Medications shall be administered in a safe and timely manner, and as prescribed.
Policy Interpretation and Implementation
1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so.
2. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions.
3. Medications must be administered in accordance with the orders, including any required time frame.
4. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident’s Attending Physician or the facility’s Medical Director to discuss the concerns.
6. The individual administering medications must verify the resident’s identity before giving the resident his/her medications. Methods of identifying the resident include:
a. Checking identification band;
b. Checking photograph attached to medical record; and
c. If necessary, verifying resident identification with other facility personnel.
7. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.
8. The following information must be checked/verified for each resident prior to administering medications:
a. Allergies to medications; and
b. Vital signs, if necessary.
9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container.
10. Vials labeled as “single dose” or “single use” will not be used on multiple residents. Such vials will be used only for one resident in a single procedure.
11. Repackaging single use vials requires compliance with USP <797> standards. If there is a need to repackage unopened single dose/single use vials for use for more than one resident or procedure, the Consultant Pharmacist will be contacted.
12. Medications that have been repackaged from unopened single-dose vials in accordance with USP <797> standards may be administered as repackaged single-dose/single use vials.
13. Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident.
14. Insulin pens will be clearly labeled with the resident’s name or other identifying information. Prior to administering insulin with an insulin pen, the Nurse will verify that the correct pen is used for that resident.
15. Post-exposure follow up procedures will be conducted if an insulin pen is used for more than one resident.
16. During administration of medications, the medication cart will be kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident’s room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
17. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the MAR may be “flagged.” After completing the medication pass, the nurse will return to the missed resident to administer the medication.
18. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.
19. The individual administering the medication must initial the resident’s MAR on the appropriate line after giving each medication and before administering the next ones.
20. As required or indicated for a medication, the individual administering the medication will record in the resident’s medical record:
a. The date and time the medication was administered;
b. The dosage;
c. The route of administration;
d. The injection site (if applicable);
e. Any complaints or symptoms for which the drug was administered;
f. Any results achieved and when those results were observed; and
g. The signature and title of the person administering the drug.
21. Topical medications used in treatments must be recorded on the resident’s treatment record (TAR).
22. Staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable.
23. Medications ordered for a particular resident may not be administered to another resident, unless permitted by State law and facility policy, and approved by the Director of Nursing Services.
24. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.
25. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team, with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, and consider whether a standing dose of medication is clinically indicated.
26. New personnel authorized to administer medications will not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility.
27. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned.
28. Each nurses’ station will have a current Physician’s Desk Reference (PDR) and/or other medication reference, as well as a copy of the surveyor guidance for F329 (Unnecessary Drugs) available.