This January 2004 position statement is presented in response to a Florida Association of Homes for the Aging’s (FAHA) proposal.

FADONA Position Summary: Florida residents want their parents to get the best possible care. This proposal will allow less-qualified individuals to administer medications, without a complete knowledge of the ramifications of their use. The care of our elderly population should be left to those most qualified to do it. The state of Florida should not put those not able to care for themselves at risk. In addition, FADONA rejects the notion that there would be any savings to nursing homes and believes that it will be an added expense lacking any real benefit.

Summary of FAHA Proposal: Create a legislatively mandated task force to study the feasibility of using medication technicians to administer routine medications under the supervision of a licensed nurse in nursing homes. The task force would consist of representatives from the Dept. of Health, the Agency for Health Care Administration, the Board of Pharmacy, the Board of Nursing, the Florida Nurses Association, the Florida Association Directors of Nursing Administration, the Dept. of Education, the Florida Association of Homes for the Aging, the Florida Health Care Association and the Florida Center for Nursing. The study could be under the Dept. of Elder Affairs, a university, or some other unbiased entity identified by the legislature.
 

Background: The usage of medication technicians (Med. Techs.) in skilled nursing facilities (SNFs) should raise a red flag. The idea would not save nursing homes money by allowing them to hire less-skilled certified nursing assistants (CNAs) to administer “routine” medication. The simple fact is that for those in skilled nursing facilities, there is very little that is “routine” about their treatments. Complications can arise and it is important for the nurse to have the proper training to recognize the symptoms and help devise a solution. While there may be individuals that could do a fine job serving as Med. Techs., the board of directors of the Florida Association Directors of Nursing Administration/LTC (FADONA) feels that they would be in the minority. This would increase the exposure of Florida’s frail and elderly, as well as the facilities, to unnecessary risks, possible injury or death, and a wave of new lawsuits.

While some might view this proposal as a cost-saving measure, the expenditures resulting from a negligent care lawsuit will far outweigh the few thousands of dollars saved in salaries. It is important that the state’s administration and the legislature realize that care for their parents, uncles, aunts and grandparents is a serious and grave issue. Medication administration or support should NEVER be taken lightly. Most medications, even when previously effective without reaction can, in fact, cause serious ramifications in subsequent use. CNAs are not trained to address such reactions and therefore our residents may be placed in harm’s way if the proposal succeeds.

Licensed nurses are trained and educated in the scope of pharmacology and understand the serious nature of drug interactions and their sometimes fatal side effects. The potential approval of Med. Techs. would prove to be an increased liability for residents, licensed nurse, the director of nursing (DON) and the administrator.

Rationale: There are several reasons why the use of Med. Techs. would be unsafe:

1. The state of Florida holds itself out as being proactive, quality driven, and enforcement savvy in its desire to enhance the quality of care and services for those residing in Florida’s SNFs. The use of a CNA with limited training and skills to administer medication can in no way be viewed as a quality-enhancing measure.
2. The lack of many CNAs’ formal education, represents the first and foremost drawback. Most states which use Med. Techs. do not even require a high school diploma, so typical applicants may have poor math and reading skills. Medication names are complex, often presented in generic and trade names, and many names are very similar. It is crucial that correct medications are given to patients because of the potential for adverse drug reactions and adverse outcomes. The potential for increasing medication errors at a time when the public is focusing on and demanding fewer medical errors is foolhardy. A recent study in two hospitals found that properly trained nurses intercepted 86 percent of medication errors before they reached patients. Studies have indicated that the percentage of nurses caring for patients improves the quality of care received. Surely this translates to nursing homes as well.
   The patients who are entrusted to us deserve quality care. The lack of an education base for Med. Techs. who will provide these services to an increasingly medically-complex elderly population, would be a step backward.
3. The Board of Nursing in Florida stipulates that CNAs are allowed to observe and report, and document on a limited basis. LPNs are allowed to observe, collect data, and report, and respond to directions from appropriate individuals within their scope. RNs are allowed to observe, collect data, assess, report, and give directions, and or respond to directions from appropriate individuals within their scope.
   Based on existing criteria, CNAs are not allowed to collect data and or assess the administration of medications in a SNF. Although a CNA can take a blood pressure, in general, the analysis process to ascertain if the medication can be given would not be permitted based on the Board’s existing interpretation.
4. Florida currently requires a minimum of 2.6 hours of hands-on care for CNAs and 1.0 for nurses (per resident, per day). In May 2004, SNFs are scheduled to increase CNA staffing to 2.9 hours a day. If CNAs are to be used as Med. Techs., how would they be classified? Would they be counted as a CNA? The Agency for Health Care Administration is stringent with these minimum requirements. A facility with an excess of nurses cannot count those nurses in direct care unless they have clear and convincing documented evidence that the nurse did in fact provide direct care during the entire shift or they must have an AHCA waiver to allow a nurse to split his or her hours.
5. If these Med. Techs. are not counted as CNAs, then this proposal has the potential of becoming a staffing nightmare and a major, unreimbursed financial burden, one which adds costs but no quality to the process. In addition, a new layer of nursing and risk management policies would have to be implemented and monitored by the facility.
6. FADONA anticipates that there will be resentment from other floor CNAs, plus fear and concern from licensed staff, especially the directors of nursing (DONs), who are responsible for the actions and inactions of their staff.
7. Professional CNAs should be applauded for the fine work that they do. And, while we continue to encourage CNAs to advance their skills within the nursing profession, we do not need a new Med. Tech. career ladder for CNAs.
8. The use of Med. Techs. would serve to dilute the well-defined scope of nursing practice. De-professionalizing the practice of nursing at a time when the nursing shortage is at crisis proportions would not serve to attract people to the profession.
9. Use of Med. Techs. has the potential to substantially increase litigation against the facilities and their licensed personnel, prompting a further rise in nursing home liability insurance rates, as well as the flight of experienced licensed nurses from long-term care.
10. The use of Med. Techs. in Florida’s nursing homes would put the licenses of supervisory staff and administrative nurses in jeopardy.
11. While Med. Techs. function in assisted living facilities (ALFs) in Florida, FADONA does not support it, nor does it minimize the risk to the ALF residents and to the RNs whose licenses they function under. In the ALF setting, they are presumably dealing with residents with far less acute illnesses. In SNFs, we are caring for residents with ever-increasing levels of acuity. The observations, assessments and care decisions that nurses make during routine medication pass would still be necessary to promote quality care and cannot be performed by anyone other than a qualified nurse.
12. The problem with some ALF medication systems is that many different pills are in a cup and if some are missed, the CNA has no idea which ones are most important. Also in this model, there is no capability to give PRN doses that require judgments they typically are not able to make.

Conclusion: FADONA believes that the use of non-licensed staff to administer medications in the SNF environment is both counter-intuitive and counterproductive in the evolution of quality care and services. It violates the very stringent Nurse Practice Act, adds cost without value to the consumers, and puts our patients at risk.

While there may be many individuals who will be able do this function very well, FADONA still feels that it is not the direction in which Florida should be moving. FADONA feels strongly that the art of providing direct care and services should be valued, and performed by those with the necessary training to provide the best care for our residents.