted?
Each entry in the medication list will be a count. The 1 tablet given 2 x daily will be one count; the 0.5 tablets 1 x daily will be its own count.

How do we manage the disposal of a used controlled medication patch, such as fentanyl, without affecting the count of the patches that are yet to be used?
Enter 'Remove fentanyl patch' as a medication. Schedule it on the days the fentanyl patch will need to be removed. Train your med passers to record the disposition under Clinical > Medication Disposition > Remove fentanyl patch. This will not affect the count of the original Fentanyl administration record.

When Are Discharged Residents Removed from the Medication Count Screen?

Once all controlled medications for a discharged resident reflect a remaining count of zero, that resident will no longer appear in the Clinical > Medication Counting list under the 'discharged resident' section. Note that while it is recommended to dispose of all medications, only controlled medications determine a resident's visibility on the Medication Counting screen .

For guidance on disposing of controlled medications, see our medication disposition documentation.