JLCD-R
Medication Procedures
I. Management of the Administration program
A. The school nurse shall be the supervisor of the medication program in the school.
B. The school nurse, the school physician, and the school health advisory committee shall develop and propose to the School Committee policies relating to the administration of medications
C. Medication Orders/Parental Consent:
1. The school nurse shall ensure that there is a proper medication order form from a licensed prescriber which is renewed as necessary, including the beginning of each academic year. A telephone order or an order for any change in medication shall be received only by the school nurse. Any such verbal order must be followed by a written order within three school days. Whenever possible, the medication order shall be obtained, and the medication administration plan shall be developed before the student enters or reenters school.
a. In accordance with standard medical practice, a medication order from a licensed prescriber shall contain:
1) the student's name
2) the name and signature of the licensed prescriber and business and emergency phone numbers
3) the name of the medication
4) the route and dosage of medication
5) the frequency and time of medication administration
6) the date of the order and discontinuation date
7) a diagnosis and any other medication condition(s) requiring medication, if not a violation of confidentiality or if not contrary to the request of a parent, guardian or student to keep confidential
8) specific direction for administration
b. Every effort shall be made to obtain from the licensed prescriber the following additional information, if appropriate:
1) any special side effects, contraindications and adverse reactions to be observed
2) any other medications being taken by the student
3) the date of the next scheduled visit, if known
c. Special Medication Situations
1) For short term medications, i.e., those requiring administration for ten (10) school days or fewer, the pharmacy-labeled container may be used in lieu of a licensed prescriber's order; if the nurse has a question, she may request a licensed prescriber's order.
2) Investigational new drugs may be administered in the schools with
a) a written order by a licensed prescriber,
b) written consent of the parent or guardian
c) a pharmacy-labeled container for dispensing. If there is a question, the school nurse may seek consultation and/or approval from the school physician to administer the medication in the school setting.
2. The school nurse shall ensure that there is a written authorization by the parent or guardian which contains:
a. the parent or guardian's printed name, signature and emergency phone number;
b. a list of all medications the student is currently receiving, if not a violation of confidentiality or contrary to the request of the parent, guardian or student that such medications not be documented;
c. approval to have the school nurse or school personnel designated by the school nurse administer the medication;
d. persons to be notified in case of a medication emergency, in addition to the parent or guardian and licensed prescriber.
D. Medication Administration Plan
1. The school nurse, in collaboration with the parent or guardian whenever possible, shall establish a medication administration plan for each student receiving a medication. Whenever possible, a student who understands the issues of medication administration shall be involved in the decision-making process and his/her preferences respected to the maximum extent possible. If appropriate, the medication administration plan shall be referenced in any other health or educational plan developed pursuant to the Massachusetts Special Education Law (Individual Education Plan under Chapter 766) or federal laws, such as the Individuals with Disabilities Education Act (IDEA) or Section 504 of the Rehabilitation Act of 1973.
2. Prior to the initiation of the medication, the school nurse shall assess the child's health status and develop a medication administration plan which includes:
a. the name of the student;
b. an order from a licensed prescriber, including business and emergency telephone numbers;
c. the signed authorization of the parent or guardian, including home and business telephone numbers;
d. any known allergies to food or medications;
e. the diagnosis, unless a violation of confidentiality or the parent, guardian or student requests that it not be documented;
f. the name of the medication;
g. the dosage of the medication, frequency of administration and route of administration;
h. any specific directions for administration;
i. any possible side effects, adverse reactions, or contraindications;
j. the quantity of medication to be received by the school from the parent;
k. the required storage conditions;
l. the duration of the prescription;
m. the designation of unlicensed school personnel, if any, who will administer the medication to the student in the absence of the nurse, and plans for back-up if the designated persons are unavailable;
n. plans, if any, for teaching self-administration of the medication;
o. with parental permission, other persons, including teachers, to be notified of medication administration and possible adverse effects of the medication;
p. list of all other medications being taken by the student, if not a violation of confidentiality or contrary to the request of the parent, guardian or student that such medication not to be documented;
q. when appropriate, the location where the administration of the medication will take place;
r. a plan for monitoring the effects of the medication;
s. provision for medication administration in the case of field trips and other short-term special events. Every effort shall be made to obtain a nurse to accompany students at special school events.
E. The school nurse shall develop a procedure to ensure the positive identification of the student who receives the medication.
F. The school nurse shall communicate significant observations relating to medication effectiveness and adverse reactions or other harmful effects to the child's parent or guardian and / or licensed prescriber.
G. In accordance with standard nursing practice, the school nurse may refuse to administer or allow to be administered any medication, which based on her/his individual assessment and professional judgment, has the potential to be harmful, dangerous or inappropriate. In these cases, the parent/guardian and licensed prescriber shall be notified immediately by the school nurse and the reason for refusal explained.
H. For the purposes of medication administration, the Licensed Practical Nurse functions under the general supervision of the school nurse who has delegating authority. (Medication administration is within the scope of practice for the Practical Nurse under M.G.L. Chapter 112).
I. The school nurse shall have a current pharmaceutical reference available for her/his use such as the Physician IS Desk Reference (PDR).
II. Self-Administration of Medications
"Self-administration" means that the student is able to consume or apply medication in the manner directed by the licensed prescriber, without additional assistance or direction.
A student may be responsible for taking his/her own medication after the school nurse has determined that the following requirements are met:
A. the student, the school nurse and parent/guardian, where appropriate, enter into an agreement which specifies the conditions under which medication may be self-administered;
B. the school nurse, as appropriate, develops a medication administration plan which contains only those elements necessary to ensure safe self-administration of medication;
C. the student's health status and abilities have been evaluated by the school nurse who then deems self-administration safe and appropriate. As necessary, the school nurse shall observe initial self-administration of the medication;
D. the school nurse is reasonably assured that the student is able to identify the appropriate medication, knows the frequency and time of day for which the medication is ordered;
E. there is a written authorization from the student's parent/guardian that the student may self-medicate unless the student has consented to treatment under M.G.L.c.l12,s.l2F or other authority permitting the student to consent to medical treatment without parental permission;
F. if requested by the school nurse the licensed prescriber provides a written order for self-administration;
G. the student follows a procedure for documentation of self-administration;
H. the school nurse establishes a policy for the safe storage of self-administered medication and as necessary, consults with teachers, the student and parent/guardian, if appropriate, to determine a safe place for storing the medication for the individual student, while providing for accessibility if the student's health needs require it. This information shall be included in the medication administration plan. In the case of an inhaler or other preventative or emergency medication, whenever possible, a backup supply of the medication shall be kept in the health room or a second readily available location;
I. the student's self-administration is monitored based on his/her abilities and health status. Monitoring may include teaching the student the correct way of taking the medication, reminding the student to take the medication, visual observation to ensure compliance, recording that the medication was taken, and notifying the parent/guardian or licensed prescriber of any side effects, variation from the plan, or the student's refusal or failure to take the medication;
J. with parental/guardian and student permission, as appropriate, the school nurse may inform appropriate teachers and administrators that the student is self-administering a medication.
III. Handling, Storage and Disposal of Medications
A. A parent, guardian or parent/guardian-designated responsible adult shall deliver all medications to be administered by school personnel or to be taken by self-medicating students, if required by the self-administration agreement, to the school nurse or other responsible person designated by the school nurse.
1. The medication must be in a pharmacy or manufacturer labeled container.
2. The school nurse or other responsible person receiving the medication shall document the quantity oft he medication delivered.
3. In extenuating circumstances, as determined by the school nurse, the medication may be delivered by other persons; provided, however, that the nurse is notified in advance by the parent/guardian of the arrangement and the quantity of medication being delivered to the school.
B. All medications shall be stored in their original pharmacy or manufacturer labeled containers and in such manner as to render them safe and effective. Expiration dates shall be checked
C. All medications to be administered by school personnel shall be kept in a securely locked cabinet used exclusively for medications. This cabinet is to be kept locked except when opened to obtain medications. The cabinet shall be substantially constructed and anchored securely to a solid surface. Medications requiring refrigeration shall be stored in either a locked box in the refrigerator or in a locked refrigerator maintained at temperatures of 38-42 degrees Fahrenheit.
D. Access to stored medications shall be limited to persons authorized to administer medications. Students who are self-medicating shall not have access to other students' medications.
E. Parents/guardians may retrieve the medications from the school at any time.
F. No more than a thirty (30) school day supply of the medication for a student shall be stored at the school.
G. Where possible, all unused, discontinued or outdated medications shall be returned to the parent/guardian and the return appropriately documented. In extenuating circumstances, with parental consent when possible, such medications may be destroyed by the school nurse in accordance with the applicable policies of the Massachusetts Department of Public Health, Division of Food and Drugs. All medications should be returned at the end of the school year.
IV. Administration of Epinephrine
The school district will register with the Department of Public Health for the limited purpose of permitting properly trained school personnel to administer epinephrine by auto injector in a life-threatening situation, when a school nurse is not immediately available, provided that the following conditions are met:
A. The school committee approves the medication policy developed by the school nurse and renews approval every two years;
B. The school committee provides an assurance to the Department of Public Health that sufficient school nurses are available to provide proper oversight of the program and provides such back-up documentation as required by the Department;
C. In consultation with the school physician, the school nurse manages and has final decision making authority about the program and selects the person(s) authorized to administer epinephrine by auto injector;
D. The school personnel authorized to administer by auto injector are trained by a physician or school nurse, and tested for competency, in accordance with standards and a curriculum established by the Department of Public Health;
1) the school nurse shall document the training and testing of competency
2) the school nurse shall provide a training review and informational update at least twice a year
3) the training at a minimum shall include:
a) proper use of the device
b) the importance of consulting and following the medication administration plan
c) recognition of the symptoms of a severe allergic reaction
d) requirements for proper storage and security, notification of appropriate persons following administration, and record keeping.
4) the school shall maintain and make available upon request by parents or staff a list of those school personnel authorized and trained to administer epinephrine by auto injector in an emergency, when the school nurse is not immediately available.
E. Epinephrine shall be administered only in accordance with a medication administration plan satisfying the applicable requirements of 105 CMR 210.005 (E) and 210.009 (A) (6), updated every year, which includes the following:
1) a diagnosis by a physician that the child is at high risk of a life-threatening allergic reaction, and a medication order containing indications for administration of epinephrine
2) written authorization by a parent/guardian
3) a home and emergency number for the parent, as well as the name(s) and phone number(s) of any other person(s) to be notified if the parent is unavailable
4) identification of the places where the epinephrine is to be stored following consideration of the need for storage at places where the student may be most at risk. The epinephrine may be stored at more than one location or carried by the student when appropriate
5) consideration of the ways and places epinephrine can be stored so as to limit access to appropriate persons, which shall not require the epinephrine to be kept under lock and key
6) a list of the school personnel who would administer the epinephrine to the student in a life-threatening situation
7) a plan for risk reduction for the student, including a plan for teaching self-management, where appropriate
F. When epinephrine is administered, there shall be immediate notification of the local emergency medical services (generally 911), followed by notification of the school nurse, the student's parents, or if the parents are not available, any other designated person(s), and the student's physician
G. There shall be procedures, in accordance with any standards established by the Department of Public Health, for:
1) developing the medication administration plan
2) properly storing medication, including limiting access to persons authorized to administer the medication and returning unused or outdated medication to a parent/guardian whenever possible
3) recording receipt and return of medication by the school nurse
4) documenting the date and time of administration
5) notifying appropriate parties of administration
6) reporting medication errors in accordance with 105 CMR 210.005 (F)(5)
7) reviewing any incident involving administration of epinephrine to determine the adequacy of the response and to consider ways of reducing risks for the particular student and the student body in general
8) planning and working with the emergency medical system to ensure the fastest possible response
H. The Department of Public Health is permitted to inspect any record related to the administration of epinephrine to ensure compliance with 105 CMR 210.000.
V. Documentation and Record-Keeping
A. Each school where medications are administered by school personnel shall maintain a medication administration record for each student who receives medication during school hours.
1. Such record at a minimum shall include a daily log and a medication administration plan, including the medication order and parent/guardian authorization.
2. The medication administration plan shall include the information as described in Section 210.005 (E) of the Regulations Governing the Administration of Prescription Medications in Public and Private Schools.
3. The daily log shall contain:
a. the dose or amount of medication administered
b. the date and time of administration or omission of administration, including the reason for omission
c. the full signature of the nurse or designated unlicensed school personnel administering the medication.
4. The school nurse shall document in the medication administration record significant observations of the medication's effectiveness, as appropriate, and any adverse reactions or other harmful effects, as well as any action taken.
5. All documentation shall be recorded in ink and shall not be altered.
6. With the consent of the parent/guardian or student where appropriate, the completed medication administration record and records pertinent to self-administration shall be filed in the student's cumulative health record. When the parent/guardian or student, where appropriate, objects, these records shall be regarded as confidential medical notes and shall be kept confidential.
B. The school district shall comply with the Department of Public Health's reporting requirements for medication administration in the schools.
C. The Department of Public Health may inspect any individual student medication record or record relating to the administration or storage of medications without prior notice to ensure compliance with the Regulations Governing the Administration of Prescription Medications in Public and Private Schools.
VI. Reporting and Documentation of Medication Errors
A. A medication error includes any failure to administer medication as prescribed for a particular student, including failure to administer the medication:
1. within appropriate time frames (the appropriate time frame should be addressed in the medication administration plan);
2. in the correct dosage;
3. in accordance with accepted practice;
4. to the correct student.
B. In the event of a medication error, the school nurse shall notify the parent/guardian immediately. The school nurse shall also notify the student's licensed prescribed or school physician.
C. Medication errors shall be documented by the school nurse on the Medication Error Report Form. These records shall be retained in the file cabinet of the health room and/or student health record. They shall be made available to the Department of Public Health upon request. All medication errors resulting in serious illness requiring medical care shall be reported to the Department of Public Health, Bureau of Family and Community Health. All suspected diversion or tampering of drugs shall be reported to the Department of Public Health, Division of Food and Drugs.
D. The school nurse shall review reports of medication errors and take necessary steps to ensure appropriate medication administration in the future.
VII. Delegation of Medication Administration
The school nurse may identify and train individual school personnel for the purpose of administering prescription medication during field trips and short term special school events providing that the school district has registered for this with the Department of Public Health (Regulation 105 CMR:21O.000, The Administration of Prescription Medications in Public and Private Schools). The school agrees to comply with the Department of Public Health Regulations which require development of a plan for medication administration during field trips and special school events. Every effort shall be made to obtain a nurse to accompany students at special school events. When this is not possible, the school nurse may delegate prescription medication to another responsible adult. Written consent from the parent/guardian for the named responsible adult to administer the prescription medication shall be obtained. The school nurse shall instruct the responsible adult on how to administer the prescription medications to the child. The Department of Public Health regulations governing the administration of medications in schools are for school hours only. The delegation of medications to non-licensed personnel by school nurses in only possible if a nurse is on duty in the school system.
VIII. Response to Medication Emergencies
See individual school's Emergency Plans.
IX. Policy Review and Revision
Review and revision of these policies and procedures shall occur as needed, but at least every two years.-
(based on Mass. General Laws 94C and Mass. DPH 105 CMR 210.000)
First Reading: 08/06/02 Second Reading: 09/10/02 ADOPTED: 09/10/02