RN Med Mixing in LTC Facilities

By Marc Stranz, PharmD, RPh

Ask the Pharmacist...

Q: I am the night supervisor in a large skilled nursing facility (primarily long-term care beds with a small number of sub-acute care beds). Sometimes the residents in the sub-acute unit need to start on IV antibiotics in the facility. In the past, the pharmacy sent the first dose within two hours after it was called in (our policy says we have to start the drug within 2 hours). We recently switched pharmacies, and our new pharmacy’s policy is to provide a locked box with medications to start stat first doses of antibiotics since their IV compounding pharmacy is more than an hour from us. Because many of these drugs have a short period of stability, they want the nurses in the facility to mix them when they’re ordered and they’ll replace them when they make the pharmacy delivery in the A.M.

Can nurses in long-term care facilities legally mix medications? Isn’t this considered compounding?

A: In the last month, I have received calls from pharmacies in several states concerning the legal ability of the facility nurse to prepare injectable drugs for administration. In each situation, the statement from the facilities involved is the same. "State regulations do not permit a nurse to prepare drugs for administration - nurses are only allowed to administer drugs prepared by the pharmacy". The involved parties want a written opinion from their state Board on the issue, refusing to even connect and activate AddVantage or Minibag Plus systems until such actions are "approved" by the state Board of Nursing.

I have made requests to the state authorities for written opinions, but each said they will discuss the issues with the involved parties, but will not issue a written opinion. I am passing this information on to save you some trouble and to alert you to a potential problem. This is not just one facility in one state making these statements.

In essence, the compliance officers of each nursing board said they would not answer this question with either a "yes" or "no". In the states I spoke to, the Boards and the nurse practice act do not explicitly exclude or permit "drug preparation for administration". Use of the word "compounding" triggered a response among compliance officers that compounding was a pharmacy activity, so watch your verbs. Each said that the legal ability to compound/prepare drugs is related to the competency of the individual nurse. A nurse who feels and can show (through training) she is competent to prepare drugs is permitted to do so. A nurse who prepares drugs and knows she is not competent is violating the intent of the nursing Act. A skilled facility can refuse to prepare drugs for administration and the nursing Board would have no issue with this as long as the facility does not accept any residents who would be put in jeopardy by this action. If the facility does accept those residents, they must avoid harm to the resident through using trained staff to prepare the products or through finding a pharmacy that can always provide the final product in a timely manner. Given that emergency situations (code) would require assembly of injectable drug components, it is unlikely that any skilled facility could declare themselves unable to activate ready-to-use products. However, they could declare themselves unable to admix drugs safely due to insufficient training.

I also spoke to a few compliance officers at Boards of Pharmacy. Pharmacy Acts usually permit placement of "interim" boxes in skilled facilities, with appropriate stipulations on control and supervision. The Acts provide a method to avoid emergency dispensing of product with the intent of improving patient safety. The pharmacy boards' authority ends with the authorization to place and maintain the drug products in the skilled facility. However, each said that it is incumbent on the pharmacy to be sure that the drugs in the interim box are used safely.

The consequence of this is that the pharmacies involved must train skilled facility staff on any drug preparation they are required to perform, the drug preparation procedure must be in the skilled facility's IV manual, and drug preparation instructions should be inside the interim boxes. The procedures must also address final labeling of the prepared product to conform to state regulations.

Addendum: there are state nursing acts that specifically address the ability of the nurse to prepare drugs for administration. For example, in South Dakota this is covered in the Scope of Practice for IV Therapy, saying nurses may administer medication, excluding first dose, "that has been mixed and labeled by a physician, pharmacist, or nurse".