The concerns for staff privacy and camp safety are addressed in the issue of how to store, handle, and document the use of prescription medication by staff members who are eighteen or older. When staff bring medication from home, how are camps preserving the staff member’s privacy and still insuring the safety and security of all camp residents — other staff and campers, as well? In the following discussion, three camp health-care experts share how their respective camps are handling this concern.
Does your camp require that staff who are eighteen and older store their prescription medications in the health center?
Mary Marugg — Yes. By state regulation, staff who are with campers may not keep their medications with them. We require other summer staff to keep their prescription meds in the health center, as well, because we are responsible for the health care of these folks and want to know what meds they are on and their medication schedule. For those who take PRN, or “as needed” medications, we want to know how often they are taking them, the dosage they’re taking, and what triggers their need to take these meds.
Linda Erceg — We also require that staff medications be kept in the health center. Our staff live with campers in a youth-centered environment. We do not have a secure, staff-only place for staff medication storage and don’t want our villagers to have access to medications via the staff members’ supply. Additionally, our program provides health care to staff. Consequently, we have a need to know what medications they are taking. Should something inadvertent happen to a staff member, we’d like to know what medication(s) they have been taking. Because we are a residential program, we recognize that some medications have side effects (like sleepiness). It is crucially important to know what our staff is taking so our expectations of staff are appropriate.
How are these medications stored for security?
Mary Marugg — Staff medications are stored under lock — it’s a combination lock that they can access when needed. Controlled substances (narcotics or Ritalin, for example) may be accessed only through the health-care staff. Camper meds are stored separately.
Linda Erceg — We store our medications in our health centers’ locked medication cabinets. Our health centers also have lockable front doors.
Stuart Weinberg — As a doctor, I look at the storage of medications as accomplishing three purposes: providing special storage needs as required (refrigeration, etc.), preventing access to the medication to those for whom it is not intended, and insuring appropriate use (and not abuse) of the medication by those for whom it is intended. These are all safety issues involving any medication at camp. I think camps can appreciate the importance of each issue by considering their liability in the following situations: What if a medication is stored inappropriately, resulting in a change in its effectiveness and a possible bad medical outcome? What if a medication is used by someone other than for whom it’s intended and there’s a bad outcome? What if a medication is underused or overused by the person for whom it’s intended and there’s a bad outcome? Despite the need to store medications for safety reasons, this must be balanced with the need to have appropriate access to medications when necessary, especially when the timing of the medication is critical. Epi-pens, albuterol inhalers, and certain migraine medicines are examples of time-critical medications where a delay can result in a bad outcome. The issue for these time-critical medications then becomes how to make sure a person can get to these medications without delay, but still considering the three safety precautions mentioned above. If a person is allowed to carry medications with them or store them with their own property, care still needs to be taken that the storage is appropriate, that other people can’t get to them (either in the cabins or in activity areas), and that the medications are used appropriately.
Given the concerns you’ve just described, Dr.Weinberg, how would you deal with staff medication?
Stuart Weinberg — I think there are distinctions that can be made in the type of staff that are on-site during the summer. There are the year-round staff — usually older, some professional — who most likely have their own living quarters that are off-site and/or off limits to normal camp activities. I think that appropriate storage and use of medications is their own responsibility. There may be more senior summer program directors or activity directors who also have their own living quarters, where storage of medications where they are living is perhaps appropriate. And then there are the summer camp staff who live in the cabins with the campers, where safety precautions are very important. Again, looking at the liability issues may help clarify what policies are appropriate for different types of staff. Clearly, the greater chance there is for inappropriate access to medications by unauthorized people, the greater the liability camp may have if there is a bad outcome.
Do you require documentation that medication has been taken?
Linda Erceg — Yes. Both daily meds and PRNs are documented. Daily meds are documented on our Daily Medication Record after noting that they have been received during staff health screening. PRNs are documented on the individual’s health record as dispensed. Documentation about medication includes the reason for using the medication and an evaluation of the medication’s effect.
Mary Marugg — There is a medication sheet on which staff document the meds they are taking themselves. This is our requirement because state regulation does not address documenting medications given to staff. It does require that the medications are inaccessible to children.
Stuart Weinberg — In today’s medicolegal world, if it wasn’t documented, it didn’t happen. Therefore, documentation becomes very important when one is placed in a position of having to defend medical issues. There have been a lot of discussions on the camp nurse e-mail list about methods of documentation, including confidentiality, use of computers, use of forms, etc. As long as the medical staff is aware that a medication has been administered, there are several current options on how that documentation can be performed. A concern, however, is how to get information about self-administered medications. Consider the following scenario: A person with mild asthma has his own inhaler. One day he has a seizure with a bad outcome, and it is later determined that he had been using his inhaler excessively for a few days, but the camp had no knowledge of this. Is the camp liable? Could the medical staff have intervened earlier if it had known about the inhaler use? Should there be some type of documentation for all self-administered medications — or for a subset of those with potential complications? It might be wise to develop a system where this information can be obtained — either a self-documenting logbook or periodic contact by the medical staff to check in. “Have you had to use your inhaler in the past few days?”
Is the documentation confidential and, if so,how do you insure this?
Linda Erceg — Documentation is confidential within the parameters described by our program’s health care plan. For example, our nursing staff and deans have access to all health records; parents have access to the record specific to their child; and staff who are legal adults have access to their own health records. Confidentiality is controlled — I hesitate to say “assured” — by limiting access to individual records to the people described above and dispensing medication so only our health-care staff and the person taking the medication know what is given. Medication envelopes are handled by health care staff.
Mary Marugg — Documentation is not confidential for each individual, because other staff accessing their meds may see the documentation sheet. If the individual requests confidentiality, or the medication is of a nature where confidentiality is important, then the records are kept confidential.
Stuart Weinberg — Staff members may be reluctant to store their prescription medications with the camp medical staff for reasons of confidentiality. Certain medications are associated with specific conditions, which might be embarrassing to staff if those conditions were not kept private. Camps can make efforts to insure confidentiality not only with their staff, but with campers as well. Logbooks that document the reasons for a wellness center visit should be viewed only by the medical staff and not open for other campers or staff to read. To avoid the reading of private prescriptions by unauthorized staff, prescription medications should be stored separately from over-the-counter medications, if non-medical staff have access to the latter.
Are medications self-administered, or do staff have to get their medication from the camp’s medical staff?
Mary Marugg — Our staff may access their medications without the health-care staff being present — unless they are controlled substances. They are required to document date, time, and dosage. Occasionally, there is a medication or circumstance — if monitoring of a health condition is important or monitoring the therapeutic effect of the medication is an issue or the staff member is unreliable or it is a controlled substance — where the only way the staff member can access his or her meds is through camp health care staff.
Linda Erceg — We don’t have medical staff on site. Our staff get their medication from our health-care staff — a team that is overseen by at least one registered nurse. Staff meds are administered from the health center and, generally, per request of the staff member. A qualifier is there because we (nursing) assess for appropriateness, but the bottom line is that staff who are legal adults have a right to access their medication(s). We administer stock medications to staff per protocol from our supervising physician.
Has your camp ever had a problem with staff medication? If so, how did you handle this problem?
Linda Erceg — My response varies depending on whose perspective I respond from. Camp nurses see different challenges from staff – staff see it differently than the camp director, and so forth. I think it is important to examine this question from the perspectives of all vested parties. For example, I think it is important that staff know — prior to arrival at camp — how medication, especially their personal medications, will be managed. This minimizes surprised reactions when staff are told the camp’s medication management policy during orientation. Staff have a right to know who has access to their health information and why. Finally, staff should be told what is considered “medication” by the camp. This is taking on greater importance as more complimentary remedies come to camp with staff and as the number of international staff grows. I think we also need greater sensitivity to the way staff interact with the camp’s health center. If they are expected to seek care only at designated times and they happen to be assigned some camp responsibility during those times, accessing their medication or any health care becomes both a challenge and a frustration. This kind of situation needs attention. Simply letting staff know when and how health care is available to them — especially access to medication — may help. I’ve run across a few situations where the person’s ability to access his or her medication immediately impacted quick resolution of a problem. For example, folks who get migraines often use a prescription medication called Imitrex. If they get that medication during the preliminary phase of their migraine — like RIGHT NOW — they can often stop the migraine from progressing. Here’s where having immediate access to one’s medication makes a huge difference. I’ve started giving these staff members what I call a “pocket pack.” We put one dose of their medication in an appropriately labeled pill envelope for them to keep in their pocket. Then the staff member has immediate access and the medication remains in the “controlled possession of the person responsible for administering” it (Standard HW-18). Sometimes there’s a problem for the nurse regarding staff medications. In all other practice settings, nurses reinforce clients’ responsibility for their medication(s). A nurse generally doesn’t pass medication unless the person is incapable of assuming that responsibility (some children, hospitalized people, etc.). Since most camps employ responsible staff, it comes as a surprise when the nurse learns she or he must pass medications to the staff, too. There may well be sound reasons for doing so, but camps neglect to inform the nurse who, in turn, feels as though health promotion has just taken a giant step backward. Just as staff should know about the camp’s medication management system, so too should the nurse. This knowledge should include the reason why things are being done in the way that they are.
Mary Marugg — At one time, there was the question of whether staff were inappropriately accessing camper medications (Ritalin). This was when staff meds were stored with camper meds, and staff were allowed to access their own meds. We moved the staff meds to a separate locked area from the camper meds. Controlled substances (narcotics and Ritalin, for example) may only be accessed through the health-care staff.
Do you have any recommendations on how camps should handle staff prescription medication safely and securely?
Mary Marugg — Know what your state regulations require. The level of credential of health-care staff is important — Are the health care staff M.D.s, R.N.s, or first-aid staff with a credential to administer medications? If health-care staff are responsible for the health care of the entire staff, they should know the medication schedule and the required compliance to that schedule for each staff member.
Linda Erceg — I have several recommendations. Camper safety ranks high, so any system should address this as a priority. I think day camps have a different profile regarding staff medication than residential camps insofar as residential camps retain in loco parentis responsibility on a twenty-four-hour basis. Since some medications have side effects that may impact a staff person’s ability to function, resident camps have a different “need to know” than our day camps. One also has to consider the maturity of staff (risk assessment). Some are quite reliable — they’d follow camp protocol regarding security of medication quite responsibly. Others are not. We typically do not have a way of knowing this prior to getting staff on site; hence the camp develops a system best suited to anticipated needs. The emerging young adult — those folks who make up the bulk of the camp staff population — have some developmental challenges that make “handling medication safely and securely” a tough call. Since camper safety is the bottom line for many of us, using a system with appropriate checks pertinent to that safety makes good sense.
Stuart Weinberg — I’d like to emphasize some of the things that I think are important. Prescription medications that are brought to camp by staff need to be stored appropriately and securely to avoid access by unauthorized individuals. There may be situations where senior staff members with their own living quarters can keep their medications with them, but camps should be aware of potential liabilities if the medications are being used inappropriately, and there is a bad outcome. Camps should also recognize that there are some time-critical medications to which staff may need immediate access, and policies should be developed to arrange for appropriate storage and documentation of these medications if used. Efforts to insure confidentiality may reduce staff reluctance in keeping their prescription medications at the wellness center.
Mary Marugg, Health care supervisor
Linda Ebner Erceg, R.N., M.S., P.H.N.