Department: Nursing Services

Policy Number NURSING1010.00

Policy Name: Assistance with the Self Administration of
Medication
Creation Date: 12/31/2018 Effective Date: 2/10/2020

1. Policy Statement: Southwest (SWK) Program shall ensure that all children at the
Behavioral Health Care Facility (BHCF) who have a prescribed medication order
receive Assistance in Self-Administration of Medication (SAOM), during the entire
length of stay on and off the facility premises.

2. Procedure:
2.1. Assistance in Self-Administration of Medication.
2.1.1. Southwest Key Programs shall ensure secure and safe processes are
observed when assisting children in Self-Administration of Medication
(SAOM) to include, monitoring medication order compliance, secure
medication storage, reminding child of the time when medication is to
be taken, opening the medication container, verifying the child applied
and/or ingested the medication, and documenting the completion of the
process in the child’s medical record.
2.1.2. At the beginning of the shift, the Medical Coordinator (MC) assigned to
assist children in SAOM shall coordinate with the Youth Care
Department to have a child with scheduled medication orders brought
to the medication room or medical area, designated for medication
dispensing, through the use of a medication list, where child’s name
and time for them to receive medication is noted.
2.1.3. Ensure to request the presence of children at the medication room
within the allowed time for self- administration of medication, which is
1hr before and 1hr after the scheduled time; 2-hour window (Military
Time).
2.1.4. Military Time can be calculated by adding 12 for time after noon (for
example 2PM + 12 =1400)
2.1.5. Assistance in SAOM times are based on the following times:
2.1.5.1. QD- 0800
2.1.5.2. BID/Q12- 0800, 2000
2.1.5.3. TID/Q6- 0800, 1400, 2000 (ATB TID would be given Q8-
0800, 1600, 0000).
2.1.6. Once children arrived at the medication room, ensure to work with one
child at a time observing hand hygiene with each child. Ensure to
instruct the child whom you are assisting to wash his or her hands, as
well.
2.1.7. Assistance in SAOM requires two SWK staff members to perform the
duties of an assistant and a witness. Both staff members are required
to be trained in Assistance in SAOM.
2.1.8. Get Medication order information for the child you are assisting from
the updated medical department medication list and from the child’s
eMAR on PCC.

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 Department: Nursing Services
Policy Number NURSING1010.00
Policy Name: Assistance with the Self Administration of
Medication
Creation Date: 12/31/2018 Effective Date: 2/10/2020

2.1.9. Double check that you have the eMAR for the right minor by identifying
the child with the picture available on PCC. It is important for you to
work with only one child at a time and to complete the task with that
individual before assisting another.
2.1.10. Gather supplies:
2.1.10.1. Take the medications out of the locked storage container or
area. It is a good idea to keep all medications for one
individual in one storage unit labeled with the child’s name.
2.1.10.2. Open the appropriate child information on the
computer/tablet/ desktop.
2.1.10.3. Verify correct date and time is set on the eMAR. Check the
color code (GREEN, RED, and YELLOW) of the medication
and filter information to display only medications to be taken
at the present time.
2.1.10.4. Get paper medication cups for tablets and capsules and a
plastic calibrated measuring cup or medication spoon for
liquid.
2.1.10.5. Get a glass of water or instruct child to do so.
2.1.10.6. Gather tissues.
2.1.11. As you take each medication container from the storage unit, read the
medication label and compare to the Medication information on PCC
for the SIX Rights:
2.1.11.1. Right individual
2.1.11.2. Right medication
2.1.11.3. Right dose
2.1.11.4. Right time - check the time on your watch or clock.
2.1.11.5. Right route
2.1.11.6. Right documentation
2.1.12. Remember to complete the medication count before child self-
administers medication.
2.1.13. Provide education to the minor in the SAOM process and remind the
minor the intent of the medication. Medication information shall be
previously provided by the HCP who prescribed the medication during
a medical evaluation.
2.1.14. Tablets or capsules: Instruct the child to pour the correct dose into the
lid of the container and then into a small paper cup. Pouring a tablet or
capsule into the bottle cap first reduces the risk of contamination. If too
many pills pour out, child is to return the pills from the bottle cap into
the container. It is a good idea to use a separate disposable paper cup
for each medication. Pouring all the medications in one paper cup
increases the risk of medication errors.

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 Department: Nursing Services
Policy Number NURSING1010.00
Policy Name: Assistance with the Self Administration of
Medication
Creation Date: 12/31/2018 Effective Date: 2/10/2020

2.1.15. For bubble packs: Instruct child to open the bubble pack individual pill
one by one by pushing each tablet/capsule out from the bubble pack
into a small paper cup or the child’s hand to get the pill pack open.
2.1.16. For liquid medication: Always shake liquid medications before pouring.
Instruct the minor to pour the correct dose into the plastic measuring
cup held at eye level. View the medication in the cup on a flat surface.
Child should pour away from the medication label to avoid staining it
with spills. If any medication spills on the bottle, wipe it away.
2.1.17. When using a measuring spoon: Locate the marking for the dose.
Instruct child to hold the device at eye level and fill to the correct
dosage marking. Child should pour away from the medication label to
avoid spills. If any spills on the bottle, wipe it away.
2.1.18. Document prescribed and Over the Counter (OTC) medication
provided to children in care in the electronic medication administration
record (eMAR) in Point Click Care (PCC). Documented information
should include name of the medication, dose, route, date & time of
administration, and the name of the staff member (s) who Assisted in
SAOM.
2.1.19. Return the medication containers and/ or bubble pack to the storage
unit.
2.1.20. Ensure to document whenever a child refused medication in eMAR,
including the reason of the refusal. In addition, complete a medication
refusal form on PCC under the child’s medical record. See Medication
Services Police for more information.
2.1.21. Limit the Assistance in SAOM from child to child, to instances when the
child receives the medication from a parent who resides in the
Behavioral Health Care Facility (BHCF).
2.2. Medication Storage:
2.2.1. Medical staff members store all prescription and non-prescription
medication in a designated area in the facility. All prescription
medications shall be locked/ double lock and inaccessible to
unauthorized staff and children.
2.2.2. Store medications in accordance with label instructions (refrigerate,
room temperature, out of direct sunlight, etc.). Prescription bottle/pills
labels cannot be altered by anyone other than the dispensing
pharmacist. Prescribed medication for children that requires
refrigeration must be centrally stored and locked in a receptacle,
drawer, or container. The medication should be kept separate from
food items.
2.2.3. Additional tips for Assistance SAOM:

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 Department: Nursing Services
Policy Number NURSING1010.00
Policy Name: Assistance with the Self Administration of
Medication
Creation Date: 12/31/2018 Effective Date: 2/10/2020

2.2.3.1. Only a calibrated measuring cup or spoon is to be used.

Regular eating spoons are not accurate enough and should
never be used. If too much liquid is poured, do not pour it
back into the bottle— discard it. Wash the calibrated
measuring device and air dry on a paper towel.
2.2.3.2. Some medications must be taken with food, and there may
be other special instructions. Make sure that you have read
any warning labels and are familiar with any special
instructions for taking the medication.
2.2.4. Stay with the child until you are sure that he or she has swallowed the
medication. If the child has difficulty drinking an adequate amount of
water or swallowing liquids, the medical staff can ask the doctor about
the individual taking the medication with: Jell-O that is semi-liquid or
jellied apple juice or other “medication-compatible” juice thickened with
cornstarch or other thickening agent.
2.2.5. Capsules should not be opened, and their contents emptied out. If the
child has trouble taking a medication, talk to the child about their needs
and preferences and then talk to the doctor about optional ways to take
the medication.
2.2.6. Never leave the medication container unattended or give to someone
else to return to the locked storage container or area.
2.2.7. IF YOU HAVE ANY DOUBT AS TO WHETHER THE MEDICATION IS
IN THE CORRECT FORM AS ORDERED OR THAT YOU CAN
ASSIST THE INDIVIDUAL WITH SELF ADMINISTRATION AS
DIRECTED ON THE LABEL, CONSULT WITH YOUR SUPERVISOR,
THE LEAD MEDICAL COORDINATOR, THE PRESCRIBING
DOCTOR OR THE PHARMACIST.

2.3. Assistance in Self-Administration of Medication while Off-Facility

Premises:
2.3.1. At times when children are scheduled to attend court hearings, medical
outings, recreational outings, or other off-site events medication
treatment compliance is maintained through a coordinated effort where
the responsible department alerts the medical department about the
child outing via email communication.
2.3.2. Once an outing email alert has been received, a Medical Coordinator
(MC) reviews the child’s medical record to verify if medication and/or
treatment order is active. An email reply from the medical department
will be sent to notify any pertinent party if a child has, indeed, to take
medication during the scheduled outing.

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 Department: Nursing Services
Policy Number NURSING1010.00
Policy Name: Assistance with the Self Administration of
Medication
Creation Date: 12/31/2018 Effective Date: 2/10/2020

2.3.3. If the child is scheduled to conduct a treatment, such as home exercise

therapy during the schedule outing, the MC is to seek the guidance of
the Lead Medical Coordinator (LMC) or on-call Registered Nurse (RN)
to have the child perform or postpone the completion of the treatment
upon his/her return to the BHCF.
2.3.4. If the child does have a current medication order to be taken and /or
applied during the time of the scheduled outing, the MC will advise the
department responsible for the outing that medication for the child
should be pick up at the medical department, before the outing takes
place.
2.3.5. When medication is taken offsite, a SWK staff member trained in
Assistance in SAOM is to take the prescribed medication in a portable
locked container, kept in a secure location, and to never leave
unattended. An additional SWK staff member certified in Assistance in
SAOM is to escort the children, as one-member assist in the SAOM
process, while the second member, acts as a witness of the entire
process.
2.3.6. The child medication shall be picked up by the assigned staff member,
where the medication container should display a pharmacy label with
clear child and medication information that matches the information
included in a paper Medication Administration Record (MAR) provided
by the medical department. MAR information is to include, child’s
name, name of medication(s), and instructions for administering the
medication, such as, route, dose, and time for self-administration.
2.3.7. The MC is to ensure that the medication is given to the
responsible/authorized staff member who will escort the child off the
facility premises and document the information in a Progress Note on
the child’s medical record in Point Click Care (PPC).
2.3.8. Upon child’s return, based on the information documented on the
paper MAR the MC will transcribed the time, date, and staff member’s
names that assisted in SAOM.

3. Legal/Contract Reference:
▪ R9-10-703. C.
▪ R9-10-712-C.22
▪ R9-10-713
▪ R9-10-718
▪ ORR Policy - 3.4.4 Medication Administration and Management

4. Attached Workflows, Desktop Protocols:

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 Department: Nursing Services
Policy Number NURSING1010.00
Policy Name: Assistance with the Self Administration of
Medication
Creation Date: 12/31/2018 Effective Date: 2/10/2020

▪ Medication List
▪ Paper MAR

Executed and made effective by:

Frank Felix Rosalyn Alcantara, RN

Vice President of Unaccompanied Interim Regional Director of Nursing
Minor Programs, Western Region of Unaccompanied Minor Programs,
Western Region

02/20/2020
On: _____________
Date

Review/Revision History
Description Date Signed
Creation 12/31/18
Revised – added procedural language 01/20/19
Annual review 01/24/2020

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