Medications in Care Homes: Rights, Oversight and As-Needed Medication

When they move into a care home, many people hand over something they have organised themselves for years: their medicines. Suddenly nursing staff set out the tablets, an unfamiliar pharmacy delivers, and the plan lists an “as needed” medicine that nobody quite knows how often it is given. Responsibility is shared — but the rights stay with the person concerned. This guide shows you who decides what in a care home, what rights residents and their relatives have, and which questions you should ask about as-needed medication.

1. Who does what? The roles in medication in a care home

In a care home, the supply of medicines rests on several shoulders. Anyone who knows the roles also knows whom to approach with which question.

Two principles apply in a care home too: the free choice of doctor — the existing GP practice can continue to provide care if it makes home visits — and the free choice of pharmacy. Care homes do conclude supply contracts with a pharmacy, but the German Pharmacies Act (Apothekengesetz) requires that residents’ free choice of pharmacy is preserved.^¹ In practice, the pharmacy supplying the home is usually the most convenient solution, because delivery, blister packing and coordination with the nursing staff are well established. There is, however, no obligation to use it.

2. Your rights — and those of your relatives

Anyone who moves into a care home remains a patient with all their rights. The Pflege-Charta (Charter of Rights for People in Need of Long-Term Care), published by the German Federal Ministry for Family Affairs and the Federal Ministry of Health, summarises them, including the right to self-determination, to information and to professional medical care.^² For medicines, this means in concrete terms:

• Information: what is a medicine for, which side effects are to be expected, what alternatives are there? This has to be explained understandably — before a treatment starts.
• Consent and refusal: no medicine may be given against the will of a person who has capacity to consent. Anyone who refuses a tablet is entitled to do so — the nursing staff document it and inform the practice.
• Access to records: residents can in principle ask to see their medical records and the nursing documentation. Relatives need a power of attorney or the consent of the person concerned to do so.
• Independence: anyone who can still manage their medicines safely themselves and wants to do so does not automatically have to hand them over. This is agreed with the home and the practice.
• Protection against deprivation of liberty: medicines may not be used to sedate someone unless the strict legal requirements are met (more on this in section 7).

3. When moving in: hand over the medication properly

The move into a care home is a critical moment. Often the new resident comes straight from hospital, with a discharge letter that does not match the tablet boxes at home. Mistakes that arise here often carry on for months. This is how the handover succeeds:

1. Bring an up-to-date medication plan. Anyone who takes at least three prescribed, systemically acting medicines long-term is entitled to the nationwide standard medication plan (bundeseinheitlicher Medikationsplan) from their GP practice.^⁴ What a good plan looks like is shown in the guide Create a medication plan.
2. Put everything on the table. Over-the-counter products, eye drops, ointments, patches, food supplements and sleep aids also belong on the list — otherwise they are easily overlooked.
3. Name allergies and intolerances, with the active substance names and the type of reaction.
4. Have the hospital discharge letter reconciled. Were medicines switched, stopped or newly started in hospital? The GP practice should confirm the list once and for all.
5. Clarify responsibilities: which practice provides care in the home? Which pharmacy delivers? Who is the contact person among the nursing staff?
6. Keep a copy. As a relative, keep a copy of the current plan — that way you will notice when something changes.

4. Setting out, giving, documenting: everyday life in the home

In most homes, the medicines are set out individually for each resident — either by qualified nursing staff in dosette boxes or already by the pharmacy in individually blister-packed pouches or strips. Every dose is documented: what, when, how much, by whom. Narcotics are kept locked away separately and every dose is fully accounted for.

Crushing tablets and swallowing problems

Many older people find large tablets hard to swallow. Crushing them is then the obvious idea, but it is not always allowed: prolonged-release tablets, gastro-resistant tablets and some other dosage forms lose their effect as a result or become dangerous. Whether a tablet may be split or crushed is something the pharmacy knows — more on this in the guide Splitting tablets. There are often alternatives such as drops, liquids, orodispersible tablets or patches that the practice can prescribe.

5. As-needed medication: what a good instruction must contain

Besides the fixed medicines, almost every care home medication plan also lists medicines “as needed”: a painkiller, a laxative, something for nausea — and often also a sleeping pill or sedative. The idea makes sense: the nursing staff can respond without having to reach the practice every time. The catch: when there is a “need” is decided in everyday practice by the nurse — and that only works if the doctor’s instruction is unambiguous.

A good as-needed instruction answers these questions in writing:

Every dose of as-needed medication is documented — ideally with the reason and the effect observed. It is precisely this documentation that is your best starting point if you want to know what is actually happening.

Five questions you can ask about as-needed medication

• What exactly has this as-needed medicine been prescribed for — and how do the nursing staff recognise the need?
• How often has it been given in the last four weeks, and at what times of day?
• With what effect? Was the effect documented — and were there side effects such as tiredness or falls?
• What was tried beforehand? Are there non-drug measures that are used first?
• When was the instruction last reviewed by a doctor? And is a medicine that is needed almost every day still correctly classed as “as needed”?

The latter is a common pattern: a painkiller “as needed” is given every evening. Then a regular, well-planned pain treatment may make more sense — conversely, a sedative that is never needed can come off the list. The treating practice decides.

6. Sedatives and antipsychotics: take a close look

Restlessness, wandering at night, calling out or aggression are — especially in dementia — among the most stressful situations in everyday care home life. The temptation to dampen them with medicines is great. The guideline is unambiguous here: first the causes are looked for and non-drug treatment is used.^⁵

Behind restlessness there are often treatable triggers:

• Pain that someone with dementia can no longer put into words — for example from osteoarthritis, teeth or pressure sores
• Infections, for example a urinary tract infection, or an incipient delirium (acute confusion)
• Constipation, urinary retention, thirst or hunger
• Side effects of other medicines
• Anxiety, boredom, noise or unfamiliar surroundings

Antipsychotics such as quetiapine are frequently used in older people with dementia, even though an increased risk of strokes and increased mortality is known for this group. The guideline therefore recommends them only if non-drug measures are not enough — at the lowest possible dose, for as short a time as possible and with regular attempts to stop them.^⁵ For the treatment of persistent aggression in Alzheimer’s dementia, only a single active substance is approved, and only for a short treatment period.

Benzodiazepines such as lorazepam and Z-drugs such as zolpidem increase the risk of falls, confusion and dependence in old age. The PRISCUS 2.0 list classifies many of these active substances as potentially inappropriate for older people.^⁶ Which alternatives exist is described in the guide Sedatives: alternatives to benzodiazepines.

7. When medicines become a deprivation of liberty

A medicine that is given so that someone no longer gets up, no longer walks around or cannot leave the ward is, legally, no longer simply treatment. It can be a measure depriving a person of liberty — just like a bed rail or a restraint belt. Professionals then speak of “chemical restraint”.

German guardianship law sets narrow limits for this:^³

• People with capacity to consent decide for themselves — without their agreement such a measure is not permitted.
• If the person lacks capacity to consent, the attorney or court-appointed legal representative must agree, and for repeated or longer-lasting measures, approval by the guardianship court (Betreuungsgericht) is usually needed as well.
• Making things easier for staff or staff shortages are not a permissible reason.
• Less restrictive means — accompaniment, activities, low-floor beds, sensor mats — take priority.

In an individual case, the line between treating distressing restlessness and sedating someone is not always easy to draw. The key question is: who does the medicine benefit? If you have the impression that someone is mainly meant to be made “easier to care for”, speak directly to the head of nursing (Pflegedienstleitung) and the practice.

8. Warning signs of too many or unsuitable medicines

Care home residents often take many medicines at the same time. Every additional tablet increases the risk of interactions and side effects — and new symptoms are easily dismissed as “old age”. You should sit up and take notice if you see:

• increasing daytime sleepiness or apathy
• new or worsening forgetfulness and confusion
• falls, unsteadiness when walking or dizziness on standing up — see also Dizziness from medications
• loss of appetite, a dry mouth, constipation or problems passing urine
• trembling, stiff movements or a fixed facial expression

A well-known pattern is the prescribing cascade: a side effect is interpreted as a new illness and treated with a further medicine. Background is explained in the guides Medications in old age and Polypharmacy.

9. Have it reviewed regularly: medication review and stopping medicines

Medication that was right on moving in is not necessarily still right two years later. The kidneys work less well, weight drops, goals shift — at 90, a strict blood sugar or cholesterol target is often less important than quality of life and avoiding falls.

• Medication review by the pharmacy: anyone who takes at least five prescribed, systemically acting long-term medicines can receive an extended medication review as a benefit covered by statutory health insurance — according to the pharmacists’ professional body, this also applies in residential and care homes.^⁷ Details in the guide Medication review at the pharmacy.
• Medical review: ask the GP practice to go through the whole list at least once a year and after every hospital stay — asking what is still needed.
• Targeted stopping (deprescribing): some medicines can be reduced or stopped when their benefits and risks are reassessed. How to do this safely is shown in the guide Reviewing long-term medication.

Anti-dementia medicines such as donepezil also belong in this regular review: their benefit is limited, and whether they still make sense at an advanced stage should be weighed up together with the practice. Which change is right is always decided by the treating practice — together with the person concerned or their representative.

10. When something goes wrong: conversation, complaint, inspection

Medication errors happen in good care homes too — most of them can be cleared up in a direct conversation. What matters is staying objective and being specific. This order has proved its worth:

1. Speak to the nurse responsible or the unit manager — with specific observations, date and time.
2. Involve the head of nursing if nothing changes. Ask to see the medication plan and the documentation of as-needed doses (with a power of attorney).
3. Approach the GP practice when it is about the treatment itself — dose, active substance, as-needed instruction.
4. Inform the residents’ council (Heimbeirat) or residents’ representative if it is a recurring problem.
5. Call in the care home supervisory authority (Heimaufsicht) of your federal state if conversations achieve nothing — it is responsible for overseeing care homes and has different names depending on the state.
6. Inform the long-term care insurance fund (Pflegekasse); it can involve the Medical Service (Medizinischer Dienst), which inspects care homes regularly.^⁸

Keep a written record of your observations: what was noticed when, whom did you speak to, what was promised? This creates clarity and takes emotion out of the conversation. If you suspect a danger to life and limb, the police are the right people to contact.

11. How brite helps you with medicines in a care home

In a care home, the nursing staff set out the tablets — brite does not replace that. Above all, the app helps you as a relative to keep track and go into conversations well prepared.

Well informed for your next talk with the care home — with brite

Medication plan, interaction check and observations in one place. Free of charge.

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