Prescribing, Labeling, Packaging, and Storage
- Must be a written practitioner’s order for EACH prescription medication, OTC medication, PRN medication, and dietary supplements. Must be maintain in their file at all times.
- Medications for internal consumption and medications for external application must be separated. If unable to do so, putting the external application medications in a sealable, plastic baggie.
- The resident’s record needs to include a current list of the type and dosage of medications or supplements, directions for use, and any change in the resident’s condition (your eMAR is most likely capable of all this).
Documentation and Reviews
- Resident medications must be reviewed by a physician or pharmacist within 30 days before or 30 days after their admission AND whenever there is a significant change in condition AND annually. Their annual physical will meet the requirement.
- Every year (at least) a physician, pharmacist or RN must conduct an on-site review of the medication administration and medication storage system, as well as provide a written report of findings.
- If a resident is on a psychotropic medication, they must be assessed by a physician, pharmacist, or RN at least quarterly to see if the medications is “working” as well as to document the presence of any side effects.
Disposal of Medications
- Be sure to have a policy regarding disposal of medications (unused, discontinued, expired, etc.). There are some medications that cannot be returned to the pharmacy, so in those cases, you need to have a “plan of action” that remains locked to only the administrator or designee and two people (one being the administrator or designee) must witness, sign, and date a record of destruction.
- Medications that cannot be returned to the pharmacy must be separated from other medication in current use in the facility. They must be stored in a locked area with access limited to the administrator or designed.
Staff Administration, Notification, and Reporting
- A proof-of-use record is required for Schedule II drugs. This record must contain the date and time administered, the resident’s name, the practitioner’s name, dose, signature of the person administering the dose, and the remaining balance of the drug. The administrator or designee must audit, sign, and date this record on a daily basis.
- When a PRN medication is given, staff must “check” with the resident in 30 minutes and document their response.
- Employees are not allowed to administer injectable, nebulizers, stomal, enteral, vaginal, or rectal medications unless they are an LPN or RN, without delegation.
- All staff need to be made aware of the potential benefits and side effects of the medications… that’s why the side effects (pamphlets provided by the pharmacy) must be posted in their files.