Med Aide

The Resident Services Medication Aide (RMA) assists Residents with his/her medications in addition to assistance with his/her activities of daily living (ADLs) and certain other instrumental activities of daily living (IADL). Using a person-centered care approach to promote Resident choice, purpose and meaning in daily life. Person centered care means that The Residents are supported in achieving their highest level of physical, emotional, and psycho-social well-being.

Following the Resident’s Individual Service Plan (ISP), the RMA is expected to place a premium on active listening to and observing of the Resident, to assure adaption to each Resident’s changing needs regardless of his/her cognitive ability.

The RMA is expected to:

• Promote the individuality of each Resident

• Offer each Resident dignity and respect

• Support each Resident’s right to privacy

• Foster the Resident’s independence by assisting with and not doing for

• Support the needs of the Resident’s families and friends

• Provide a supportive, safe, and caring environment

• Work collaborative with the Resident, his/her family and health care team

• Respect the Resident’s right to choose.

The RMA will conform to company policy and procedure, State Department of Health Regulations as well as protocols specific to his/her role in providing supervision of Resident’s self-administration of medications. The Director of Wellness will delegate the RMA’s duties and responsibilities in accordance with company policy and State Department of Health Regulations.

DUTIES AND KEY RESPONSIBILITIES:

I. Resident File Oversight

a. The RMA will maintain Resident Medication Administration Record (MAR) system:

i. Conduct weekly medication cart and Resident Medical Record and MAR reviews, ensuring that the current medication regimen, as ordered by the licensed prescriber, is being followed:

1. Assure a current and valid prescription (copy) is on file in the Resident’s medical file for all prescribed and over the counter (OTC) medications

> Assure all mandated records and forms are in proper order

> File new and/or updated clinical and administrative documentation in Resident medical records

> Assure staff and physician sign-offs as required

> Reads physician and nursing notes

b. Assure that a minimum of monthly reviews (chart to cart) for each Resident will include a cross comparison review of:

i. Initial/annual physician evaluation medication list, prescriptions on file, medication container labels, MAR, change in direction orders and stickers affixed to the medication container as appropriate, discontinue orders on file as appropriate

c. Review of interval documentation and documents to assure accuracy, fidelity, and completeness with regard to current medication regimen, and as these pertain to policy and State Department of Health regulations

i. Refers to the immediate supervisor any interval or other pertinent and related documentation that is observed as incomplete, incorrect, or coming due

d. Maintain historical medical records as per policy and State Department of Health Regulations and assures all needed documents specific to the Resident’s medical file are present, current and appropriately filed

e. Assure the following information is present on each Resident’s MAR:

i. Resident’s information:

1. First and last name

2. Date of birth

3. Known allergies (food and medication)

4. Apartment number

5. Primary and secondary diagnoses

ii. Physician’s first and last name and phone number

iii. PRN medications include the physician’s indication for use

iv. Pain medications:

1. Pain scale entries present prior to assistance and after one hour of assistance

v. Parameter medication orders:

1. Appropriate documentation is present

II. Communication

a. Immediately reports to the Director of Wellness/Designee a Resident’s adverse reaction to medication

b. Immediately report Resident/Family complaints/grievances to immediate Supervisor

c. Communicate to the Director of Resident Services/Designee the need to speak with the pharmacy, physician’s or the physician’s office, Nurse Practitioner for clarification of new orders, re-orders, and/or discontinuation orders, etc.:

i. In the absence of the Director of Wellness, the LPN Supervisor will contact the pharmacy for clarifications and/or requests

d. Assure the re-order and renewal schedule for Resident’s who do not use the house pharmacy

e. Advise the Director of Wellness / LPN Supervisor of a Resident’s refusal of any medication at any time

i. Complete the “Refusal of Medication Form” and submit to the Director of Wellness or LPN Supervisor in the absence of the Director of Wellness

f. Assure the presence in the Main and Reflections dining rooms of ALL Residents and maintains the Dining Room Attendance Record

i. Follow company policy regarding response protocol whenever a Resident is identified as absent from the Dining Room(s)

g. Immediately reports medication errors and/or incidents to the Director of Wellness or LPN Shift Supervisor in the absence of the Director of Wellness

h. Reads the Medication Communication Log at the beginning of his/her shift

i. Enters needed information into the Medication Communication Log:

i. Delivery of Residents medications

ii. Changes in a Resident’s medication regimen (including new/discontinued, dose or time changes, need to hold medications)

iii. Needed follow-up by next shift

III. Administrative Responsibility

a. Assure the medication room and cart are neat and clean:

i. Wipes down the medication cart at the start and end of each shift

ii. Wiped down the medication room counter at the start and end of each shift

iii. Replenish supplies on the medication cart as needed:

Black pen Change in Direction Stickers

Writing pad Scissors (locked inside cart)

Pill Crusher and plastic sleeves Tissues

Soft (soufflé) & hard medication cups Hand sanitizer

b. Follow policy and State Department of Health regulations regarding Controlled Substances:

i. Conducts inventory count at the start and end of each shift with the on-coming or off-going medication aide

ii. Assures hand off of Controlled Substance Keys at the end of the inventory count to the person with whom the count was conducted

1. At no time are the keys to be given to another medication aide during the shift

2. Assure the second medication aide not in possession of the controlled substance keys is provided his/her controlled substance medication containers needed for scheduled medication passes

> The second medication aide will assure that the controlled substance medications received from the first medication aide holding the controlled substance keys, are placed into the locked medication cart and that the cart is locked as well.

iii. Enters into the Controlled Substance Delivery Log (marble notebook) the following information for each controlled substance delivered:

iv. Assures the sign out of any controlled substance into the Controlled Substance Log (Declination Log) at the time the medication is removed from the medication container

v. Protects the safety and compliance of the Controlled Substances by upholding policy and procedure and understanding the State Department of Health’s regulation for Controlled Substances

IV. Assists Residents with Medication Administration

a. Assures the privacy and dignity of Residents is maintained while assisting with medications:

i. Only by mouth medications are administered in a common area of the Community

ii. Patches, drops, sprays, ointments/creams, injections, inhalants, are to be provided in the Wellness or Reflections Office or in the Resident’s apartment

iii. Discussion of a Resident’s medications with another Resident is not permitted

iv. Assure the privacy of Resident health information at all times

b. Assure the safety of Residents:

i. Remain with the Resident until all medication has been ingested and swallowed

ii. Medication cart is locked at all times

iii. Medications will not be left unattended at any time

c. Assure any changes in the Resident’s medication instructions are upheld

d. Protect and uphold the six rights of medication safety:

i. Right Medication:

1. Two- step check: checks the label to the MAR for Resident’s name, name of medication then repeats check by checking MAR to label

2. Check Resident name on the label and the

ii. Right Dose:

1. Assure the correct number of tablets/drops or doses are being provided

2. Assure the assistance is at the correct time of day (as ordered by the physician)

3. Assure the correct duration of treatment

iii. Right Time:

1. Assure the correct time of day, as ordered by physician is entered onto the MAR

2. Assure any special instructions noted on the MAR regarding whether or not to take medication with food, after or before a meal, or with a snack

iv. Right Route:

1. Assure appropriate prompts (swallow, do not chew, drink full glass of water)

2. Assure medication can be crushed if necessary (and that an order to do so is present

v. Right Resident

1. Assure assistance is being provided to the correct Resident by checking the Resident’s picture in the medication Kardex

2. Wait with the Resident until the medication is ingested and swallowed

vi. Right documentation:

1. Endorse the MAR immediately following assistance

2. Enter appropriate information onto the MAR as follows”

> R = Resident refuses medication

> O = Resident out of building

> H = Resident in hospital

> W = With held

> P = Mediation not available

3. Enter the appropriate information for pain medications:

> Using appropriate pain observation scale:

i. Document pain level prior to assistance

ii. Document pain level one hour after assistance

4. Enter the appropriate information for PRN medications:

> Document the indication for medication

> Document the observe or Resident’s reported response to the medication

V. Additional Responsibilities:

a. Assist Resident in personal care duties and/or ADLs or IADLs as directed from Resident’s individual service plan and as requested by the Director of Wellness/Designee (see Resident Care Aide Job Description)

ii. As needed, change bed linen and maintain Residents’ apartment in a clean and orderly condition

iii. Engage Resident and be present and participate in group and individual programming and activities

b. Provide meal service in Reflections.

c. Carries beeper at all times when on duty and completes appropriate accountability documentation

d. Committed to assuring the self-respect, personal dignity and physical safety of each Resident

e. Performs other duties as assigned by the Director of Wellness/Designee

f. Participates in educational programs as required by the company

g. Completes a minimum of 12 hours per year of mandatory in-service

h. Upholds all company’s policy and procedures.