Nurses in residential aged care homes – legal requirements

Schedule 4 and Schedule 8 poisons in residential aged care homes

Residential care situations – medicine administration

Management of medicine by registered nurses

The Drugs, Poisons and Controlled Substances Act 1981 (the Act) specifies that registered residential aged care providers are required to ensure that a registered nurse manages the administration of Drugs of Dependence and Schedules 4, 8 or 9 medication. The registered nurse must manage this medication in accordance with the relevant codes, standards or for guidance (if any) issued by the Nursing and Midwifery Board of Australia.

An enrolled nurse cannot manage the administration of medication to residents living in residential aged care.

The registered nurse with overall responsibility for management of medicine must be readily identifiable to service staff and able to be contacted by the Victorian Health Regulator. The position is expected to be formalised in the service’s organisational framework and role description. Staff should be made aware of the registered nurse’s role.

The registered nurse must be free from coercion.

S. 136 of the Schedule to the Health Practitioner Regulation National Law (Victoria) Act 2009 states that ‘A person must not direct or incite a registered health practitioner to do anything, in the course of the practitioner’s practice of the health profession, that amounts to unprofessional conduct or professional misconduct’.

The registered nurse must have the necessary resources to manage medication accordance with their professional judgement and nursing standards – for example, in regard to the Nursing and Midwifery Board of Australia’s decision-making framework.

Delegation of administering medicine

The registered nurse who is managing the administration of dispensed medication can delegate medication management to another registered nurse or enrolled nurse who is working under their supervision. This is a judgment for the registered nurse that must be exercised in accordance with professional nursing codes, standards or guidelines for supervision and delegation.

All nurses are accountable for their professional decisions and actions. The nurse manager must be able to demonstrate that delegation decisions have been properly made in accordance with professional practice guidelines and that appropriate supervision and monitoring arrangements have been put in place and followed. The worker to whom a task of administering dispensed medicine is delegated is also held accountable to the extent of their training, and for following the systems and procedures required.

Personal care workers cannot administer Schedule 4 and 8 medications, unless an exemption applies. This includes medication in a Dose Administration Aid. For more information see Medication Administration in Residential Aged Care.

Nurse administration of Schedule 4 and Schedule 8 poisons

Where a nurse (not including an enrolled nurse who does not hold a Nursing and Midwifery Board of Australia-approved qualification in medicine administration) is required to administer Schedule 4 or Schedule 8 medications, regulation 96 and regulation 97 of the Drugs, Poisons and Controlled Substances Regulations 2017 (the Regulations) require the nurse to first refer to authoritative instructions in the form of:

• written instruction of a medical practitioner or other authorised practitioner (the most common option)
• oral instructions of a medical practitioner or other authorised practitioner if, in the opinion of the practitioner, an emergency exists (for example, telephone orders)
• written transcription of the emergency instructions by the nurse who received them
• directions for use on a container supplied by a medical practitioner, pharmacist or authorised practitioner(meaning administration of a person’s own lawfully supplied medicine).

Self-administration

There are some circumstances where a person living in residential aged care administers their own dispensed medication. The registered nurse managing medication administration remains responsible for the resident’s medication. For more information, see the Commonwealth Government’s Department of Health, Disability and Ageing’s Guiding Principles for Medication Management in Residential Aged Care.

Aged care services – storage of, access to and destruction of Schedule 4 and Schedule 8 medications

Storage of, and access to, Schedule 4 and Schedule 8 medications

• Schedule 4 medications must be stored in a lockable facility.
• Schedule 8 medications must be stored in a lockable room and/or in a lockable storage facility that is firmly fixed to a floor or wall. A steel drug cabinet is not mandated, because of the prevalence of dose administration containers. However, a steel drug cabinet:
  • is strongly recommended for the storage of Schedule 8 medication in original containers
  • is strongly recommended for the storage of Schedule 8 medication that cannot be packed into dose administration containers
  • is required for the storage of Schedule 8 imprest medication, where a health services permit is held
  • may be required (for example, for larger quantities of Schedule 8 medication), if directed by the Department of Health .
• Facilities for the storage of Schedule 4 and Schedule 8 poisons must be locked to prevent unauthorised access.

Records of transactions

Regulation 115 authorises a nurse to act as the witness when a Schedule 8 medication is to be destroyed by a medical practitioner, nurse practitioner, pharmacist or dentist. Note: This does not mean that two nurses may destroy Schedule 8 medication.

Regulation 115 authorises a nurse to destroy (for example, discard) the remaining, unused contents of a previously sterile container (for example, a partially used ampoule) or the unused portion of a tablet or lozenge, provided that the nurse makes an appropriate record. Note: As a suitably qualified person might not be available, a witness is not mandated. However many establishments have a policy that requires a witness if another nurse is available.

Destruction of Schedule 8 medications

Regulation 115 authorises a nurse to act as the witness when a Schedule 8 medication is to be destroyed by a medical practitioner, nurse practitioner, pharmacist or dentist. Note: This does not mean that two nurses may destroy Schedule 8 medication.

To clarify the situation relating to an accepted and necessary practice, this regulation specifically authorises a nurse to destroy (for example, discard) the remaining, unused contents of a previously sterile container (for example, a partially used ampoule), provided that the nurse makes an appropriate record. Note: As a suitably qualified person might not be available, a witness is not mandated. However many establishments have a policy that requires a witness if another nurse is available.

Health services permit to obtain ‘imprest medicine’

Some residential aged care services choose to obtain a health services permit, for which an annual fee must be paid. The health services permit enables them to obtain medicine that has not been prescribed for specific patients, so that selected medicine is readily available for immediate administration. Such medicine is referred to in this document as imprest medicine.

Each health services permit contains conditions that are specific to the type of health service provided. The health service must complete an online form that details how the medicine will be managed.

For all relevant application forms, see the Licences and permits to possess (and possibly supply) scheduled substances page.

Basic issues

Most medication in residential aged care services is supplied on prescription for specific residents. However, if a residential aged care home holds a current health services permit, Schedule 4 and Schedule 8 poisons may be administered for urgent administration, to any resident, in accordance with the instructions of a medical practitioner or authorised practitioner.

Steps to obtain imprest medicine

If an aged care home holds a permit to obtain imprest medications , it should provide their supplier (which could be a pharmacy) with a copy of their permit. This will demonstrate to the supplier that the service holds a current permit and it identifies the medicines that may be obtained.

When an imprest medicine is ordered by a permit holder from a pharmacist, the pharmacist may supply the medicine in accordance with regulation 47(1)(h) and regulation 48(1)(e) and must make a record of the transaction. Imprest medicine is not supplied on a prescription or chart instruction, so the pharmacist needs not attach additional labels to the original containers.

The permit holder should store imprest medicine separately from medicine supplied on a prescription or chart instruction and should manage it in accordance with the documentation supporting the health services permit.

When a nurse has a written or verbal instruction from a medical practitioner or other authorised practitioner to administer an imprest medicine to a patient, the nurse may remove the required dose(s) of medicine from the imprest store and must make a record of the transaction.

The container from which the initial dose(s) of an imprest medicine was obtained will then contain fewer doses. It should be returned to the imprest store and replaced when necessary.

If the medical practitioner or other authorised practitioner provides a prescription or chart instruction authorising the pharmacist to supply the medicine for the patient, the pharmacist must supply the quantity specified on the prescription or chart instruction, label the corresponding container in the manner described in regulation 72 and make a record of the transaction.

Medicine dispensed using a prescription or chart instruction will be labelled for a specific person, and is essentially owned by that person. It must not be administered to any person other than the person named on the prescription or medication chart. Hence, a container of medicine obtained on a prescription or chart instruction (i.e. labelled to be administered to one specific person) must not be used to replace a container that was removed from the imprest store, in order to stock an imprest store (i.e. where it could be used to be administered to any person).