Regulations for BOE Policy 7513

SUBJECT: GUIDELINES FOR ADMINISTERING MEDICATION IN SCHOOLS


Glossary

Controlled Substances

Certain drugs with abuse potential that are regulated by State and Federal Government in a manner more restrictive than other drugs. A complete list of controlled substances in New York is set forth at New York State Public Health Law, Section 3306.

Double-Lock

A system of two separate locks to secure medications, especially controlled substances (i.e., a locked box within a locked cabinet).

Licensed Practical Nurse

An individual licensed pursuant to Article 139 of the Education Law ("The Nurse Practice Act") performing tasks and responsibilities within the framework of case finding, health teaching, health counseling and the provision of supportive and restorative care under the direction of a registered professional nurse or licensed physician, dentist or other licensed health care provider.

Licensed Prescriber

Health care professionals who have authority to prescribe medications in their practice including physicians, dentists, podiatrists, nurse practitioners, physician assistants or specialist assistants, optometrists, and midwives.

Medication

As used in these guidelines will refer to both prescription and nonprescription drugs.

Nonprescription Drugs

Medications which may be obtained over the counter without a prescription. These medications are sometimes referred to as over-the-counter (OTC) drugs and include, but are not limited to, oral, inhalation, and topical forms.

Prescription Drugs

Drugs requiring a written order for dispensing signed by a licensed prescriber.

PRN

As needed.

Route of Administration

Route through the body whereby a medication is administered including oral, subcutaneous, intramuscular, intravenous, inhalant.

School Nursing Personnel

Registered professional nurses licensed pursuant to Article 139 of the Education Law including school nurses, school nurse-teachers, school nurse-practitioners, or other specialty nurse practitioners employed by the School District or BOCES pursuant to Education Law Section 902.

Self-directed

An individual who is capable and competent to understand a personal care procedure, can correctly administer it to himself/herself each time it is required, has the ability to make choices about the activity, understands the impact of these choices, and assumes responsibility for the results of the choices.

Under the Direction

"Under the direction" means that a registered professional nurse should be present on the premises or will immediately respond by written and/or verbal communication when professional services are rendered by a licensed practical nurse. The degree of supervision shall be appropriate to the circumstances. This term implies an active process of directing, guiding and influencing the outcome of an individual's performance of an activity. "Under the direction" is generally categorized as onsite (the registered professional nurse is physically present or immediately available while the activity is being performed) or off-site (the registered professional nurse has the ability to provide direction through written and/or verbal communications). The degree of direction is appropriate to the circumstance.

Procedures

A program for the administration of medication to students in school must be managed and supervised by school nursing personnel.

1) Only those medications which are necessary to maintain the student in school and which must be given during school hours should be administered. Any student who is required to take medication during the regular school day or while participating in school-sponsored activities (e.g., field trips, athletics) should comply with all procedures.

2) Any prescribed medication which requires administration through a subcutaneous, intramuscular, intravenous or rectal route or prescribed medications being administered through pumps, tubes or nebulizers; or oral, topical or inhalant medication needed by non-self-directed students must be given by school nursing personnel or licensed practical nurses under the direction of school nursing personnel. Administration of such prescribed medications may not be performed by unlicensed persons.

3) Unlicensed persons in the school setting, following assignment and in conjunction with approval by school nursing personnel, may assist self-directed students with the taking of their own oral, topical and inhalant medication. School nursing personnel and the administration should assure that the unlicensed person receives the training and supervision needed to perform these tasks in a safe and effective manner.

4) Best practices indicate that all schools should be staffed with a registered professional nurse.

5) A written order from a duly licensed prescriber and written parental permission to administer the medication are required.

Written Order From a Licensed Prescriber Is Required

All medications, including nonprescription drugs, given in school shall be prescribed by a licensed prescriber on an individual basis as determined by the student's health status.

1) Written orders for prescription and nonprescription medications should minimally include:

a. Student's name and date of birth.
b. Diagnosis.
c. Name of medication.
d. Dosage and route of administration.
e. Self-administration orders -- if indicated.
f. Frequency and time of administration.
g. For prn (as necessary) medications -- conditions under which medication should be administered.
h. Potential adverse reactions - if indicated.
i. Date written.
j. Prescriber's name, title, and signature.
k. Prescriber's phone number.

2) Special considerations

a. Medication orders must be renewed annually or when there is a change in medication or dosage.

b. The pharmacy label does not constitute a written order and cannot be used in lieu of a written order from a licensed prescriber.

c. When a properly labeled medication comes to the health office accompanied by a written request from the parent/person in parental relation for administration of the medication, but without a written order from a licensed prescriber, the following procedure should be followed:

(1) Contact parent/person in parental relation regarding need for written order from a licensed prescriber.

(2) Contact licensed prescriber to obtain verbal permission to administer medication.

(3) Request fax or written orders to be received within forty-eight (48) hours.

(4) Contact parent/person in parental relation and discontinue medication if written orders are not received in forty-eight (48) hours.

(5) Document above steps.

Written Statement from Parent or Guardian Is Required

A written statement from the parent or person in parental relation requesting administration of the medication in school as ordered by the licensed prescriber is required. The parent or person in parental relation must assume responsibility to have the medication delivered directly to the health office in a properly labeled original container.

1) Prescription medications

The pharmacy label must display:

a. Student name.
b. Name and phone number of pharmacy.
c. Licensed prescriber's name.
d. Date and number of refills.
e. Name of medication/dosage.
f. Frequency of administration.
g. Route of administration and/or other directions.

2) Over-the-counter medications must be in the original manufacturer's container/package with the student's name affixed to the container. The same applies to drug samples.

3) For certain medications, especially controlled substances, the school registered professional nurse should count the medication upon receipt from the parent/person in parental relation and periodically thereafter. This is not a legal requirement but constitutes a sound practice when handling controlled substances. Discrepancies should be reported to the parent immediately. The school administration should be informed of any discrepancies when such discoveries occur. Close supervision of the taking of controlled medication is advised.

4) Medications should not be transported daily to and from school. Parents/persons in parental relation should be advised to ask the pharmacist for two (2) containers - one to remain at home and one at school.

Medication is to be stored in a locked cabinet or separate locked drawer in the health office. Medication requiring refrigeration should be refrigerated in a secure area.

Medication Administration

All students requiring medication during school hours should receive their medication in the health office except in those instances where students are allowed to carry their own medication and self-administer.

Carry and Self-Administer Medication

School nursing personnel may receive a request to permit a student to carry and self-administer his/her own medication. Under certain conditions this may be allowed. Such decisions should be made on an individual basis. The criteria for determining when a student can self-administer medication are:

1) Severity of health care problems, particularly asthmatic or allergic conditions.

2) Licensed prescriber's order directing that the student be allowed to carry his/her medication and self-administer.

3) Parent/person in parental relation statement requesting compliance with licensed prescriber's order.

4) Student has been instructed in the procedure of self-administration and can assume responsibility for carrying properly labeled medication in original container on his/her person or keeping in school or physical education locker.

5) School nursing assessment that student is self-directed to carry and self-administer his/her medication properly.

6) Parent/person in parental relation contact made to clarify parental/person in parental relation responsibility regarding the monitoring of the child on an ongoing/daily basis to ensure that the child is carrying and taking the medication as ordered. This contact should be documented.

Any student self-administering medication without proper authorization should be counseled by the school nursing personnel. In addition, the parents/persons in parental relation should be notified. In some instances school administration should also be informed. Periodic reevaluation of the effectiveness of the procedure should be instituted.

Emergency Medication

The requirements allowing registered professional nurses to administer agents used in the emergency treatment of anaphylaxis include:

1) Following non-patient specific standing orders and protocols authorized by a physician or a nurse practitioner.

2) Maintaining or ensuring the maintenance of a copy of the standing order(s) and protocol(s) that authorizes them to administer anaphylactic treatment agents.

However, the administration of emergency medication (injectable and/or oral) to a student for extreme hypersensitivity may be performed by any school staff member responding to the emergency. Such a response would fall under the "Good Samaritan Act" for rendering emergency care during a life threatening situation.

Procedures for Taking Oral, Topical or Inhalant Medications Off School Grounds or After School Hours While Participating in a School-Sponsored Activity

The school nursing personnel should assure:

1) Oversight of self-administration to:

a. Student who is self-directed;

b. Voluntary staff member who has been appropriately instructed by the school nursing personnel to assist self-directed student. (Note: Consistent with good practice, the employee's willingness to perform the task should be considered in making the assignment.)

2) Preparation of medication

When oral medication is to be given off school grounds or after school hours, it should be placed in a single dose medication envelope by school nursing personnel and properly labeled with:

a. Student's name.

b. Name of medication and dosage.

c. Date and time to be given.

d. Special instructions.

e. Possible side effects.

Administration of oral, topical or inhalant medications to non-self-directed students and injectable medications to any one must remain the responsibility of the school registered professional nurse, licensed practical nurse under the direction of a school's registered professional nurse, physician, or parent/person in parental relation. However, Epi-Pen type injectables may be administered by an LPN in the absence of an RN. Epi-pens must be pre-measured and self-inject in emergency situations.

Herbal Remedies, Dietary Supplements, Natural Products and Other Non-FDA Sanctioned Requests

Requests for use of herbal remedies, dietary supplements and natural products do not need to be honored by a school district or school registered professional nurse as they are not sanctioned by the FDA. Such matters should be explained to the parent and their cooperation sought to have such medications administered outside of school. An appropriate notation should be made on the student's health record.

Emergency Building Evacuation and Medications

Good nursing practice dictates that each health office be supplied with a readily accessible, easily carried, and recognizable emergency pack that includes supplies for basic first aid, including supplies for infection control, a stock Epi-pen with non-patient specific orders and a glucose source, such as glucose gel or honey sticks. A plan for communicating with the principal should be established. A list of all students with significant medical conditions and medical orders for prescription medication, including emergency contact numbers, should be kept in the emergency pack.

Responsibilities of School Nursing Personnel

General

1) Facilitate policies and procedures regarding the administration of medication in schools.

2) Ensure proper and appropriate techniques for the administration of medication in schools.

3) Provide and/or document adequate in-service education for unlicensed persons assisting students with self-medication.

4) Maintain adequate and secure storage of all medications.

5) Document or assure documentation by other licensed or unlicensed persons for each dose of medication given or taken on a daily log and periodically summarize in each student's cumulative health record.

6) Perform intermittent evaluation of the practices and procedures related to the administration of medications and modify as needed.

Specific for each student

1) Observe and evaluate the student's health status and response to medication, informing parents/persons in parental relation or prescriber as deemed necessary.

2) Educate the student regarding the importance of medication and encourage the student's self-directed involvement in the process including coming to the health office on time and receiving or taking medications. If a student forgets, it is recommended that the school registered professional nurse call for the student to ensure that medication is not missed. Parents/persons in parental relation should be advised if their child is not fully participating in the established school procedure.

3) Involve school staff only as needed to ensure student safety and only where disclosure of the health information is permitted by law.

Storage of Medication

No medication should be brought into school without knowledge of the health office. Publicized procedures that facilitate this practice so that parents and students do not feel the need to hide medication or to circumvent cumbersome procedures are essential.

All medications, except as otherwise arranged, should be properly stored and secured within a health office cabinet, drawer or refrigerator designated for medications only. This site must include a lock for the cabinet, drawer and refrigerator, as well as a lock to the outside health office door. Controlled substances must always be secured and must never be left open or accessible to the public at any time. Even self-directed students should not be given unsupervised access to controlled substances under the care of the school.

Whenever possible, medication storage units ideally should be secured to the wall or floor, and should not have breakable glass doors. Ideally, all medications should be stored in a health office. However, there may be instances when either requests are made by a parent and physician for a student to carry and self-administer medications because of the emerging nature of the health problem or the severity of the health condition.

Disposal of Medications

If a medication regimen is changed or discontinued, and/or at the end of each school year, the medication must be returned to the parent/person in parental relation or disposed of. Parents/persons in parental relation should be notified of options such as:

1) Disposal of medication by flushing in presence of witness; or

2) Parent/person in parental relation or responsible designee picking up medication from health office.

Disposal of Needles and Syringes

Needles and syringes should be disposed of in a manner consistent with the following guidelines:

1) Needles should not be recapped and should not be purposely bent or broken.

2) Disposable syringes and needles (and other sharp items) should be placed in approved sharps' containers and labeled "BIOHAZARD."

3) Arrangements should be made with custodial staff or an appropriate agency to dispose of containers at periodic intervals according to established procedures of the school regarding regulated medical waste.

Record Keeping

School nursing personnel should maintain accurate records of the medication administered, any special circumstances related to the procedure, and student's reactions/responses.

The following procedure for record keeping is recommended:

1) Retain the written order from the prescriber.

2) Retain the parent/person in parental relation request letter.

3) Retain pertinent information about medication on cumulative health record.

4) Maintain an individual daily medication record for each student taking medication during time frame medication is being given.

5) Periodically summarize daily medication record on cumulative health record.

Student and Parent/Guardian Education

School nursing personnel can avoid many communication problems by widely circulating the requirements for administration of medication in school. Suggestions for publicizing the requirements for administration of medication in school include:

1) Student-parent handbook.

2) School publications/calendars.

3) Local newspapers.

4) Insert with report cards.

5) Mailing to physicians and/or local medical societies.

6) Individual parent or person in parental relation/student counseling.

7) Pharmacies.


Reviewed: April 7, 2009