NH BOARD OF NURSING Medication Administration

1. NH BOARD OF NURSINGMedication Administration The role of the LNA and MNA in Assisted Living Residences Dee Houle, M.S., R.N. Program Specialist IV

2. Board of Nursing Licensure • Licensed Nursing Assistants RSA 326-B:14 • Medication Nursing Assistants RSA 326-B:27

3. Licensed Nursing Assistants (LNAs) and the Law • RSA 326-B:14 “An LNA shall, with or without compensation or personal profit, practice under the supervision of an RN, ARNP, or LPN” and “Provide safe nursing-related activities under the supervision of an RN or an LPN. • Scope of practice based on activities taught during initial educational program, Nur 704.09

4. LNA Scope of Practice • Additional activities may be added based on specific BON approval, Nur 404.12, such as: Straight urinary catheters, application of TENS unit, feeding tubes, phlebotomy, wound care, vagus nerve stimulation, pulse oximetry, incentive spirometry, oral suctioning, oxygen mask placement/cannula placement, chest physiotherapy, peripheral vein IV removal, colostomy irrigations, medicated lotions, ointments and creams, blood glucose monitoring, fingerstick PT/INR testing, reminding clients to take their medications and transcribing medical orders.

5. LNA Scope of Practice • The LNA may also assist in oxygen as a treatment therapy and change the collar that holds a tracheostomy tube in place as delegated by the nurse. • It is not within the scope of practice for a Licensed Nursing Assistant to engage in the following activities: • Insertion of intravenous catheters, • Calling in Prescribing Practitioner orders to the Pharmacy • Insertion of indwelling catheters

6. Medication Nursing Assistants • A Medication Nursing Assistant (MNA) is a Licensed Nursing Assistant (LNA) with a NH Board Approved Certificate to administer medications under the supervision of a RN/LPN to “stable” clients living in facilities and in the community.

7. What’s the definition of “stable”? • The client whose health status is under control and raises no expectations that the client’s symptoms, vital signs or reactions to medications will suddenly change. • There are predictable outcomes to care.

8. The BON definition of supervision October 20, 2005 Clinical Practice Advisory Question: How does the Board define direct vs. indirect supervision? Board Response: The board affirmed a previous definition that direct supervision refers to having the supervisor in close proximity to the licensee either in the same room or the same building. Indirect supervision requires the supervisor to be readily accessible but not necessarily on the floor or in the building. Thus, having telephone communication with a supervisor who is available to assist in an identified problem would meet the definition of indirect supervision.

9. Nursing Delegation Rules Nur 404 • Nurse Practice Act revised in 2005 and Nursing Rules updated in 2001 • Pertains to delegation among licensees as well as to delegation to unlicensed assistive personnel • Must be in keeping with Nur 404 • RSA-B:33 III “No person may coerce a licensed nurse into compromising patient safety by requiring the licensed nurse to delegate if the license nurse determines it is inappropriate to do so…….”

10. What is Delegation? • Nur 401.01(f): The transfer, at the discretion of the nurse, of authority for the performance of a task of client care from the licensed nurse with the authority to perform the task to someone who does not otherwise have such authority

11. Nur 404.05 • A MNA shall NOTperform a task involving the administration of medication if: -the task requires the determination of the client’s need for the medication, the calculation of the dosage or the conversion of the dosage; -the delegating nurse is unavailable to monitor the progress of the client and the effect of the medication; -the client is not stable or has changing needs.

12. Can LNAs administer medications? The short answer is no! …but it has been opined to be within the LNA scope of practice to apply medicated lotions, ointments and creams.

13. What about He-P 805.17? • (af) If a resident self-administers medication with supervision, as defined in He-P 805.03 (bc), personnel may be permitted to: • (1) Remind the resident to take the correct dose of his or her medication at the correct time; • (2) Place the medication container within reach of the resident; • (3) Remain with the resident to observe the resident taking the appropriate amount and type of medication as ordered by the licensed practitioner; • (4) Record on the resident's daily medication record that they have supervised the resident taking his or her medication; and • (5) Document in the resident’s record any observed or reported side effects, adverse reactions, and refusal to take medications and or medications not taken.

14. What can the LNA do under He-P 805.17 (af)? • Special Notation from 2/15/07 board meeting: Numerous questions have come to the Board regarding the New Assisted Living Rules HeP-805. • Specific issues addressed by the board at its 2/15/07 meeting included the LNA scope of practice. The board opined the following: • Board consensus that issue with self-directed medication for cognitively intact individuals with physical disabilities is within the scope of LNA practice. • Board further agreed that HeP 805.17 (af) (1-3 & 5) are within LNA scope. Board reinforced that (4) is NOT within LNA scope; LNA cannot supervise medications consumed or tell patient what to consume. • The He-P 800 Residential Care and Health Facility rules may be accessed via this link: http://gencourt.state.nh.us/rules/he-p800.html

15. Medication AdministrationHand-over-Hand From BON Clinical Practice Advisory 1998-1999 QUESTION: Can a LNA assist clients with medication administration using a hand over hand approach? ANSWER: Yes, the LNA can place hands over clients hands to assist client with medication administration is within the scope of the LNA practice when the client has cognitive abilities to determine medication needs. This process is utilized for the motor process or becomes the hands of an individual who is physically impaired.

16. Medication AdministrationHand-over-Hand The client: • must have a care plan specific to their impairment with hand over hand details, • must be self directed, • can be prompted or reminded of medication needs

17. LNA Scope of Practice • There has been a “blurring” of LNA and MNA roles in the healthcare community • LNA Scope of Practice has not changed and remains consistent within the Nurse Practice Act and Nursing Administrative rules across all practice areas

18. Contact us… Telephone: 271-2323, 271-6282 mwalker@nursing.state.nh.us dhoule@nursing.state.nh.us web site: www. state.nh.us/nursing email: boardquestions@nursing.state.nh.us