Covert Medication Administration and the Competent Adult

I am a non-nurse manager at a long-term care facility that employs RNs as part of the health care team. We were recently in the process of completing the admission of a new resident. The resident care coordinator stated that she had been informed by the RN transferring care that in the previous facility the RN staff participated in “covert medication administration.”  The resident, who has been deemed competent, would sometimes refuse to take the medications the physician prescribed; therefore, the physician asked the RNs to tell the resident it was something like a blood pressure pill that he would be willing to take, and the RN staff complied. I am being told by the care coordinator that this practice is considered unethical and does not follow best practices. Please help me understand the ethical and professional obligations for RNs in this situation.

• RNs are accountable and accept responsibility for their own actions and decisions (1).
• RNs challenge and take action on unclear or questionable orders, decisions or actions made by other health care team members (2).
• RNs support and empower clients in making informed decisions about their health care and respect their decisions (3).
• RNs practice in accordance with the current CNA Code of Ethics for Registered Nurses (4) and utilize these principles while administering medications.
• RNs promote and protect a client’s right to autonomy, respect, privacy, dignity and access to information (5).
• RNs apply knowledge of pharmacology and principles of safe medication practice (6).
• RNs build trustworthy relationships with persons receiving care as the foundation of meaningful communication, recognizing that building these relationships involves a conscious effort. Such relationships are critical to understanding people’s needs and concerns (7).
• Professional boundaries are the spaces between the RN’s power and the client’s vulnerability and distinguish the parameters of the therapeutic nurse-client relationship. RNs demonstrate accountability by respecting the power imbalance, and by establishing and maintaining professional boundaries that are client-centered and meet the therapeutic needs of the client (8).
• When the integrity of RNs is compromised by patterns of institutional behaviour or professional practice that erode the ethical environment and the safety of persons receiving care (generating moral distress), RNs express and report their concern individually or collectively to the appropriate authority or committee (9).
• RNs provide persons receiving care with the information they need to make informed and autonomous decisions related to their health and well-being. They also work to ensure that health information is given to those persons in an open, accurate, understandable and transparent manner (10).
• RNs advocate for persons receiving care if they believe the health of those persons is being compromised by factors beyond their control, including the decision-making of others (11).
• Addressing this concern as a team will support the consistent practice of transparent medication administration with the resident. Developing a care plan that acknowledges the client’s right to refuse medications, while establishing clear monitoring and reporting practices ensures effective medication management. By sharing these responsibilities and best practices among all providers, the healthcare team fosters trust- both between the client and the team and amongst team members themselves- leading to improved collaboration and continuity of care. Deviations from this planned care may contribute to mistrust between the resident and the team as well as between team members.

CRNS Resources

CNA Code of Ethics for Registered Nurses (2017)

Registered Nurse Practice Standards (2024)

Registered Nurse Entry Level Competencies (2024)

Medication Management Guidelines: Decision Tree (2021) page 11

Professional Boundary Considerations for Nurse-Client Relationships (2021)