Current through Register Vol. 56, No. 18, September 16, 2024
(a) Persons served
receiving medication shall take their own medication to the extent that it is
possible, as assessed and determined by the TDT, documented in the person's ITP
and in accordance with licensee procedure.
(b) If the person served is not responsible
for or capable of taking his or her own medication, trained staff members shall
assist and supervise the administration of the medication as
prescribed.
(c) A written record
shall be maintained of all medication administered by the trained staff
members.
1. The record shall include the
following:
i. The name of the person
served;
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. Medication
administration codes; and
ix. All
known allergies.
(d) If a person served 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 record
of each person served and updated as changes occur.
(e) Written documentation shall be filed in
the record of the person served 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 written medication record by staff consistent with the licensee's
procedure.
1. Verbal orders from the
physician or advanced practice nurse shall be signed by the physician or
advanced practice nurse 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 insure no interruption in the medication
schedule, shall be available to persons served 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 persons served who are not self-administering their own
medication;
2. Each person served
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 person served 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. A person served who is self-medicating may
choose adaptive equipment that continues to assure the safe storage of
medication;
6.
Medications that are outdated or no longer in use shall be safely disposed of
according to licensee procedure;
7.
When medication is prescribed PRN (as needed), the prescription label shall
include the following:
i. The name of the
person served:
ii. The
date;
iii. The name of the
medication;
iv. The
dosage;
v. The specification of the
interval between dosages;
vi. The
maximum amount to be given during a 24-hour period;
vii. A stop date, when appropriate;
and
viii. Under what conditions the
PRN medication shall be administered; and
8. The administration of PRN medication,
along with the time of administration, shall be documented on the written
medication record and shall be communicated to the on-coming shift of
residential staff.
(j) A
statement signed by the physician or advanced practice nurse regarding the
usage and contraindications of over-the-counter medications shall be available
for staff reference and use and shall be updated annually. This statement shall
constitute a physician's order.
(k)
For medications available over-the-counter, the manufacturer's label shall be
sufficient for identification purposes.
