Nurses in residential aged care facilities – legal requirements

Schedule 4 and Schedule 8 poisons in residential aged care facilities

Who can possess Schedule 4 and Schedule 8 poisons

Most medicine used in residential aged care services is supplied on administration to specific patients, in the same way that medicine is supplied for a person in private residential accommodation.

Some medicine used in residential aged care services may be supplied on a chart instruction written on hospital medication chart (Schedule 4 or Schedule 8 poison) for a resident at discharge from hospital or a day procedure centre or a chart instruction written on a residential medication chart (Schedule 4 poison) for administration to a specific resident.

Any person who has the care of (or is assisting in the care of) a resident for whom a medicine has been supplied on a prescription or chart instruction (dispensed medicine) is authorised to possess that medicine for the specific purpose for which it was supplied. In a residential aged care service, such a person may be a nurse or a personal care worker.

Residential care situations – medicine administration

Management of medicine by registered nurses

The Drugs, Poisons and Controlled Substances Act 1981 (the Act) specifies that the administration of Schedule 4 or Schedule 8 poisons to the resident of an aged care facility must be managed by a registered nurse in accordance with the relevant code for guidance (if any) issued by the Nursing and Midwifery Board of Australia.

Compliance with the legal requirement by a registered nurse may occur in a variety of ways. Compliance with this document is in line with compliance with the Act. An enrolled nurse cannot manage the administration of medicine to residents receiving a high level of 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 Drugs and Poisons Regulation. 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 the medicine in accordance with their professional judgement and nursing standards – for example, in regard to delegation and supervision.

Delegation of administering medicine

The registered nurse who is managing the administration of dispensed medicine to residents could delegate the routine supervision of other workers to whom they have delegated the task of administering medicine. This is a judgment for the registered nurse that must be exercised in accordance with professional nursing codes or guidelines for supervision and delegation.

All nurses are accountable for their professional decisions and actions. The nurse manager must 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.

A registered nurse may only delegate the administration of medicine to someone appropriately qualified to administer medicine. This means that the registered nurse manager may use their professional judgment about whether to administer a medicine themselves or delegate the administration to another nurse or personal care worker with appropriate qualifications or scope of practice to administer the medicine by the specified route.

Enrolled nurses (who do not hold a qualification in medicine administration approved by the Nursing and Midwifery Board of Australia) and personal care workers (with appropriate medicine administration training) may, in some circumstances, be competent to administer medicine under the delegation of a registered nurse. If a registered nurse judges that an enrolled nurse or personal care worker is not appropriately qualified to administer the medicine to a particular resident, they should administer the medicine themselves or delegate the administration to appropriately qualified personnel. Appropriate supervision must be provided.

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 poisons, 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).

Nurse-initiated medications

Residents who are not receiving the equivalent of a high level of care are likely to be personally involved in the management and administration of their own medicine, with assistance as required.

Other residents

It is anticipated that a resident not requiring high-level care is more likely to be personally involved in the management and administration of their own medicines, with assistance as required.

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

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

• Schedule 4 poisons must be stored in a lockable facility.
• Schedule 8 poisons 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 poisons in original containers
  • is strongly recommended for the storage of Schedule 8 poisons that cannot be packed into dose administration containers
  • is required for the storage of Schedule 8 imprest medicine, where a health services permit is held
  • may be required (for example, for larger quantities of Schedule 8 poisons), if directed by the Department of Health and Human Services.
• 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 poison 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 poisons.

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 poisons

Regulation 115 authorises a nurse to act as the witness when a Schedule 8 poison 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 poisons.

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 (& possibly supply) scheduled substances page.

Basic issues

Most medicine in residential aged care services is supplied on prescription for specific patients. However, if a facility holds a current health services permit, Schedule 4 and Schedule 8 poisons may be supplied (without prescription or chart instructions) for urgent administration, to any resident, in accordance with instructions of a medical practitioner or authorised practitioner.

A pharmacist is considered to have supplied imprest medicine when possession or control of, or access to the drugs is transferred to nurses at the aged care service. When a payment occurs is irrelevant to when supply is said to have occurred.

Steps to obtain imprest medicine

The permit holder (that is, the aged care service) should provide the pharmacy with a copy of their health services permit. This will demonstrate to the pharmacist that the service holds a current health services permit and it identifies the poison schedules of the medicine that may be obtained.

When an imprest medicine is ordered, 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 need 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. It is not acceptable to attach a dispensing label, corresponding to the subsequent prescription or chart instruction, to the container that was removed from the imprest store.

The Regulations make it an offence to administer medicine obtained on a prescription or chart instruction 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 must not be used to replace a container that was removed from the imprest store.