Medication administration in long-term care is complicated

By | 2021-02-22T09:44:24-05:00 February 26th, 2018|17 Comments

A reader submitted a question about whether it was legal for a nursing supervisor in a long-term care facility to ask one of its nurses to pass medications on two floors. Here is my response.

Long-term care facilities are highly regulated at both the state and federal levels. I am not familiar with all of these regulations so it would be difficult to respond to this question without doing extensive research. But let’s assume that such a request is not illegal.

Even though it’s not against the law, other questions come to mind: Is such a request safe for patients? Is accepting this request a potential problem under the Nurse Practice Act?

The medication administration process is not to be taken lightly. It is highly structured and regulated by standards of nursing practice. Specific requirements must be followed to avoid, insofar as possible, medication pouring and medication administration errors.

Nursing literature has tons of information on the right ways in which to execute the medication administration process. Some experts have written there are “Five Rights” to the medication administration process, while others list six or more. Nurse consultant Vivian Nwagwa lists 10 in her training session, and they include:

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— Right patient
— Right medication
— Right dose
— Right time
— Right route
— Right education (of patient or family)
— Right to refuse (the medication)
— Right assessment (of patient before administration of medication)
— Right evaluation (of patient after administration of medication)
— Right documentation

Regardless of which model you use, the medication administration process in long-term care can be troublesome because of many factors, including no on-site physicians to directly observe residents’ condition and medication needs, off-site pharmacies and limited time spent by pharmacists on site, according to a study.

Other factors include a medically frail patient population, multiple medications ordered for each patient and the timeliness of administering medications.

An earlier study by Scott-Cawiezell,Vogelsmeier and others, “Nursing Home Error and Level of Staff Credential,” revealed the average medication pass in nursing homes involves 73 medications and takes an average of 113 minutes.

Assuming these numbers are fairly common in most long-term care facilities, the next question that arises is, what about the propensity for a medication error or errors if you double the numbers when passing medications on two floors?

A medication error, defined in part by the National Coordinating Council for Medication Error Reporting and Prevention, a medication error is “any preventable event that may cause or lead to inappropriate use or harm while the medicine is in control of the healthcare practitioner.” This definition includes professional practice and [healthcare] procedures and systems.

Nursing literature contains volumes of research and articles on medication errors in long-term care. One study done in 25 nursing homes in North Carolina over a 1-year period found 23 (92%) of the sites reported 631 error reports for 2,731 “discrete error instances when weighted by the number of times the errors were repeated.” Fifty-one of the errors were grouped as being serious enough to require nursing monitoring or intervention or more.

The most common errors included dose omission (203, or 32%), wrong patient (38, or 6%), and wrong product (38, or 6%).

The errors normally took place during medication administration (296, or 47%), according to, “Preventing Medication Errors in Long-Term Care: Results and Evaluation of a Large Scale Web-Based Error Reporting System.”

In addition to this information, state boards of nursing are empowered to discipline a nurse for a medication error that causes serious injury or death to a patient. Even if the medication error does not result in patient injury or death, a nurse licensee who does not comply with acceptable and current standards of nursing practice when handling the medication administration process may also be disciplined.

And there is that all-encompassing phrase for potential discipline if you are engaged in unprofessional or dishonorable conduct that might harm the public. Although the specific language varies in the acts, it remains a plausible basis for discipline when you are involved in the medication administration process.

How would you respond to this request?

Editor’s note: Nancy Brent’s posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state.  Visit The American Association of Nurse Attorneys website to search its attorney referral database by state.

Courses related to ‘medication administration’

60150: Preventing Medication Errors
(2 contact hrs)

Despite the efforts of healthcare providers, medical error rates in communities, healthcare facilities, and homes remain high. Patients and families pay for errors through disability and death. Preventable medical errors not only affect patients, family members, and healthcare professionals, but also contribute to soaring healthcare costs. This activity will explore approaches to prevent medical errors that are both system-based and human performance-based and describe The Joint Commission National Patient Safety Goals as they pertain to medical errors in hospitals

WEB318: Eagle Eye: Exercises in Reducing Medication Errors 
(1 contact hr)

Medication error safety is an issue of ongoing importance and concern in the healthcare field. Despite significant attention, the estimated cost of morbidity and mortality associated with medication errors is $21 billion. This module has been designed to provide sample cases of medication errors for the healthcare team to review and apply skills to. It is recommended that prior to taking this course, the attendee first complete a more in-depth course on medication errors. By maintaining constant vigilance, honing skills related to recognizing and reporting medication errors, and developing strategies to address deficiencies in the healthcare delivery system, it is possible to make a significant impact on this epidemic.

CE214-60: Polypharmacy in the Elderly 
(1 contact hr)

Polypharmacy, the concurrent use of several drugs, increases the risk of adverse drug reactions and interactions in older adults. Besides adverse drug reactions and drug-drug interactions, other clinical consequences of polypharmacy include nonadherence, unintentional overdose, increased risk of hospitalizations and medication errors. While taking more than two drugs can increase the risk of an adverse effect, taking more than five drugs increases that risk. As the number of drugs taken and the age of the person increases, so does the risk for adverse drug interactions.

About the Author:

Nancy J. Brent, MS, JD, RN
Our legal information columnist Nancy J. Brent, MS, JD, RN, concentrates her solo law practice in health law and legal representation, consultation, and education for healthcare professionals, school of nursing faculty and healthcare delivery facilities. Brent has conducted many seminars on legal issues and has published extensively in the area of law and nursing practice. She brings more than 40 years of experience to her role of legal information columnist. Her posts are designed for educational purposes only and are not to be taken as specific legal or other advice. Individuals who need advice on a specific incident or work situation should contact a nurse attorney or attorney in their state. 


  1. Avatar
    Gail Falligan March 2, 2018 at 2:51 am - Reply

    i have worked in long term care for over 30 yrs as a lpn in phila. there’s 60 residents on most long term care units. being a regular nurse on the unit and knowing the resident is still room for error. being asked to pass meds on two units is a invite for mistakes. you may not know the resident and there’s a time limit to pass meds (1 hour before and 1 hours after) the dose is ordered by the dr. i wouldn’t put myself in that situation. we have to work hard for our license to lose it due to staffing problems. the nursing supervisor should call someone in or ask another nurse like a unit manager, rnac, adon to pass the meds on the second unit.

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    .. June 14, 2018 at 2:27 am - Reply

    I regularly pass on two unites with 74-80 patients on average 350-360 meds per pass pm/hs. It’s incredibly unsafe. There’s very few cmt’s I’ve worked with that can handle the load. Admin keeps telling us we’re not budgeted for 2 cmts on evenings. I’ve been having that argument for 5 years…

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    Alexandria pacelli September 11, 2018 at 3:49 pm - Reply

    Looking for info on a question… if a nurse is sitting in front of her med cart though cannot view the lock, does it need to be locked? She is 2 feet away and can see anyone approaching med cart

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    Kathy Griffiths November 5, 2018 at 3:22 am - Reply

    I am a LPN in a large state prison. Due to the recent surge in mental health, our pm med administration has jumped to approximately 1850 doses that 2 nurses are expected to administer in a 3 hour period from 6 -9 pm. We do use computers with scanning, but I feel that this is unsafe for the inmates as well as the nurse. This has been brought to management and nobody seems to get it! Looking for some guidance as to the amt of meds that is legal to dispense.

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    Brenda Jean Walker February 24, 2019 at 3:42 am - Reply

    My question is. When you have ordered medication from the pharmacy and they haven’t arrived in a day and you refax the order again when is it considered a med error? Thank you.

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    Lee Parry June 2, 2019 at 10:42 pm - Reply

    I have recently took on a part time Job at a beautiful high end Retirement Home. My position is a care giver on night shift. Shadowed a women that has no Medical back ground and is now in charge of dispensing medications. These include narcotic , checking insulin levels and giving Insulin ..I have worked in the Medical Field as RNA did not renew my License. Is this not illegal ? A 3 hour course of medication review is absolutely not acceptable . I am not comfortable with this at all.
    What should I do ??? Is there someone that could give me advice plz
    Thank you

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    josephine mcshea September 27, 2019 at 5:47 pm - Reply

    is it illegal to interrupt a med pass

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      Kim October 4, 2021 at 1:11 am - Reply

      YES, medication nurses should never be interrupted during a med pass unless it is a emergency. Nursing homes have gotten away with expecting their nursing staff to multitask during medication passes that do increase the risk of medication errors, however during state surveys people come out of the woodwork during that time and the State knows this, if they haven’t realized this then shame on them.

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    jeff mcguigan October 16, 2019 at 3:07 pm - Reply

    My wife is a brand new lpn and she has been told that she will be passing for 27 residents on the NOC shift, Is 27 to high of a number for her being a new lpn?

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    Sherrie Hauck March 17, 2021 at 4:05 pm - Reply

    When you have passed the test to be a qualified medication proffesiana how long can you do it before you have to be tested again

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    Jennifer Sweet August 27, 2021 at 7:59 am - Reply

    Is it illegal to give medication without a mar

    • Avatar
      Sharon Informatives October 16, 2021 at 3:29 am - Reply

      I would like to know the answer to this as well.

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    Luna Rodriguez April 4, 2022 at 10:19 pm - Reply

    I am a Qmap and work in assisted living. My question is can a Qmap pass medication on 2 floors (total of 49 plus people) and do baths and laundry and trash and feed and whatever else is required because they only have 2 Maps or 3 and NO care staff on floors? Is this legal?

    Can you clarify this question and, if it’s illegal, who do I call to file a complaint?

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      To tired November 11, 2022 at 11:23 am - Reply

      I am an LPN and, yes, caring for as many residents as they can push on you is legal. I have had as many as 60 or more. And yet still got yelled at and told that I need to work harder.

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    Princessanabelle November 19, 2022 at 5:14 pm - Reply

    Is it illegal to give meds to the elderly out in the open for everyone to see?

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    shelley koehn February 6, 2023 at 3:58 pm - Reply

    Is it against Kansas state regulations to pass medications in the dining room at a nursing home or long-term facility?

  14. Avatar
    Carol Taylor February 19, 2023 at 4:27 pm - Reply

    What is the protocol for administering meds in a long term nursing home in SK – (1) nursing staff leave the meds and leave the room or (2) nursing staff administer the meds to the resident and remain in the room until all meds have been taken?

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