Health Care Department Operations Manual

Chapter 3 – Health Care Operations

Article 5 – Pharmacy and Medication Services

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3.5.29 Medication Administration

Policy
- This policy promotes the health and safety of patients by ensuring the safe administration or delivery and thorough documentation of medications by licensed health care staff.
Responsibility
- Statewide
  - The Deputy Director (DD), Medical Services; DD, Mental Health; DD, Dental Services; DD, Nursing Services; DD, Institution Operations; and Statewide Chief of Pharmacy Services are responsible for the statewide planning, implementation, and evaluation of the Medication Administration policy.
- Regional
  - The regional leadership team is responsible for ensuring adherence to this policy at the subset of institutions within an assigned region.
- Institution
  - The Chief Executive Officer (CEO) is responsible for partnering with all stakeholders to operationalize this policy.
Procedure
- Medication and Patient Verification Procedures
  - Licensed health care staff shall issue, administer, monitor, and document administration or delivery of all medications ordered by authorized prescribers (e.g., physician, nurse practitioner, physician’s assistant, dentist, psychiatrist, podiatrist) within their scope of licensure under California law.
  - Prior to administering medications, licensed health care staff shall:
    - Check each patient’s Electronic Health Record System (EHRS) Medication Administration Wizard or electronic Medication Administration Record (MAW or MAR) for potential allergies.
    - Verify the medication order has not expired.
    - Verify the medication has not expired.
  - Medications shall be prepared by licensed health care staff when the patient presents for their medications at the medication line or window.
  - Prepared medications shall be administered by licensed health care staff on the shift they are prepared.
  - The same licensed health care staff who prepares and administers the unit dose package medication shall document the administration of the medication during the same shift that they are prepared or packaged.
  - At the time of medication administration, licensed health care staff shall ensure that the “Six Rights” are followed (refer to the EHRS Workflow 500-90, Nursing_Care Admin BCMA – Med Line):
    - Right Patient – Medication administration staff shall verify the correct patient by checking the patient’s California Department of Corrections and Rehabilitation (CDCR) picture identification (ID) card and one other patient identifier. In restricted housing units, the patient’s picture ID or bed card with picture should be posted next to the cell door. Custody staff shall be consulted if there is any concern regarding the accurate ID of the patient or need for ID card replacement pursuant to California Code of Regulations, Title 15, Section 3019, Identification.
    - Right Medication – Compare the medication label to the MAW or MAR to verify medication. Barcode scanning shall be employed to verify the medication before administration (including for KOP [Keep-on-Person] and for release medications) unless not possible (e.g., during downtime).
    - Right Dose – Compare the medication label to the MAW or MAR to verify dose.
    - Right Route – Compare the medication label to the MAW or MAR to verify route.
    - Right Time – Compare the medication label to the MAW or MAR to verify time.
    - Right Documentation – Licensed health care staff administering medication shall record the medication administered on the patient’s MAW or MAR directly after administration. The route of administration and injection site shall also be recorded on the MAW or MAR if a medication is administered by injection. Additional information pertinent to the medication administration shall be documented in the health record following statewide-approved workflows, policies, and procedures.
  - Medications ordered on an “AM and PM” or twice daily basis shall be administered with at least eight hours between the two dosing times unless otherwise indicated on the medication order or on the CDC 7221, Physician’s Orders.
  - Hour of Sleep (HS) Medications – When clinically indicated, medications may be ordered at bedtime, or HS. Medications ordered at bedtime, or hour of sleep, shall be administered after 2000 hours.
  - Every effort shall be made to ensure that unit dose medications are not opened until the time of administration.
  - At no time shall medication of any type be slid or placed under the door or between the door and doorjamb of a patient’s cell.
  - If unable to access the EHRS, follow downtime procedures and the EHRS Workflow 500-100, Integrated_Medication Administration Non-Scanning and submit paper MAW or MARs and pertinent documentation to Health Information Management (HIM).
- Medication Administration Times
  - Outpatient (Non-Licensed Units)
    - Medication shall be administered up to four times daily in medication lines with the exception of Fire Camps. A sample administration schedule may include:
      - Morning (AM)
      - Noon
      - Evening (PM)
      - Bedtime, or HS (after 2000 hours)
    - Medications may be administered outside of the time frames identified above at the discretion of the provider.
  - Inpatient (Licensed Bed Units)
    - Inpatient includes beds licensed by the California Department of Public Health, e.g., Correctional Treatment Center (CTC), Mental Health Crisis Bed, Psychiatric Inpatient Program, Skilled Nursing Facility (SNF), and Hospice.
    - Dosages shall be administered within one hour of the prescribed administration time.
    - Drugs ordered “STAT” shall be administered immediately in the nursing unit or within one hour if the medication needs to be obtained from the pharmacy during regular pharmacy business hours.
    - Drugs ordered “STAT” shall be administered immediately in the nursing unit or within two hours if the pharmacy is closed.
    - In the event the medication is not available within the specified time periods, refer to Health Care Department Operations Manual (HCDOM), Section 3.5.24, After-Hours Pharmacy Services, for additional directions.
- Medication Administration Lines – General Population
  - All general population (GP) patients, including those housed in Level IV 180 design units, shall receive all medications at a medication window as a routine function of regular programming. Cell front medication delivery shall not occur in a GP setting unless there is no other reasonable alternative available as determined by the CEO, or designee, in consultation with the Warden or designee.
  - Custody staff shall be present at the designated medication distribution points to directly observe the medication process, maintain order, and provide assistance if necessary.
  - Patients shall bring a cup of water to the designated medication distribution point unless Local Operating Procedures (LOPs) direct otherwise and remove any mask or face covering.
  - Medication lines shall continue until the last patient in line has received their prescribed medication. For all patients who have not received their medications, refer to HCDOM, Section 3.5.30, Medication Adherence.
  - At the conclusion of the medication line, the licensed health care staff who administered the medications shall review the post-medication report, and print as necessary, to identify patients who did not present to the designated medication distribution point to receive their routine medications. The licensed health care staff shall coordinate with custody staff to attempt to locate the patient for:
    - Medication administration.
    - Documentation of refusal of medication and the reason for refusal on the MAW/MAR.
    - Documentation of barriers that prevented the patient from presenting to the medication line.
- Medication Administration at Cell Front – Restricted Housing Units
  - Custody staff shall accompany licensed health care staff on medication administration rounds to facilitate opening of the food port or the cell door, if necessary, for administration of medications.
  - The patient shall be instructed to turn on the light, bring a cup of water, remove any mask or face covering, and come to the cell front to be clearly visible.
  - Licensed health care staff shall provide the patient’s oral medication through the opened cell door, food port, or bars of the cell door. At the request of licensed nursing staff, custody staff shall open cell doors during medication administration to permit reasonable visualization of the patient’s ingestion of medication.
  - At no time shall medication of any type be slid or placed under the door or between the door and doorjamb of a patient’s cell.
  - Medication administration shall continue until all patients in the unit with prescribed medications have received or refused the prescribed medication.
- Medication Administration During Lockdown or Modified Program
  - When the state of the lockdown or modified program is such that no movement is permitted, medication administration may occur at the cell front or podium pass until restrictions on movement are adjusted to the extent that once again permit patient access to the medication window.
  - If GP patients on lockdown or modified program are provided any yard access, programming, or receive their meals in the dining facility, they also have access to the medication window to receive their medication. Health care shall confer with custody management to determine the safest way to distribute medication.
  - The institution shall work towards routine medication delivery promptly, and this shall be discussed at the daily Program Status Report meetings between health care and custody managers. When the lockdown or modified program is more than 14 days, the institution shall notify the Regional Health Care Executive and Associate Director, Division of Adult Institutions, and any medication delivery concerns not resolved at the institutional level shall be addressed at this meeting.
  - The method of medication delivery for the above concerns shall be determined or approved by the CEO, or designee, in agreement with the Warden, or designee.
- Methods of Medication Administration or Delivery
  - Recommendations on selecting a medication administration or delivery type is available on Lifeline at https://cdcr.sharepoint.com/sites/cchcs_lifeline_pharmacy/SiteAssets/SitePages/Best-Practices/kopnadot-recommendations.pdf
  - Directly Observed Therapy (DOT)
    - Required for patients:
      - Receiving medications with Penal Code (PC) 2602 or PC 2604 court orders or other court-ordered process.
      - Receiving any Drug Enforcement Administration (DEA) controlled substances except those used in the treatment of substance use disorder and approved for KOP by the Systemwide Pharmacy and Therapeutics (P&T) Committee.
      - Receiving medications on the Systemwide P&T Committee Mandatory Crush/Open List.
      - Receiving medications for active tuberculosis (TB) or suspected TB disease.
      - Receiving medications for latent TB infection.
      - Whenever specified by the prescriber.
    - DOT Procedure
      - The patient shall present to the medication line (GP) or the cell front (restricted housing units) with a cup of water and remove any mask or face covering.
      - Licensed health care staff administering medication shall verify the patient’s identity and use the “Six Rights” of medication administration by following the steps outlined in Section (c)(1)(F).
      - Licensed health care staff shall provide the prescribed oral medication to the patient and observe the patient take the oral medications into their mouth and swallow all pills followed by an adequate amount of water. The patient shall remain clearly visible to health care staff.
      - Licensed health care staff, with assistance from custody staff as needed, shall verify that the patient swallowed the medications by completing a visual mouth check, viewing the empty cup, and other checks as indicated.
      - If staff cannot verify that the patient swallowed the medication and followed all steps of the above procedure, licensed health care staff shall request that custody staff escort the patient to an area with clear visibility where medication administration can be verified.
    - Orders for DOT administration of medications that are not required per pharmacy policy to be DOT shall have clinical justification for DOT documented in the health record. Before determining the means of administration, the provider shall consider the following:
      - Potential for self-harm.
      - Potential for diversion.
      - History of non-compliance or overdosing.
      - Problems with medication adherence.
      - Recent history (within the past year) of suicidal ideation, threats, or attempts.
    - “Crush/Open and Float” Requirements
      - It is the policy of California Correctional Health Care Services to administer oral medications with significant potential for diversion as “crush/open and float” when product formulation permits. The Systemwide P&T Committee shall maintain the current list of such medications.
      - Strict adherence to this policy is required from all licensed health care staff administering “crush/open and float” medications.
    - DOT Procedure for Sublingual DEA Controlled Substances
      - The patient shall present to the medication line (GP) or the cell front (restricted housing units) with a cup of water and remove any mask or face covering.
      - Licensed health care staff administering medication shall verify the patient’s identity and use the “Six Rights” of medication administration by following the steps outlined in Section (c)(1)(F).
      - Licensed health care staff shall administer the sublingual DEA controlled substance after all other prescribed medications have been taken.
      - Licensed health care staff administering medication shall have the patient wet their mouth with a small drink of water before administration.
      - Licensed health care staff shall observe the patient take the sublingual DEA controlled substance into their mouth, and the patient shall be instructed not to chew, swallow, talk, or open their mouth while the medication is dissolving. The patient shall remain clearly visible to health care staff.
      - Once the medication is administered, licensed health care staff shall provide face-to-face patient education or instruction to ensure initiation of the dissolution process over the recommended observation time.
      - Observation of the sublingual medication (e.g., buprenorphine-naloxone sublingual film) entering the mouth and completion of the face-to-face education or instruction to initiate dissolution as outlined shall satisfy the verification of administration as required by the DOT procedure in Section (c)(5)(A)2.
  - Nurse Administered (NA)
    - NA is required for patients:
      - Who cannot safely or properly self-administer medications.
      - Who are receiving medications required by policy to be NA.
      - Whenever specified by the prescriber.
    - NA Procedure
      - The patient shall present to the medication line (GP) or the cell front (restricted housing units) with a cup of water and remove any mask or face covering.
      - Licensed health care staff administering the medication shall verify the patient’s identity and use the “Six Rights” of medication administration by following the steps outlined in Section (c)(1)(F).
      - The licensed health care staff shall give the medication to the patient, observe the patient take the oral medications into their mouth followed by an adequate amount of water and swallow all pills. The patient shall remain clearly visible to health care staff.
      - If staff cannot verify that the patient swallowed the medication and followed all steps of the above procedure, licensed health care staff shall request that custody staff escort the patient to an area with clear visibility where medication administration can be verified.
  - KOP: Self-Administered
    - Patients receiving prescribed KOP medications shall be able to produce a valid current label for each medication.
    - All inhalers shall be refilled on a one-to-one exchange basis. If the patient does not return their inhaler, a new inhaler shall be issued and custody shall be notified for assistance in locating the missing inhaler.
    - Patients shall be notified that their KOP medications are available for pick up at the medication window. Notification methods may include:
      - Posting the KOP Ready List at the clinic for patients whose KOP medications are available for pick up.
      - A verbal notification to the patient.
      - Contacting the housing officer to announce that the patient should report to the medication line.
      - Providing a KOP Ready List to the program offices for distribution to the housing units.
      - KOP medications for patients in restricted housing units shall be delivered during medication administration rounds in accordance with their LOP.
    - In the event a patient does not pick up the KOP medications within four business days of the medication becoming available, the licensed health care staff shall utilize the institution’s established process in accordance with their LOP to ensure the patient reports to the medication line to accept or refuse the medication. These processes may include:
      - Ducating the patient to the medication line.
      - Notifying custody staff to have the patient escorted to the medication line.
    - Documentation on the MAW or MAR shall indicate patient receipt or refusal of the KOP medication.
      - Medication administration.
      - Documentation of barriers that prevented the patient from presenting to the medication line.
    - Patients who refuse KOP medications shall be referred to the prescribing provider for appropriate management.
  - Parenteral Medications
    - Licensed health care staff shall record the route of administration and injection site on the MAW or MAR. The MAW or MAR shall include the following:
      - Patient name
      - CDCR number
      - Prescription number
      - Date, time, and signature of the licensed health care staff administering the medication
      - Injection site
    - Parenteral medications shall not be administered through the food port or cell bars. If a patient requires medication to be administered by injection and self-administered injection as referenced in (c)(6)(D)(4) below has not been approved, custody staff shall have the patient escorted to an injection room or clinical space in the housing unit (if available) or to the clinic where the licensed health care staff can safely administer the medication. If these options are not available, custody staff shall escort the patient from the cell to a safe and appropriate location as designated by the CEO and Warden.
    - Injections shall be drawn at the time of administration. In the case of mass vaccination campaigns, a small quantity of the injections may be pre-drawn no more than one hour prior to administration. Each licensed health care staff may draw a small quantity of vaccine to meet the initial needs of the clinic, but no more than can be administered in one hour.
    - Self-Administered Injections
      - After demonstrating self-injection skills, patients on insulin may self-inject while under close observation by a licensed nurse. Nursing staff shall prepare the insulin for administration, observe the injection, and record on the MAW or MAR.
      - After administration, custody staff shall observe the patient placing any needles and syringes directly into the sharps container.
      - Patients shall never self-inject DEA controlled substances.
    - Injectable DEA Controlled Substances
      - Consider using when medication adherence or misuse concerns exist (e.g., cheeking, diversion).
      - Prior to considering injectable DEA controlled substances for a patient, health care staff shall:
        
        Conduct an investigation to understand the facts of the suspicion,
        
        Meet with the patient,
        
        Seek case consultation through use of Care Team Education Conferences,
        
        Consider alternative medication types via existing procedures, and
        
        Document the outcome of the above steps in a progress note in the health record.
    - Infusions
      - Infusions shall occur in specialized beds (e.g., CTC, SNF, Outpatient Housing Unit, Triage and Treatment Area, Hospice) or other areas with approval by the Systemwide Medication Management Subcommittee.
      - Intravenous therapy shall only be conducted by authorized staff in accordance with licensure and scope of practice.
      - Whenever possible, closed systems (e.g., ADD-Vantage, Mini-Bag plus) should be used. Intravenous medication prepared at bedside shall be administered according to manufacturer’s recommendations as close to the administration time as possible within the standards from USP General Chapter <797>, federal and state regulations, etc.
      - If unavailable, the intravenous medication may be ordered and prepared by a state-contracted sterile compounding vendor.
  - Administration of medications by a contracted narcotic treatment program (NTP)
    - The contracted NTP shall:
      - Supply patient-specific medications.
      - Administer patient-specific medications.
      - Record the administration and submit the medication administration record to the designated health care staff.
    - The health care staff member shall forward the record to HIM to scan into the health record.
- Involuntary Medication Administration
  - Emergency medication may be administered to a patient who cannot or does not consent, without obtaining a court order, in response to a life-threatening medical or psychiatric emergency. Emergency medications shall only be ordered per episode and for only as long as the emergency exists. In such cases, immediate intervention may be necessary for the safety of the patient or others.
  - Involuntary psychiatric medications may be continued beyond 72 hours by filing a petition for involuntary treatment. This requires an ex-parte order that allows that medications be continued beyond 72 hours.
  - In most cases, patients comply with the court order and take medications without incident. Such administration is expected to be completed with the least reliance on force.
    - PC 2602
      - Certain patients are under court order to receive involuntary administration of mental health medications.
      - Medications ordered under PC 2602 are administered NA (for injectable medications) or DOT (for oral medications).
      - The PC 2602 Coordinator shall forward a list of all patients under PC 2602 orders to designated personnel.
    - The provider shall denote PC 2602 on the medication order such that the licensed health care staff administering medications is aware of those patients under court order for involuntary medication administration.
    - PC 2604
      - In rare circumstances, there may be a patient for whom a court order has been issued for involuntary medical treatment which may include medications.
      - Medications ordered under PC 2604 are administered NA (for injectable medications) or DOT (for oral medications).
      - Institution medical management shall inform designated personnel of patients with PC 2604 orders.
  - In situations where a patient refuses their court-ordered regularly scheduled medication (under PC 2602 or PC 2604), backup medications may need to be administered. This may, after clinical supervisory review, require a controlled use of force team to enter the cell, physically restrain the patient while medications or treatment are administered, and exit the cell with the least reliance on force. In these cases, all of the requirements of controlled use of force pursuant to the CDCR, Department Operations Manual, Sections 51020.12 Controlled Use of Force General Requirements and 51020.12.4 Controlled Use of Force in Health Care Facilities, and efforts by clinical and custody staff to talk the individual into complying with the medication order remain in effect.
References
- California Business and Professions Code, Division 2, Chapter 9, Article 2, Section 4016
- California Penal Code, Part 3, Title 1, Chapter 3, Article 1, Section 2602
- California Penal Code, Part 3, Title 1, Chapter 3, Article 1, Section 2604
- California Code of Regulations, Title 15, Division 3, Chapter 1, Rules and Regulations of Adult Operations and Programs
- California Code of Regulations, Title 15, Division 3, Chapter 1, Article 1, Section 3019, Identification
- California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 4, Article 5, Section 3317.2(a)(1)
- California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79635(a)(7)
- California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79649(a)(1)(A)
- US Pharmacopeia, USP General Chapter <797> Pharmaceutical Compounding – Sterile Preparations 2019
- Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.8, Prescription/Order Requirements and Medication Availability
- Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.24, After-Hours Pharmacy Services
- Health Care Department Operations Manual, Chapter 4, Article 1, Section 4.1.3, Medical Evaluation for Assaults, Cell Extractions, and Use of Force
- California Department of Corrections and Rehabilitation, Department Operations Manual, Sections 51020.1 through 51020.24
Revision History
Effective: 10/2008
Revised: 11/18/2025