Current through Register Vol. 56, No. 18, September 16, 2024
(a) Individuals
receiving medication shall take their own medication to the extent that it is
possible, as assessed and determined by the PT, documented in the individual's
record, and in accordance with licensee procedure.
(b) If the individual is not responsible for
or capable of taking his or her own medication, the licensee or his or her
designee shall assist and supervise the administration of the medication as
prescribed.
(c) A record shall be
maintained of all medication administered by the licensee or the designee.
1. The record shall include the following:
i. The individual's name;
ii. The date;
iii. The name of medication;
iv. The type of medication;
v. The dosage;
vi. The frequency;
vii. The initials and corresponding
signatures of staff administering the medication or in the case of electronic
records, a means by which the identification of the administering staff is
verified;
viii. All known
allergies; and
ix. Medication
administration codes.
(d) If an individual is capable of taking
medication without assistance, no daily medication administration record is
required.
1. A current list identifying the
name of the medication(s), type of medication(s), dosage, frequency, date
prescribed, and the location of the medication(s) shall be filed in the
individual's record and updated as changes occur.
(e) Written documentation shall be filed in
the individual's record indicating that all prescribed medication was
re-evaluated at least annually by the prescribing physician or advanced
practice nurse.
(f) Staff shall
have access to medication information, either in a reference book or an online
resource approved by the licensee, current within three years and written for
lay persons, which shall include information on side effects and drug
interaction.
(g) Any new medication
or change in medication order by the physician or advanced practice nurse, as
well as new and discontinued prescriptions, shall be immediately noted on the
current medication record by staff consistent with the licensee's procedure.
1. Verbal orders from the physician or
advanced practice nurse shall be confirmed, in writing, within 24 hours or by
the first business day following receipt of the verbal order.
2. The prescription shall be revised at the
earliest opportunity.
(h) A supply of medication and prescribed
nutritional supplements, adequate to ensure no interruption in the medication
schedule, shall be available to individuals at all times.
(i) The licensee or designee shall supervise
the use and storage of prescription medication, ensuring that:
1. A storage area of adequate size for both
prescription and over-the-counter medications shall be provided and kept locked
for those individuals who are not self-administering their own
medication.
2. Each individual who
administers his or her own medication shall receive training and monitoring by
the licensee regarding the safekeeping of medications for the protection of
others, as necessary.
i. Medication shall be
kept in an area that provides for the safety of others, if necessary;
3. Staff shall have a key to
permit access to all medication at all times and to permit accountability
checks and emergency access to medication.
i.
Specific controls regarding the maintenance and use of the key to stored
medication shall be established by agency procedure;
4. Prescribed medication for each individual
shall be separated within the storage areas, as follows:
i. Oral medications, eye drops, and ear drops
shall be separated from other medications; and
ii. If necessary, medications that require
refrigeration shall be maintained in a manner that provides for the safety of
others, for example, by using locked boxes.
5. All medications shall be kept in their
original containers from the pharmacy and shall be properly identified with the
pharmacist's label.
i. An individual who is
self-medicating may choose adaptive equipment that continues to assure the safe
storage of medication;
6. No stock supply of prescription
medications shall be kept;
7.
Medications that are outdated or no longer in use shall be safely disposed of,
according to licensee procedure;
8.
When medication is prescribed PRN (as needed), the prescription label shall
include the following: the individual's name, date, name of medication, dosage,
specification of interval between dosages, maximum amount to be given during a
24-hour period, a stop date, when appropriate, and under what conditions the
PRN medication shall be administered; and
9. The administration of PRN medication,
along with the time of administration, shall be documented on the medication
record and shall be communicated to the on-coming shift of residential
staff.
