RANDOLPH COUNTY SHERIFF'S OFFICE

6.2.1 PURPOSE

The purpose of this Standard Operating Procedure is to establish standardized guidelines for the safe, secure, accurate, and consistent storage, handling, and distribution of medication to detainees. This procedure is intended to:

• Minimize risk to detainee health and safety

• Ensure staff accountability

• Maintain compliance with applicable laws and regulations

• Reduce agency liability associated with medication errors or improper administration

6.2.2 POLICY

It is the policy of the Randolph County Detention Center that all pharmaceuticals shall be managed in a controlled, secure, and medically supervised manner to ensure proper storage, accountability, distribution, and utilization.

All personnel assigned to medication distribution shall strictly adhere to established procedures. Medication administration shall be conducted with a high degree of accuracy, direct observation, and accountability. Any deviation from this procedure is strictly prohibited.

Southern Health Partners, Inc. shall be responsible for the ordering, storage oversight, and medical direction of pharmaceutical services within the facility.

6.2.3 SCOPE

This procedure applies to all sworn and non-sworn personnel assigned to, assisting with, or supervising medication distribution within the facility, including temporary or relief assignments, and medical personnel contracted through Southern Health Partners, Inc.

6.2.4 PROCEDURES

A. Regulatory Compliance and Medical Authority

1. All pharmaceutical practices shall comply with regulations established by the State Board of Pharmacy and applicable federal and state laws.

2. Medications shall be distributed only as prescribed by authorized medical personnel from Southern Health Partners, Inc.

3. Detention center staff may distribute medication only under the direction and authority of the detention center nurse or authorized medical provider.

B. Detainee Identification Verification

1. Staff shall positively identify each detainee prior to medication administration.

2. Identification shall include:

2. • Visual confirmation of the detainee

2. • Verification against the Medication Administration Record (MAR) or approved log

2. • Confirmation that the detainee matches the name on the medication packaging or order

3. Identity verification shall be conducted prior to each dose without exception.

C. Medication Preparation

1. All medications shall be prepared in accordance with the prescribing authority and facility protocol.

2. Medication shall be placed in a disposable medication cup.

3. Oral medications shall be floated in water prior to issuance unless otherwise directed by medical staff.

D. Observed Ingestion (Direct Observation Requirement)

1. The issuing officer shall maintain direct visual contact during ingestion.

2. The officer shall observe and confirm that the detainee:

2. • Places the medication in their mouth

2. • Swallows the medication completely

2. • Does not conceal, pocket, or “cheek” medication

3. The officer shall not proceed to the next detainee until ingestion is confirmed.

E. No Walk-Offs / Retention Prohibition

1. Detainees shall not be permitted to leave the medication distribution area with medication in their possession.

2. All medication shall be consumed in the immediate presence of the issuing officer.

3. Any attempt to retain medication shall result in immediate intervention and documentation.

F. Controlled Distribution Environment

1. Medication distribution shall occur in an orderly, secure, and supervised setting.

2. Detainees shall comply with staff direction and form a line when instructed.

3. Any detainee attempting to bypass procedures shall be redirected.

4. Failure to comply with lawful commands may result in corrective action, including lockdown if authorized by a supervisor.

G. Storage and Security of Pharmaceuticals

1. All medications, particularly controlled substances, shall be securely stored in designated, locked areas.

2. Access to pharmaceuticals shall be strictly limited to authorized personnel.

3. The Detention Center Nurse and Administrator shall ensure compliance with all storage and security requirements.

H. Inventory and Control Measures

1. The Detention Center Nurse shall conduct and document weekly inventories of:

1. • Controlled substances

1. • Syringes

1. • Surgical instruments

2. Any discrepancies shall be immediately reported and investigated.

I. Over-the-Counter (OTC) Medications

1. The Detention Center Nurse shall maintain an approved stock of OTC medications.

2. OTC medications shall be distributed only under the direction of medical staff.

6.2.5 TRAINING AND SUPERVISION

1. All new personnel shall receive training in medication distribution procedures in coordination with medical staff.

2. No personnel shall conduct medication distribution independently.

3. Medication distribution shall be conducted under dual control at all times.

4. Supervisors are responsible for ensuring personnel are trained, compliant, and properly supervised.

6.2.6 DOCUMENTATION AND ACCOUNTABILITY

1. All medication distribution shall be documented in the approved log or electronic system.

2. Documentation shall include:

2. • Detainee name and identification number

2. • Medication name, dosage, and time administered

2. • Initials or signature of administering officer

2. • Any refusal, incident, or irregularity

3. Staff shall verify ingestion in accordance with established procedures.

6.2.7 INCIDENT ACCOUNTABILITY

1. Any medication error, including misidentification or incorrect issuance, shall be immediately reported to a supervisor and documented.

2. Medication errors are considered serious safety breaches and may result in:

2. • Immediate review and investigation

2. • Mandatory retraining

2. • Administrative action based on severity

6.2.8 DISCIPLINARY ACTION

Failure to comply with this SOP will result in disciplinary action up to and including termination.

• First Violation: Counseling, documented reprimand, and/or retraining

• Second Violation: Suspension or progressive discipline

• Gross Negligence or Willful Misconduct: Immediate suspension pending investigation and potential termination

Supervisors who fail to enforce this SOP or allow non-compliance are subject to disciplinary action.

6.2.9 EFFECTIVE DATE

This Standard Operating Procedure is effective immediately and applies to all personnel, assignments, and shifts without exception. Supervisors are responsible for ensuring full compliance and enforcement.