Policies & Procedures: Pharmaceutical Care in The Long Term Care Setting
Policies & Procedures: Pharmaceutical Care in The Long Term Care Setting
Policies & Procedures: Pharmaceutical Care in The Long Term Care Setting
Pharmaceutical Care
in the
Long Term Care Setting
MEDICINE CHEST POLICIES AND PROCEDURES FOR
PHARMACEUTICAL CARE IN THE LONG-TERM CARE SETTING
(Revised September 2016)
TABLE OF CONTENTS
Annual Policy and Procedure Authorization Page
Pharmaceutical Services Subcommittee Roster
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III. MEDICATION MONITORING- pgs. 86-95
1. Drug Regimen Review (Monthly Report)
2. Medication Administration Monitoring
3. Psychoactive Drug Monitoring
Antianxiety/Sedative Medications
Antidepressants
Antipsychotics
Hypnotics
4. Documentation and Communication of Consultant Pharmacist
Recommendations
V. APPENDICES
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MEDICINE CHEST POLICIES AND PROCEDURES FOR
PHARMACEUTICAL CARE IN THE LONG-TERM CARE SETTING
Director of Pharmacy
Name Title
Name Title
Name Title
Name Title
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PHARMACEUTICAL SERVICES SUBCOMMITTEE ROSTER
Name Title
Name Title
Name Title
Name Title
Effective Date___________________
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ORGANIZATIONAL ASPECTS
BACKGROUND
Procedures
The Pharmaceutical Services Subcommittee is composed of the administrator, director of
nursing, consultant pharmacist and/or a pharmacist from the provider pharmacy, and a physician.
A current member roster is maintained in the facility.
A. The Subcommittee
1) reviews pharmaceutical policies and procedures and their implementation as
often as deemed necessary by the chairperson or upon recommendation of the
Consultant Pharmacist or Pharmacy Provider and at least annually;
2) reviews information on new drug delivery systems as appropriate and
establishes policies and procedures regarding their use within the facility;
3) reviews patient monitoring programs such as those developed for psychotropic
drugs and anticoagulants when appropriate, and makes recommendations
regarding implementation within the facility, including the development of
policies and procedures;
4) reviews reports submitted by the Consultant Pharmacist, regulatory agencies,
and nursing and medical staff related to pharmaceutical services and
medication administration; and makes appropriate recommendations to the
Quality Assessment and Assurance Committee.
a) Each of the areas reviewed is discussed and an action plan developed
for improvement, as appropriate. The plan is submitted to the Quality
Assessment and Assurance Committee for approval of implementation.
b) A copy of MEDICINE CHEST ’s Pharmaceutical Services Policies
and Procedures Manual is maintained at each facility to assure adequate
access by staff. New attending physicians and medical staff are
familiarized with MEDICINE CHEST ’s Pharmaceutical Services
Policies and Procedures at or prior to the time they first admit a resident
to the facility. New nursing staff and assistants are familiarized with the
facility’s Pharmaceutical Services Policies and Procedures at the time
of employment.
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This subcommittee is optional. Where its use is not desired, the functions described
above may be carried out by the Quality Assessment and Assurance or other designated
committee.
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2. MEDICINE CHEST PHARMACY—REQUIREMENTS
Policy
Regular and reliable pharmaceutical service is available to provide residents with prescription
and nonprescription medications, services, and related equipment and supplies. A written
agreement with MEDICINE CHEST Pharmacy stipulates financial arrangements and the terms
of the services provided.
Procedures
a. The Facility maintains a written agreement with MEDICINE CHEST Pharmacy, signed
by the administrator and an authorized representative of MEDICINE CHEST pharmacy.
c. MEDICINE CHEST is responsible for rendering the required service in accordance with
local, state, and federal laws and regulations, facility policies and procedures, community
standards of practice and professional standards of practice.
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procedures
(14) total number of containers if more than one per prescription.
6) Providing routine and timely pharmacy services and emergency pharmacy service
24 hours per day, seven days per week.
7) Performing an initial medication use assessment for each new resident to ensure
that the medication regimen meets the resident’s needs.
8) Maintaining a medication profile on each resident that includes all medications
dispensed and facility-provided information such as resident’s age, diagnoses,
weight, condition, medication allergies, diet, and any other pertinent information.
9) Screening each new medication order for an appropriate indication or diagnosis;
for drug interactions with other medications ordered for the resident; for
duplication of therapy with other drugs in the same therapeutic class ordered for
the resident; and for appropriate drug dose, dosing interval, and route of
administration, based on resident and other pertinent variables. If diagnosis or
indication is not available, notifying the nursing staff of the need to obtain the
information from the prescriber prior to administering the drug.
10) Providing medication information and consultation to the facility’s nursing staff.
11) Providing and maintaining an emergency medication supply in a sealed and
properly labeled container.
12) Where appropriate, assisting the physician in documenting the need for a
“noncovered” or nonformulary medication ordered for a resident otherwise
eligible for medication benefits through Medicaid or other third-party programs.
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3. CONSULTANT PHARMACIST SERVICES PROVIDER—REQUIREMENTS
Policy
Regular and reliable consultant pharmacist services are provided to residents. A written
agreement with a consultant pharmacist stipulates financial arrangements and the terms of the
services provided.
Procedures
a. The facility maintains a written agreement with the consultant pharmacist signed
by the administrator and the consultant pharmacist.
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8) Submitting a written report of findings and recommendations resulting
from the review of medication therapy documentation as described above.
9) Assisting in the assessment and improvement in nursing staff medication
administration through medication pass observation as requested by
nursing and administration, and through medication record reviews.
10) Working with the provider pharmacy to establish a system of records of
receipt and disposition of all controlled substances that produces an
accurate reconciliation and account of use on a periodic basis. Assisting in
the accounting, destruction, and reconciliation of unused controlled
substances and noncontrolled substances as required by state and federal
law.
11) Assisting the administrator (Pharmaceutical Services Subcommittee;
Quality Assessment and Assurance Committee) in setting standards and
developing, implementing, and monitoring policies and procedures for the
safe and effective distribution, control, and use of medications and related
equipment and services in the facility.
12) Serving on facility committees as required or requested, including but not
limited to (Pharmaceutical Services Subcommittee; Quality Assessment
and Assurance Committee; Infection Control Committee).
13) Helping to resolve problems with pharmacy providers/suppliers at the
request of the administrator or director of nursing.
14) Providing in-service education programs and other educational activities
for the facility staff on medication-related topics for a fee or per contract,
as follows:
a) Provide current reviews and updates on federal, state, and local
laws pertaining to medications in the nursing facility as part of in-
service education.
b) Use a variety of teaching techniques to keep educational programs
informative and entertaining.
c) Maintain a record of each in-service training program provided,
listing subject matter and attendees.
d) Develop an in-service education program schedule that includes
timely topics of relevance to the facility in regard to patient mix,
types of therapy or findings of reviews, studies, etc.
15) Participating in other facility activities as requested by Administrator or
director of nursing and as agreeable to both parties.
16) The consultant pharmacist maintains a record of time spent in the facility
and documents activities performed and services provided on behalf of the
residents and the facility.
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4. INFUSION THERAPY PRODUCTS PROVIDER
Policy
The facility maintains an agreement with a pharmacy provider qualified in infusion therapy
preparation and distribution for infusion therapy products, and for consultation on the use of such
products. Infusion therapy products include solutions with no additives, solutions with additives,
and supplies for administering solutions and for preparation of emergency or unstable solutions.
If appropriate, a supplier other than the contract pharmacy is used.
Procedures
a. The infusion therapy provider furnishes the infusion therapy products on a timely
basis.
b. The infusion therapy provider maintains a medication profile for each resident for
whom infusion therapy products are provided and reviews the profile prior to
dispensing any infusion therapy products.
c. Infusion therapy product preparation is done in a laminar flow clean air center, by
qualified personnel.
e. The infusion therapy product provider contacts the facility daily if needed to
obtain updates on resident infusion therapy product needs before delivery to the
facility.
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5. ARRANGEMENTS WITH NONCONTRACT PHARMACY
Policy
A resident, or responsible party, may request that medications be obtained from a pharmacy
other than MEDICINE CHEST. This policy and procedure for use of a noncontract pharmacy is
provided to the noncontract pharmacy prior to approving the use of that pharmacy. Only
pharmacies that agree to abide by the policy and procedures are approved.
Procedures
a. The facility business office representative will offer a copy of relevant policies
and procedures upon request to residents or responsible parties who wish to
purchase medications from a noncontract pharmacy. A second copy is available to
MEDICINE CHEST.
b. The person distributing these copies documents this activity and signs and dates
the entry. Notification of agreement by the noncontract pharmacy to strictly
adhere to the facility policy and procedure for pharmacy services is documented
in the resident’s business office record. The provider pharmacy is informed about
the arrangement with the noncontract pharmacy. A note is displayed prominently
on the resident’s medical record to inform nursing staff that the resident is using a
pharmacy other than MEDICINE CHEST.
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i) prescription number
j) precautionary labels indicating special storage requirements or
procedures
k) total number of containers if more than one per prescription
f. Nonprescription medications without a prescription label are provided in the
manufacturer’s original container and labeled with the resident’s name.
h. If the prescription label is not accurate or current and it is impractical to return the
medication to the pharmacy for relabeling, the pharmacy is to provide a corrected
label on the container the next time the medication is dispensed. Under no
circumstances are unattached labels requested or accepted from the pharmacy.
Only the pharmacy may place a label on the medication container.
The nurse receiving the order change or detecting the label error places a signal
label (“order change”) on the container to indicate that directions for medication
administration on the label are incorrect.
i. When medication is ordered for use at the bedside, the medication label contains,
in addition to the instructions for use, a notation that it may be stored at the
bedside.
l. Controlled medications listed in Schedules II, III, and IV are provided by the
noncontract pharmacy in easily accountable quantities and in containers designed
for easy counting of contents to facilitate inventory control.
m. Schedule II medications that cannot be refilled and that can be dispensed only
upon the receipt of an original written prescription are reordered when a (seven-
day) supply remains. The noncontract pharmacy then has the responsibility to
obtain a valid prescription from the physician; however, the facility assists in the
acquisition of the prescription if possible. If unable to obtain the prescription and
provide the medication prior to the depletion of the current supply, the
noncontract pharmacy will notify the facility immediately. MEDICINE CHEST
may then be asked to obtain and fill the prescription.
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n. New medications are received from the noncontract pharmacy on a prompt and
timely basis. Prompt and timely availability is interpreted as follows:
1) Medications ordered from the noncontract pharmacy during its regularly
scheduled business hours on an emergency or “stat” basis are available for
administration as per facility/pharmacy agreement.
2) All other new medication orders are received and available for
administration on the day they are ordered by the physician or before the
time the first dose would ordinarily be administered.
o. All medications delivered to the facility from the noncontract pharmacy are
received by a licensed nurse. Medications, whether prescription or
nonprescription, are never brought directly to the resident.
p. The noncontract pharmacy bills the resident or responsible party directly for all
medications and supplies provided. If the resident is insured through the state
Medicaid program, applicable state laws for payment of the noncontract
pharmacy apply. If the resident is insured through a non-Medicaid managed care
or other type of insurance program, methods of payment are ascertained at the
time of admission to the facility.
q. The noncontract pharmacy provides the facility with a delivery and on-call
schedule and notifies the facility immediately of any changes in the schedule.
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MEDICATION ORDERS
Procedures
a. Elements of the Medication Order.
1) Medication orders specify the following:
a) Name of medication.
b) Strength of medication, where indicated.
c) Dosage.
d) Time or frequency of administration.
e) Route of administration, if other than oral.
f) Quantity or duration (length) of therapy. If not specified by
prescriber on a new order, the duration is limited by automatic stop
order policy.
g) Diagnosis or indication for use.
2) Any dose or order that appears inappropriate considering the resident’s
age, condition, or diagnosis is verified with the attending physician.
b. Documentation of the Medication Order.
1) Each medication order is documented in the resident’s medical record with
the date, time, and signature of the person receiving the order. The
order is recorded on the physician order sheet or the telephone
order sheet if it is a verbal order, and on the Medication
Administration Record (MAR) or Treatment Administration
Record (TAR).
c. New Handwritten Orders by the prescriber while present at the nurse’s station.
The charge nurse on duty at the time the order is received enters it on the
(physician order sheet /telephone order sheet) if not written there by the
prescriber, and notes the order as follows: (“Noted 3:00 p.m., 5/17/98, M.
Jones, R.N.”). If necessary, the order and the indication for its use is
clarified and the prescriber’s signature is obtained before the prescriber
leaves the nursing station.
d. New Verbal Orders.
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The nurse documents an order and the reason for its use by telephone or in
person, on the telephone order sheet and the physician’s order sheet , notes
the order as follows: (“Noted 3:00 p.m. 5/17/87, M. Jones, R.N.”) and
completes the following steps.
1) Mail the appropriate copy of the telephone order form to the prescriber for
signing.
2) Transmit the appropriate copy to the pharmacy for
dispensing.
3) Obtain prescriber signature within (48) hours.
4) Place the signed copy on the designated page in the
resident’s medical record.
5) Accept verbal orders for Schedule II medications only in an
emergency, to be followed with a written order from the
prescriber within (72) hours.
e. Written Transfer Orders (sent with a resident by a hospital or other health care
facility).
1) Implement a transfer order without further validation if it is
signed and dated by the resident’s current attending
physician, unless the order is unclear or incomplete or the
date signed is different from the date of admission.
2) If the order is unsigned or signed by another prescriber or the date is other
than the date of admission, the receiving nurse verifies the order with the
current attending physician before medications are administered. The
nurse documents verification on the admission order record by entering
the time, date, and signature. Example: “Order verified by phone with Dr.
Smith/M. Jones, R.N.”
3) Obtain the indication for each medication ordered.
4) The nurse who transcribes the orders to the physician order
sheet and MAR documents on the admission form the date, the time and
by whom the orders were noted, as follows: (“Noted 3:00 p.m., 5/17/98,
M. Jones, R.N.”)
f. Renewed or Recapitulated (Recapped) Orders (to continue a
medication therapy beyond a previous order with limited duration).
1) The prescriber renews the order either by repeating the
entire order process or with a statement such as “continue
medication for ten days.” The prescriber writes a new order for continued
therapies that require a change in directions, dosage form, or strength.
2) Medication orders are recapped on a (monthly) basis when the prescriber
signs the physician order summary. The order summary is reviewed by a
designated nurse before giving it to the prescriber to sign.
g. Orders Faxed From the Physician’s Office
1) The charge nurse on duty at the time the order is received
notes the order and enters it on the physician order sheet .
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a) Clarify the order.
b) Enter the orders on the Medication Order form.
c) Call or fax the medication order to the provider pharmacy.
d) Transcribe newly prescribed medications on the MAR or treatment
record. When a new order changes the dosage of a previously
prescribed medication, discontinue the previous entry by (writing
“DC’d” and the date and highlighting the entry in yellow.) Enter
the new order on the MAR/TAR.
e) After completion, document each medication order entered on the
appropriate form with date, time, and signature. (Example: “Noted
1:15 p.m., 5/17/98. M. Jones, R.N.”)
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2. RECOMMENDED GUIDE FOR STOP ORDERS
Policy
New medication orders are subject to automatic stop orders unless the medication orders
specify the number of doses or duration of medication. A time limit is included in
recapped orders.
Procedures
a. The following classes of medications, whether the order is for routine or p.r.n.
use, are stopped automatically after the indicated number of days, unless the
prescriber specifies a different number of doses or duration of therapy to be given.
1) Antibiotics for acute conditions (10 days).
2) Ophthalmic antibiotic and steroid preparations for acute problems (10
days).
3) Cough and cold preparations (10 days).
4) Decongestants and antihistamines for acute conditions (10 days).
5) Controlled substance analgesics for acute conditions (10 days).
b. All other medications are stopped automatically after (45) days unless reordered.
c. All p.r.n. medication orders, except for nitroglycerin and those listed in section a1
through 5 above, are discontinued in 60 days if not utilized at all during that time,
unless the prescriber specifically orders them to be continued indefinitely or for a
specified period of time. (The prescriber is notified of this discontinuation
through the completion of a telephone order form, sent to the prescriber’s office
for signature.) The discontinue (D/C) order is also entered on the Physician
Orders sheet and noted on the MAR.
d. All medication orders that do not specify duration or number of doses are
automatically discontinued in accordance with the Stop Order Policy. When the
prescriber gives the order for a medication covered by the Stop Order Policy, the
nurse requests a specific duration of therapy for that order. This then supersedes
the Automatic Stop Order Policy.
e. When implementing the Stop Order Policy for routine medications, the prescriber
is notified before the administration of the last dose to allow the alternative of
continuing the medication without interruption of the medication regimen.
f. When entering medications covered by the Stop Order Policy on the MAR, the
automatic stop date is recorded in the appropriate area on the MAR. (The blocks
of time before the medication is given are crossed out, and the blocks of time after
the medication is given are “yellowed” out and “D/C” written in, once the last
dose is given per facility procedure).
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g. A current copy of the Automatic Stop Order Policy is kept in the front of each
Medication Administration Book.
h. A copy of the facility “Automatic Stop Order Policy” is sent to all physicians with
an explanatory cover letter.
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3. STANDING ORDERS
Policy
Certain self-limited conditions are often amenable to treatment with nonprescription
medications, using good nursing judgment. To facilitate prompt treatment of such conditions,
and to avoid unnecessary telephone calls to those prescribers who approve, standing orders are
used.
Procedures
a. Standing orders are implemented by licensed nurses only. Professional judgment is used
in the initiation and administration of standing orders.
b. The order is written following the procedure for verbal prescriber orders, as detailed in
Section I.B., Medication Orders. In indicating the source of the order, the abbreviation
“s.o.” is used to indicate a standing order.
c. Documentation of the situation requiring the use of the standing order is placed in the
Nursing Notes section of the resident’s medical record prior to initiation of the order.
d. All standing orders are countersigned by the authorized prescriber within (48) hours of
initiation.
e. The corresponding automatic stop order listed for each condition and treatment is used
when initiating a standing order.
f. Standing orders are not renewable. If the condition persists after the stop order deadline,
or sooner if professional judgment warrants it, the primary care provider is contacted.
g. A copy of facility “Standing Orders” is sent to all physicians with an explanatory cover
letter. The facility “Standing Orders” are posted at each nursing station or placed in the
MAR per facility procedure.
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MEDICATION ORDERING AND RECEIVING
FROM PHARMACY PROVIDER
Procedures
a. The administrator, director of nursing, and provider pharmacy establish a
daily delivery and pick-up schedule for medication orders
b. The schedule lists the pharmacy’s regular and after business hours, applicable
telephone numbers, routine medication order, and delivery times, and other
pertinent information, such as the poison control center telephone number. (1-
800-222-1222)
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2. ORDERING AND RECEIVING MEDICATIONS FROM MEDICINE CHEST
PHARMACY
Policy
Medications and related products are received from MEDICINE CHEST on a timely basis. The
facility maintains accurate records of medication order and receipt.
Procedures
a. Ordering Medications From MEDICINE CHEST Pharmacy.
1) Medication orders are written on a medication order form provided by the
pharmacy and transmitted to the pharmacy. The written entry includes:
a) Date ordered.
b) Whether the order is new or a repeat order (refill). If the order is a repeat
order (refill), include the prescription number.
c) Resident’s name.
d) Medication name and strength, when indicated.
e) Directions for use, if a new order, or direction changes to a previous order.
f) Name of pharmacy supplier if other than MEDICINE CHEST
g) According to dispensing regulations, all branded oral medications funded
by federal pay sources must be dispensed in a 14 day supply or less
supply.
2) Repeat medications (refills) are (written on a medication order form/ordered by
peeling the top label from the physician order sheet and placing it in the
appropriate area on the order form) provided by the pharmacy for that purpose
and ordered as follows:
a) Reorder medication (seven) days in advance of need to assure an adequate
supply is on hand. When reordering medication that requires special
processing (such as Schedule II controlled substances, Department of
Veterans Affairs prescriptions), order at least (seven days) in advance of
need.
) The nurse who reorders the medication is responsible for notifying the
pharmacy of changes in directions for use or previous labeling errors.
c) The refill order is called in, faxed, or otherwise transmitted to the
pharmacy.
3) New medications, except for emergency or “stat” medications, are ordered as
follows:
a) If needed before the next regular delivery, phone the medication order to
MEDICINE CHEST immediately upon receipt. Inform pharmacist of the
need for prompt delivery and request delivery within (4) hours.
b) Timely delivery of new orders is required so that medication
administration is not delayed. The emergency kit is used when the resident
needs a medication prior to pharmacy delivery.
4) “Stat” and emergency medications are ordered as follows:
a) During regular pharmacy hours, the emergency or “stat” order is phoned or
faxed to the pharmacy. If available, the initial dose is obtained from the
emergency kit, when necessary.
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5) When phoning or faxing a medication order to the pharmacy, the following
information is given:
a) Resident’s name.
b) Prescription number if a refill.
c) Complete order if a new medication order or direction changes to a
previous order.
d) Name of prescriber if a new order.
e) Indication for use.
f) Name of person calling in order.
6) New Admission Orders:
a) When calling/faxing medication orders for a newly admitted resident, the
pharmacy is also given all allergies, and diagnoses to facilitate generation
of a patient profile and computer summary sheet, and permit initial
medication use assessment.
b) The medication order form is also used to notify MEDICINE CHEST of
changes in dosage, directions for use, etc. of current medications.
c) Fax a face sheet with billing information included
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3. CONTROLLED MEDICATIONS—ORDERING AND RECEIPT
Policy
Medications included in the Drug Enforcement Administration (DEA) classification as
controlled substances, and medications classified as controlled substances by state law, are
subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance
with federal and state laws and regulations.
Procedures
a. The director of nursing and the consultant pharmacist maintain the facility’s compliance
with federal and state laws and regulations in the handling of controlled medications.
Only authorized, licensed nursing and pharmacy personnel have access to controlled
medications.
b. Schedule II controlled medications prescribed for a specific resident are delivered to the
facility only if a (written/or fax copy of the written) prescription has been received by the
pharmacy prior to dispensing. In an emergency situation, MEDICINE CHEST can
accept a telephone order. A follow-up written (original) prescription is sent to the
provider pharmacy by the facility or the prescriber within (72 hours). A facsimile order
may be sent to the provider pharmacy if it is written by the prescriber.
c. New and refill orders for controlled medications other than those in Schedule II are
ordered as detailed in the procedure for ordering and receiving medications.
d. Medications listed in Schedules II, III, IV, and V are dispensed by the pharmacy in
readily accountable quantities and containers designed for easy counting of contents.
When possible, injectable controlled substance medications are dispensed in ampules or
vials of the smallest available dosage unit.
f. Medications listed in Schedules II, III, IV, and V are stored under double lock.
Alternatively, in a unit dose system, Schedule III, IV, and V medications may be
distributed with other medications throughout the cart, while the Schedule II medications
are kept under double lock. The access key to controlled medications is not the same key
that allows access to other medications. The medication nurse on duty maintains
possession of a key to controlled medications. Back-up keys to all medication storage
areas, including those for controlled medications, are in the control of the Director of
Nursing.
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g. Schedule II controlled substance medications are reordered when a (seven-day) supply
remains to allow for transmittal of the required original written prescription to the
pharmacist.
h. The facility may designate a particular drug, which is not mandated as a controlled
substance by state or federal laws and subject to abuse or diversion, to be handled under
these procedures for controlled medications.
i. The facility obtains and keeps current and on file any permits required by state agencies
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4. EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS
Policy
Emergency pharmaceutical service is available on a 24-hour basis. Emergency needs for
medication are met by using the facility’s approved emergency medication supply or by special
order from the provider pharmacy. An emergency supply of medications, including emergency
drugs, antibiotics, controlled substances (and products for infusion) is supplied by the provider
pharmacy in limited quantities (in portable, sealed containers), in compliance with applicable
state regulations.
Procedures
a. Telephone/fax numbers for emergency pharmacy service are posted (at nursing
stations)
d. Medications are not borrowed from other residents. The ordered medication is
obtained either from the emergency box or from MEDICINE CHEST.
f. When an emergency or starter dose of a medication is needed, the nurse (unlocks the
container/cabinet/breaks the container seal) and removes the required medication.
g. As soon as possible, the nurse records the medication use on the medication order form
and faxes or calls the pharmacy.
i. Before reporting off duty, the charge nurse indicates the “opened” status of the
emergency kit at the shift change report, and transmits the new medication orders to
oncoming staff.
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j. A perpetual inventory is kept by the pharmacy for each emergency kit. It is
imperative that the facility staff notify the pharmacy each time a dose is removed
from the kit. Opened emergency kits are replaced, at the next scheduled delivery
time, when any one (1) medication within the kit becomes 40 percent of the originally
stocked value.
k. If exchanging kits, when the replacement kit arrives, the receiving nurse gives the
used kit to the pharmacy personnel for return to the pharmacy. If replacing used doses
of medication, the nurse replaces the medication in the appropriate area of the kit. A
new seal is placed on the kit after the replacement medication has been added.
l. If exchanging the narcotic emergency kit, the facility charge nurse and pharmacy
delivery driver should follow this procedure.
a. The facility nurse and pharmacy driver must verify the count of each
medication of the old narcotic kit and initial each page of the count book. Once
this has been verified and all of the counts are correct for each medication then
the driver and facility nurse must both sign the cover sheet verifying all counts are
correct. The kit should be resealed before the pharmacy staff leaves with the old
kit. The facility nurse should make a copy of the narcotic book with the signatures
of both parties to keep for their facility record.
b. The facility nurse and pharmacy delivery driver must verify the count of each
narcotic in the new narcotic kit being received from the pharmacy and initial each
page. After the counts have been verified the kit must be resealed with a new
lock tag. Once this has been verified and all of the counts are correct for each
medication then the driver and facility nurse must both sign the cover sheet
verifying all counts are correct.
c. If any of the medication counts are not correct then the narcotic kit may not be
exchanged. The medications must be accounted for and signed out for the
appropriate residents before the kit may be exchanged.
n. Kits opened during the weekend or on holidays are reported to the pharmacy
(immediately/the following Monday or the first working day after the kit is opened).
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o. Attending physicians are informed regarding the availability of emergency medications
in the facility
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5. MULTIPLE-SOURCE DRUG PRODUCTS
Policy
The cost of medications is controlled, in part, by the use of multiple-source drug products, when
appropriate. All provisions of state law, Food and Drug Administration (FDA) bioequivalence
guidelines, and the physician’s therapeutic objectives are followed in choosing multiple-source
drug products.
Definitions
Pharmaceutically Equivalent Drug Products: Drug products that contain the same active
ingredient(s), in identical amounts, in identical dosage forms, administered by the same route of
administration and that meet existing standards in the United States Pharmacopeia (USP). The
products may differ in characteristics such as color, flavor, shape, packaging, inert ingredients,
and the method of manufacture.
Therapeutically Equivalent Drug Products: Pharmaceutically equivalent drug products that when
administered under similar conditions provide the same therapeutic effect as measured by control
of a symptom or disease, or other outcome.
Multiple-Source Drug Products: Pharmaceutically equivalent drug products that are marketed by
different pharmaceutical companies.
Innovator Brand Products: A drug product manufactured and marketed by the pharmaceutical
company that introduces it to the market. In most cases, this is the same company that
conducted the research and obtained the patent for the drug product. Often referred to as “brand
name” product.
Procedures
a. MEDICINE CHEST dispenses non-innovator multiple-source (“generic”) drug products
whenever feasible and when required according to Medicaid, Medicare, or other third-
party payer programs that dictate multiple-source drug product use in place of innovator
products, unless the prescriber complies with item b. below.
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a) The physician must certify in his or her own handwriting that a specific
brand is “medically necessary” for a particular recipient. The handwritten
phrase “brand necessary” or “brand medically necessary” must appear on
the face of the prescription.
b) The prescriber must also document in the resident record the reason why
the drug is medically necessary.
2) On facility orders:
a) (In addition to the above, the prescriber certification must be made on
each order written for that drug for that resident. The certification is good
only for the length of time that the order is valid. Updated written
certifications are required for each new prescription order written. A
cover letter or blanket order for “brand medically necessary” is not
sufficient to cover individual residents or individual drugs).
b) MEDICINE CHEST uses sound professional judgment and prudent
buying concepts when selecting non-innovator multiple-source (“generic”)
drug product substitutes for innovator products, including bioequivalence
data, FDA comparative data, etc.
c) MEDICINE CHEST labels non-innovator multiple source (“generic”)
drug products according to applicable state laws.
d) Each attending physician is notified by letter of the facility policy
regarding multiple-source (“generic”) drug products.
e) Regulations regarding multiple-source drug products may vary by state.
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6. DRUG INFORMATION
Policy
The licensed nursing staff has access to reference materials that include current information on
medication effects, cautions, available strengths, dosage forms, recommended doses, and
nomenclature.
Procedures
a. A copy of the current Physicians’ Desk Reference/Facts and
Comparisons/Geriatric Dosage Handbook is available for all nursing staff.
c. When information about a medication is not available, the charge nurse requests it
from MEDICINE CHEST .
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7. MEDICATION LABELS
Policy
Medications are labeled in accordance with facility requirements and state and federal laws. Only
the provider pharmacy can modify or change prescription labels.
Procedures
a. Each prescription medication label includes:
1) Resident’s name.
2) Specific directions for use, including route of administration.
3) Medication name. Non-innovator multiple-source drug products dispensed in
place of innovator brand products are labeled with the non-innovator multiple
source drug product (generic) name. If ordered by innovator product name, an
explanatory statement is included on the label, e.g., “ordered as,” “used for,” or
“replaces” preceding the brand name.
Example: Hydrochlorothiazide used for HydroDiuril.
4) Strength of medication.
Injectables: strength per ml (cc) and the amount to be given in mls equivalent on
label. Example: When furosemide 40 mg is ordered and the pharmacy supplies it
in an ampule containing 40 mg/ml, the directions read “Inject 40 mg (1 ml).”
Liquids: strength per ml, e.g., 125mg/ml. Directions for use are expressed in mls,
e.g., “Give 2.5ml.”
5) Physician’s name.
6) Date medication is dispensed.
7) Quantity.
8) Expiration date.
9) Name, address, and telephone number of provider pharmacy.
10) Prescription number.
11) Accessory labels indicating storage requirements and special procedures.
Example: “Shake well” “Take on empty stomach, one hour before or 2 hours after
meals.”
12) Container number and total number of containers (e.g., 1 of 3, 2 of 3, 3 of 3) when
multiple containers are dispensed for one prescription.
13) NDC number of medication dispensed.
d. Nonprescription medications not labeled by the pharmacy are kept in the manufacturer’s
original container and identified with the resident’s name. Facility personnel may write
the resident’s name on the container or label as long as the required information is not
covered.
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e. Medication labels are not altered, modified, or marked in any way by nursing personnel.
Contents are not transferred from one container to another. Only the pharmacy may
place a label on the medication container.
1) If the physician’s directions for use change or the label is inaccurate, the nurse
may place a “change of order—check chart” label on the container indicating
there is a change in directions for use, taking care not to cover important label
information.
2) When such a label appears on the container, the medication nurse checks the
resident’s medication administration record (MAR) or the physician’s order for
current information.
f. If directions for use change, the provider pharmacy is informed prior to the next refill of
the prescription so the new container will show an accurate label.
i. Floor stock medications are labeled as “floor stock” or “house supply” and kept in the
original manufacturer’s container with the expiration date and lot number clearly evident.
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8. INFUSION THERAPY PRODUCT LABELS
Policy
Infusion therapy products are labeled in accordance with facility requirements and applicable
state and federal laws. The label includes sufficient additional information as required to assure
safe and efficient administration to residents.
Procedures
a. Infusion therapy products are labeled by the provider with:
1) Resident name
2) Physician name
3) Pharmacy name, address, and telephone number
4) Contents of solution, including:
a) Name of diluent (e.g. NS)
b) Name and amounts of each additive
5) Date dispensed
6) Directions for administration
7) Prescription number
8) Storage instructions
9) Expiration date and time
10) Initials of dispensing pharmacist
11) Container number and total number of containers (e.g., 1 of 3, 2 of 3, 3 of 3)
when multiple containers are dispensed for one prescription at one time
b. An auxiliary label is affixed to each infusion therapy product container, which provides
for information about its administration to be completed.
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9. MEDICATION PACKAGING
Policy
Medications are provided in packaging to facilitate proper administration of the medication.
Procedures
a. Solid oral medication forms (tablets and capsules) are supplied by the provider pharmacy
using the Blister Pack and Unit Dose Distribution System.
b. Medications not in or on the medication trays include:
1) Medications requiring refrigeration
2) Schedule II controlled substances
3) Liquid medications
4) Injectable medications
5) Externally applied medications, e.g., ointments, sprays, and other treatment
5) Oversize or irregularly shaped medication containers
36
10. ORDERING AND RECEIVING MEDICATIONS FROM NONCONTRACT
PHARMACIES
Policy
A resident, or responsible party, may request purchase of medications from a pharmacy other
than the facility’s contract supplier. Such noncontract pharmacies will adhere to facility
medication policies and procedures and assure delivery on a timely basis, as detailed in the
policy and procedures on arrangements with noncontract pharmacy. This and other relevant
policy and procedures are provided to the noncontract pharmacy provider.
Procedures
a. The charge nurse is notified of the resident’s choice of a noncontract pharmacy by the
business office representative after the noncontract pharmacy has agreed to the terms of
the “Arrangement With Noncontract Pharmacy”.
b. The charge nurse marks the resident’s chart with the name of the selected pharmacy.
c. The provider pharmacy will provide a policy and procedure manual available to the
noncontract pharmacy upon request .
d. Medications and related supplies are delivered (to the appropriate nursing station/to the
facility office) by the noncontract pharmacy. Delivery of prescription or non-prescription
medications directly to a resident’s bedside is prohibited.
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11. MEDICATIONS BROUGHT TO FACILITY BY RESIDENT OR FAMILY MEMBER
Policy
Medications brought into the facility by a resident or family member are used only upon written
order by the resident’s attending physician, after the contents are verified, and if the packaging
meets the facility’s guidelines. Other unauthorized medications are not accepted by the facility.
Procedures
a. Use of medications brought to the facility by a resident or family member is allowed only
when the following conditions are met:
1) The medication name, dosage form, and strength have been verified by:
(a) consulting a tablet identification reference, e.g., Physician’s Desk
Reference, or
(b) calling the dispensing pharmacy for a physical description of the
medication.
2) The medication was ordered by the resident’s physician and entered in the
resident’s medical record for bedside storage and self-administration by the
resident.
3) The medication container is clearly labeled in accordance with facility procedures
for medication labeling and packaged in a manner consistent with facility
guidelines for medications.
4) The medications are received directly from another health care facility, e.g.,
discharge medications arriving with the resident from an acute hospital in the
interim until medications for the resident are received from the provider
pharmacy.
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MEDICATION STORAGE IN THE FACILITY
1. STORAGE OF MEDICATIONS
Policy
Medications and biologicals are stored safely, securely, and properly, following manufacturer’s
recommendations or those of the supplier. The medication supply is accessible only to licensed
nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer
medications.
Procedures
a. The provider pharmacy dispenses medications in containers that meet legal requirements,
including requirements of good manufacturing practices. Medications are kept in these
containers. Transfer of medications from one container to another is done only by the
pharmacy.
b. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to
administer medications (such as medication aides) are allowed access to medications.
Medication rooms, carts, and medication supplies are locked or attended by persons with
authorized access.
c. Orally administered medications are kept separate from externally used medications, such
as suppositories, liquids, and lotions.
f. Except for those requiring refrigeration, medications intended for internal use are stored
in a medication cart or other designated area.
g. Medications labeled for individual residents are stored separately from floor stock
medications when not in the medication cart.
h. Potentially harmful substances (such as urine test reagent tablets, household poisons,
cleaning supplies, disinfectants) are clearly identified and stored in a locked area
separately from medications.
i. Schedule III and IV controlled medications are stored separately from other medications
in a locked drawer or compartment designated for that purpose. In a unit-dose system,
Schedule III-V medications may be stored in the trays with the other medications.
Schedule II medications are then stored in a separate area under double lock.
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j. Medications requiring storage at “room temperature” are kept at temperatures ranging
from 15ºC (59ºF) to 30ºC (86ºF).
k. Medications requiring “refrigeration” or “temperatures between 2ºC (36ºF) and 8ºC
(46ºF)” are kept in a refrigerator with a thermometer to allow temperature monitoring.
Medications requiring storage “in a cool place” are refrigerated unless otherwise directed
on the label.
l. Refrigerated medications are kept in closed and labeled containers, with internal and
external medications separated and separate from fruit juices, applesauce, and other foods
used in administering medications. (Other foods such as employee lunches, activity
department refreshments are not stored in this refrigerator.)
n. Medication storage areas are kept clean, well-lit, and free of clutter and extreme
temperatures.
o. Medication storage conditions are monitored on a (monthly) basis and corrective action
taken if problems are identified.
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2. INFUSION THERAPY PRODUCTS STORAGE
Policy
Infusion therapy products and supplies are stored (separately from other medications and
biologicals), under appropriate temperature and sterility conditions, and following the
manufacturer’s recommendations or those of the supplier.
Procedures
a. Infusion therapy products prepared by the infusion therapy provider are stored at room
temperature or in refrigerator as noted on the label.
b. If refrigerated, one liter infusion therapy solution containers are removed from the
refrigerator (one (1) to two (2) hours) before use. Smaller containers are removed (up to
one (1) hour) before use. Some infusion therapy products may be stored frozen. Frozen
products should be thawed (six (6) to eight (8) hours) in the refrigerator before
administration.
c. Infusion therapy solutions not prepared or modified by the infusion therapy products
provider (“stock solutions”) are stored at temperatures not exceeding 86ºF (16ºC).
d. The infusion therapy product storage area is kept clean and free of clutter.
e. Infusion therapy product’s expiration dates and storage conditions are monitored by the
consultant pharmacist during the inspection of medication storage areas.
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3. CONTROLLED MEDICATION STORAGE
Policy
Medications included in the Drug Enforcement Administration (DEA) classification as
controlled substances are subject to special handling, storage, disposal and recordkeeping
in the facility in accordance with federal, state and other applicable laws and regulations.
Procedures
a. The director of nursing and the consultant pharmacist maintain the facility’s
compliance with federal and state laws and regulations in the handling of
controlled medications. Only authorized licensed/and or certified nursing and
pharmacy personnel have access to controlled medications.
b. Medications listed in Schedules II, III, IV, and V are stored under double lock in a
locked cabinet or safe designated for that purpose, separate from all other
medications. Alternatively, in a unit dose system, Schedule III, IV, and V
medications may be kept with other medications in the cart or in a separate locked
drawer on the cart. The access key to controlled medications in not the same key
giving access to other medications. The medication nurse on duty maintains
possession of the key to controlled medication storage areas. Back-up keys to all
medication storage areas, including those for controlled medications, are kept by
the director of nursing.
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e. Any discrepancy in controlled substance medication counts is reported to the
director of nursing immediately. The director or designee investigates and makes
every reasonable effort to reconcile all reported discrepancies. Irreconcilable
discrepancies are documented by the director of nursing in a report to the
administrator. If a major discrepancy or a pattern of discrepancies occurs or if
there is apparent criminal activity, the director of nursing notifies the
administrator and the consultant pharmacist immediately. A determination is
made by the administrator, the consultant pharmacist, and the director of nursing
concerning possible notification of police or other enforcement agencies and any
other actions to be taken.
f. Current controlled medication accountability records are kept with the MAR.
When completed, accountability records are submitted to the director of nursing
and kept on file for 3 years at the facility.
h. Controlled medications remaining in the facility after the order has been
discontinued are (retained in the facility in a securely locked area with restricted
access until destroyed by a DEA representative; destroyed by the facility’s
director of nursing or administrator, and consultant pharmacist; or as otherwise
directed by state law).
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4. BEDSIDE STORAGE OF MEDICATIONS
Policy
Bedside medication storage is permitted for residents who are able to self-administer
medications, upon the written order of the prescriber and when it is deemed appropriate in the
judgment of the facility’s interdisciplinary resident assessment team.
Procedures
a. A written order for the bedside storage of medication is present in the resident’s medical
record.
b. Bedside storage of medications is indicated on the resident medication administration
record (MAR) for the appropriate medications.
c. For residents who self-administer medications the following conditions are met for
bedside storage to occur:
1) The manner of storage prevents access by other residents. Lockable drawers or
cabinets are required only if unlocked storage is ineffective.
2) The medications provided to the resident for bedside storage are kept in the
containers dispensed by the provider pharmacy (or in the original container if a
nonprescription medication).
3) The bedside medication record is reviewed according to individual facility policy.
d. The resident is instructed in the proper use of bedside medications, including what the
medication is for, how it is to be used, how often it may be used, proper cleaning of
inhalers where applicable, proper storage of the medication, and the importance of
communicating to the licensed staff when a medication has been used . The completion
of this instruction is documented in the resident’s medical record. Periodic review of
these instructions with the resident are undertaken by the nursing staff as deemed
necessary.
e. At least once during each shift, the nursing staff checks for usage of the emergency
medications by the resident, with the exception that the resident is not awakened to obtain
this information. If the resident remains asleep at the end of the shift, the incoming shift
nurse is informed that this information was not obtained so that the resident may be
questioned upon arising.
f. All nurses and aides are required to report to the charge nurse on duty any medications
found at the bedside not authorized for bedside storage and to give unauthorized
medications to the charge nurse for return to the family or responsible party. Families or
responsible parties are reminded of this procedure and related policy when necessary.
g. Medications stored at the bedside are reordered in the same manner as other medications.
The nursing staff is responsible for proper rotation of bedside stock and removal of
expired medications.
h. Bedside medication storage is routinely monitored by the consultant pharmacist during
medication storage review.
i. Candy, cough drops, mouthwashes, aftershave lotions, colognes and perfumes, hair
sprays, dentifrices, deodorants, lotions, and dry skin creams not considered medications
may be stored at the bedside in small quantities in accordance with the facility’s policy
44
and procedures for personal items, and are not included in the provisions of this policy
and procedure.
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DISPOSAL OF MEDICATIONS, SYRINGES, AND NEEDLES
1. CONTROLLED MEDICATIONS—DISPOSAL
Policy
Medications included in the Drug Enforcement Administration (DEA) classification as
controlled substances are subject to special handling, storage, disposal, and recordkeeping in the
facility in accordance with federal and state laws and regulations.
Procedures
a. The director of nursing and the consultant pharmacist are responsible for the facility’s
compliance with federal and state laws and regulations in the handling of controlled
medications. Only authorized licensed nursing and pharmacy personnel have access to
controlled medications.
b. When a dose of a controlled medication is removed from the container for administration
but refused by the resident or not given for any reason, it is not placed back in the
container. It is destroyed in the presence of (two licensed nurses), and the disposal is
documented on the accountability record on the line representing that dose. The same
process applies to the disposal of unused partial tablets and unused portions of single
dose ampules and doses of controlled substances wasted for any reason.
c. Schedule II medications remaining in the facility after a resident has been discharged, or
the order discontinued, are disposed of (either in the facility by the administrator and/or
director of nursing and/or consultant pharmacist; by returning to the Drug Enforcement
Administration (DEA); or by retaining for destruction by an agent of the DEA), as
directed by state laws, regulations, and/or the DEA.
d. Schedule III, IV, and V controlled substances are (disposed of at the facility by two
licensed personnel), as directed by state law.
e. Fentanyl Patches – When a Fentanyl patch is removed from a resident there is 28% to
84.4% of original drug present on the patch. The patch is destroyed in the presence of
two licensed nurses and the patch should be placed in a storage method awaiting final
disposition. (Sharps container is appropriate.)
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2. DISCHARGE MEDICATIONS
Policy
Medications are sent with the resident upon discharge only under conditions that protect the
resident and assure compliance with applicable state laws.
Procedures
a. Medications may be sent with the resident on discharge if this has been authorized by the
prescriber.
b. The labels of discharge medications are verified for completeness and accuracy by
checking them against the most recent physician’s orders. Directions for use are reviewed
with the resident or responsible party. If current directions for use are not the same as
those on a prescription label, the medication name, strength, and the correct directions for
use are written on a separate piece of paper. The correct directions are given to the
resident or responsible party, not affixed to the container. If the discharging nurse is
unable to answer a MEDICINE CHEST ion about these medications, the provider
pharmacy is called for the information before releasing the medications. The telephone
number of the provider pharmacy is given to the resident or responsible party to use in
the event that additional information is needed regarding drug therapy.
d. The resident or responsible party is informed if the container is not child-resistant. This
is documented on the discharge instruction form or in the resident’s medical record.
e. If medications were brought into the facility by a resident or responsible party and not
returned or destroyed, the nurse returns these medications to the resident and documents
return of the medications to the resident or responsible party along with other property or
valuables upon discharge.
47
3. DISCONTINUED MEDICATIONS
Policy
When medications are discontinued by physician order, a resident is transferred or discharged
and does not take medications with him/her, or in the event of resident’s death, the medications
are marked as “discontinued” and destroyed.
Procedures
a. Medications awaiting disposal are stored in a locked secure area designated for that
purpose until destroyed. Medications are removed from the medication cart immediately
upon receipt of an order to discontinue (to avoid inadvertent administration).
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4. MEDICATION DESTRUCTION
Policy
Discontinued medications and medications left in the facility after a resident’s discharge, which
do not qualify for “Return to Pharmacy” for credit.
Procedures
a. Unreturnable discontinued medications should be removed from the storage area and
secured until destroyed.
c. Then place the unwanted, sealed medication mixture in the facility’s biohazard waste bin
for destruction pickup.
d. Medication destruction occurs only in the presence of (the facility administrator), (two)
licensed nurses or (one) licensed nurse and a pharmacist.
e. The (administrator), nurse(s) and/or pharmacist witnessing the destruction ensures that
the following information is entered on the (medication disposition form) for individual
resident medications:
1) Date of destruction
2) Name and strength of medication
3) Prescription number
(Additional information is available at the pharmacy if needed)
4) Amount of medication destroyed
5) Signatures of witnesses
e. The (medication disposition form) with controlled substances disposal information is kept
on file in the facility for (two) years.
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MISCELLANEOUS SPECIAL SITUATIONS
1. OUT-ON-PASS MEDICATIONS
Policy
The charge nurse on duty assures that residents have their necessary medications before leaving
the facility on pass or therapeutic leave.
Procedures
a. When receiving a physician’s order for a resident to go out on pass, the charge nurse on
duty reviews the resident’s medication orders and directions for use (with the physician).
It may be possible to alter administration times to eliminate the need for out-on-pass
medications if the resident’s physician concurs and gives an order to do so.
b. All medications provided to the resident or responsible party for administration while on
pass are properly labeled with full directions for use. If an entire medication container is
to be taken on pass, the resident or responsible party must sign out for it on a record of
medication release.
c. Current medication orders and directions for use are reviewed with the resident or
responsible party before the resident leaves the facility. If there is a question about the
medication that the charge nurse is unable to answer, the provider pharmacy is called for
the information before releasing the medication.
d. If the provider pharmacy has advance notice of the resident’s intent to go out on pass
when dispensing the regular medication supply, the pharmacy may provide a portion of
the resident’s medication in a separate container for that purpose. In no case will a nurse
repackage medications in this manner, since this constitutes dispensing.
e. The out-on-pass medication(s) taken by the resident are recorded on the resident’s current
medication administration record (MAR) or similar form. Doses are not documented on
the front of the MAR unless the nurse administers the medication. However, the licensed
nurse on duty at the time the resident returns to the facility may enter, in the nurse’s
notes, a summary of the resident’s or responsible party’s report of compliance with the
dosage instructions. (Example: “5/17/98, 7:00 p.m., Sally Johnson, daughter of Mrs.
Johnson, states that resident took digoxin, as directed, each morning. (signed) M. Jones,
R.N.”)
f. A circled initial is placed on the MAR for each dose of regularly scheduled medications
that would normally have been administered by the facility while a resident is out on
pass. The reason for the circled initial (for example, “out on pass with meds”) is
explained in the nursing comments section on the back of the MAR for each medication
dose due.
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g. Medications may be self-administered by residents participating in facility-sponsored
activities away from the building under the following conditions:
1) A self-administration order was given by the resident’s physician.
2) The medications are kept by a facility staff person until time for administration.
3) A staff member observes self-administration and notes it in the resident’s medical
records. (If the staff member is lawfully authorized to administer medications
administration is noted on the MAR. If not, the charge nurse initials and circles
the dose on the front of the MAR and on the reverse side documents the staff
member’s comments.)
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2. MEDICATION ERROR AND ADVERSE DRUG REACTION REPORTING
Policy
Significant medication errors and adverse drug reactions are assessed, documented, and reported
as appropriate to the resident’s attending physician, the (Pharmaceutical Services Subcommittee
and/or the Quality Assessment and Assurance Committee), and the pharmacy.
Definitions
Medication Error/Discrepancy: An incorrect medication prescribed, dispensed, or administered
to a resident; an omission of a vital medication due to a prescribing, dispensing, or administering
error; medication administered to an individual with a documented allergy to that medication.
Procedures
a. In the event of a significant medication error or adverse drug reaction, immediate action
is taken, as necessary, to protect the resident’s safety and welfare.
c. The physician’s orders are implemented, and the resident is monitored closely for 24 to
72 hours or as directed.
d. The incident is described on the shift change report to alert staff of the need to monitor
the resident.
e. The following information is documented (in the resident’s medical record) and/or on the
incident report):
1) Factual description of the error or adverse reaction
2) Name of physician and time notified
3) Physician’s subsequent orders
4) Resident’s condition for 24 to 72 hours or as directed
f. The consultant pharmacist reviews all medication error reports. For medication errors
involving pharmacy and for adverse drug reactions, the consultant pharmacist and/or the
52
provider pharmacist are involved in completing the incident report. When an incident
appears to involve a problem with drug formulation or other aspects of drug quality, the
information is given to MEDICINE CHEST for investigation of the incident and report
to the drug quality reporting program.
g. Medication Error and Adverse Drug Reaction Reports are reviewed on a (quarterly) basis
by the (Pharmaceutical Services Subcommittee and/or the Quality Assessment and
Assurance Committee) and acted upon as appropriate.
h. Adverse drug reactions and medication errors identified by the consultant pharmacist
during drug regimen review are reported to the director of nursing.
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PREPARATION FOR MEDICATION ADMINISTRATION
Procedures
a. The following equipment and supplies are acquired and maintained by the facility for the
proper storage, preparation, and administration of medications:
1) Lockable medication carts and medication cabinets, drawers, or rooms with well-
lit dose preparation areas.
2) A refrigerator with a thermometer.
3) Counter space for medication preparation with access to a convenient water
source.
4) Oral syringes, parenteral syringes, needles, droppers, soufflé cups, water pitchers,
and calibrated glass or plastic medication cups.
5) A device for crushing tablets.
b. The charge nurse on duty ensures equipment and supplies relating to medication storage
and use are clean and orderly.
c. The charge nurse is notified if supplies are inadequate or equipment fails to work
properly. The charge nurse reports equipment and supply deficiencies to the director of
nursing.
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2. MEDICATION ADMINISTRATION—GENERAL GUIDELINES
Policy
Medications are administered as prescribed in accordance with good nursing principles and
practices and only by persons legally authorized to do so. Personnel authorized to administer
medications do so only after they have familiarized themselves with the medication.
Procedures
Preparation
a. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel
authorized by state laws and regulations to prepare medications.
c. Prior to administration, the medication and dosage schedule on the resident’s MAR is
compared with the medication label. If the label and MAR are different and the container
is not flagged indicating a change in directions or if there is any other reason to
MEDICINE CHEST ion the dosage or directions, the physician’s orders are checked for
the correct dosage schedule.
d. If breaking tablets is necessary to administer the proper dose, hands are washed with soap
and water or alcohol gel prior to handling tablets and the following guidelines are
followed:
1) A tablet-splitter is used to avoid contact with the tablet.
2) If the tablet is scored, every attempt is made to break along score lines.
3) Unused tablet portions are disposed of per facility procedure. If using only one-
half of the tablet from a unit-dose package, the remainder is used within 24 hours
or disposed of. If in a vial, the 1/2 tablet is returned to the vial.
4) The administration of partial tablets is clearly identified or highlighted on the
resident’s MAR (using bold print, different color ink).
5) Since unscored tablets may not be accurately broken, their use is discouraged if a
suitable alternative is available (such as liquid or half-strength tablet).
6) Where possible, the provider pharmacy is requested to package half tablets.
e. If it is safe to do so, medication tablets may be crushed or capsules emptied out when a
resident has difficulty swallowing or is tube-fed, using the following guidelines.
1) Long-acting or enteric coated dosage forms should generally not be crushed; an
alternative should be sought.
2) Each medication preparation area includes a device that is specifically used for
crushing medications.
3) Medications are crushed (in two soufflé cups) to prevent contact between the
medication and the crushing device.
55
4) For residents able to swallow, tablets which can be appropriately crushed may be
ground coarsely and mixed with the appropriate vehicle (such as applesauce) so
that the resident receives the entire dose ordered.
5) If the resident is tube-fed, medications are crushed finely to prevent clogging the
tube. This is best accomplished using a mortar and pestle. If it is not possible to
use paper cups to prevent direct contact of medications with the mortar and pestle,
the mortar and pestle are cleaned thoroughly after each use. If paper cups are
used, paper is not ground into the medication.
6) The need for crushing medications is indicated on the resident’s orders
and the MAR so that all personnel administering medications are aware of this
need and the consultant pharmacist can advise on safety and alternatives, if
appropriate, during drug regimen reviews.
f. Liquid dosage forms may be a practical alternative in place of solid tablets, especially if
tablets have a coating and will not crush finely. The nurse checks with the provider
pharmacy to determine if a liquid form is available and covered by the applicable
payment program. (The physician is contacted for a new order before changing the
dosage form).
h. When administering PRN medications at times other than the medication pass, the dose
may be prepared in the medication cart storage area and taken to the resident’s bedside,
leaving the cart locked and secured.
Administration
i. Medications are administered only by licensed nursing, medical, pharmacy or other
personnel authorized by state laws and regulations to administer medications.
k. Medications are administered at the time they are prepared. Medications are not pre-
poured.
l. The person who prepares the dose for administration is the person who administers the
dose.
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m. Residents are identified before medication is administered. Methods of identification
include:
1) Checking identification band
2) Checking photograph attached to medical record
3) Calling resident by name
4) If necessary, verifying resident identification with other facility personnel
n. Hands are washed before and after administration of topical, ophthalmic, otic, parenteral,
enteral, rectal, and vaginal medications.
o. At least (4 ounces) of water or other acceptable liquid are given with oral medications.
p. Medications are administered within (60 minutes) of scheduled time, except before or
after meal orders, which are administered (based on mealtimes). Unless otherwise
specified by the prescriber, routine medications are administered according to the
established medication administration schedule for the facility.
r. Medications supplied for one resident are never administered to another resident.
s. During administration of medications, the medication cart is kept closed and locked when
out of sight of the medication nurse. 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.
t. For residents not in their rooms or otherwise unavailable to receive medication on the
pass, the MAR is “flagged” with (tags, colored plastic strips, drinking straws, or paper
clips). After completing the medication pass, the nurse returns to the missed resident to
administer the medication.
u. The resident is always observed after administration to ensure that the dose was
completely ingested. If only a partial dose is ingested, this is noted on the MAR, and
action is taken as appropriate.
Documentation
v. The individual who administers the medication dose records the administration on the
resident’s MAR directly after the medication is given. At the end of each medication
pass, the person administering the medications reviews the MAR to ensure necessary
doses were administered and documented. In no case should the individual who
administered the medications report off-duty without first recording the administration of
any medications.
57
w. Current medications, except topicals used for treatments, are listed on the resident’s
medication administration record (MAR)
x. Topical medications used in treatments are listed on the treatment administration record
(TAR)
y. The resident’s MAR is initialed by the person administering the medication, in the space
provided under the date, and on the line for that specific medication dose administration.
Initials on each MAR are verified with a full signature in the space provided.
aa. If a dose of regularly scheduled medication is withheld, refused, or given at other than the
scheduled time (for example, the resident is not in the facility at scheduled dose time, or a
starter dose of antibiotic is needed), (the space provided on the front of the MAR for that
dosage administration is initialed and circled. An explanatory note is entered on the
reverse side of the record provided for PRN documentation). If (two consecutive doses)
of a vital medication are withheld or refused, the physician is notified.
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3. VIALS AND AMPULES OF INJECTABLE MEDICATIONS
Policy
Vials and ampules of injectable medications are used in accordance with the manufacturer’s
recommendations or the provider pharmacy’s directions for storage, use, and disposal.
Procedures
a. Vials and ampules sent from the provider pharmacy in a box or container with the label
on the outside are kept in that box or container.
b. The date opened and the initials of the first person to use the vial are recorded on
multidose vials (on the vial label or an accessory label affixed for that purpose).
d. The solution in multidose vials is inspected prior to each use for unusual cloudiness,
precipitation, or foreign bodies. The rubber stopper is inspected for deterioration.
f. Medication in multidose vials may be used (until the manufacturer’s expiration date/for
the length of time allowed by state law/by facility policy for six months) if inspection
reveals no problems during that time.
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4. PREPARATION OF EMERGENCY OR UNSTABLE INFUSION THERAPY
PRODUCTS
Policy
Infusion therapy products are prepared and delivered by the infusion therapy product provider.
Procedures
a. The infusion therapy product provider notifies the charge nurse about any transfer
instability of an infusion therapy product.
b. Such notification is documented and the need for a nurse to prepare the admixture is
indicated on the infusion therapy record and on the care plan.
c. The infusion therapy product provider supplies complete preparation and handling
instructions along with the products to be mixed, and a label to be completed and affixed
to the infusion therapy product container.
e. Infusion therapy products are prepared in accordance with infection control standards and
with equipment and medication manufacturer’s recommendations.
f. The area in which infusion therapy supplies and products are stored is kept clean and free
of clutter.
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5. INFUSION THERAPY PRODUCTS: GENERAL INFORMATION
Policy
Infusion therapy products are safely and accurately administered by a facility-
certified nurse using a method approved by the Quality Assessment and Assurance Committee
or other designated patient care committee.
Procedures
a. Prior to administration of infusion therapy products, information about the stability,
storage, and/or diluent is obtained from the manufacturer package insert and labeling,
The Handbook of Injectable Drugs, AHFS Drug Information, or other reference approved
by the (Pharmaceutical Services Subcommittee).
b. The infusion therapy products provider is contacted for information about the stability,
storage, and/or diluent, if not available from the above-named references.
c. The resident’s medical record is checked for known allergies, and the resident is
monitored closely for any signs of adverse reactions after the first and second doses of
the medication. The lack of adverse reaction is charted in the resident’s medical record.
d. “Piggyback” solutions are prepared and labeled by the infusion therapy products provider
in the same manner as other medications in solution.
e. The method of infusion therapy administration selected is consistent with the resident’s
care plan and facility policy.
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6. CONTROLLED MEDICATIONS
Policy
Medications included in the Drug Enforcement Administration (DEA) classification as
controlled substances are subject to special handling, storage, disposal, and recordkeeping in the
facility, in accordance with federal and state laws and regulations.
Procedures
a. The Director of Nursing and the consultant pharmacist maintain the facility’s compliance
with federal and state laws and regulations in the handling of controlled medications.
Only authorized licensed nursing and pharmacy personnel have access to controlled
medications.
b. Medications are obtained from the locked cabinet or safe, or medication cart (if a
Schedule III, IV, or V medication).
c. Preparation of the dosage form occurs following the procedures detailed in Guidelines for
Medication Administration, steps a-q, s-u, and w-y.
e. When a dose of a controlled medication is removed from the container for administration
but refused by the resident or not given for any reason, it is not placed back in the
container. It must be destroyed (in the presence of two licensed nurses) and the disposal
documented on the accountability record on the line representing that dose. The same
process applies to the disposal of unused partial tablets and unused portions of single
dose ampules.
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7. IRRIGATION SOLUTIONS
Policy
Irrigation solutions are used in accordance with label directions for storage, use, and disposal.
Aseptic technique is used in the handling and application of irrigation solutions.
Procedures
a. Irrigation solutions are labeled with the date and time immediately upon opening.
c. Solutions prepared in the facility (such as Neosporin G.U., hydrogen peroxide solutions)
are disposed of within (24) hours.
e. When expired, unused solutions are (poured down the drain). It is not necessary to
record disposal of partial containers.
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8. ENTERAL TUBE MEDICATION ADMINISTRATION
Policy
The facility assures the safe and effective administration of enteral formulas and medications.
Selection of enteral formulas, routes and methods of administration, and the decision to
administer medications via enteral tubes are based on nursing assessment of the resident’s
condition, in consultation with the physician, dietitian, and consultant pharmacist.
Procedures
a. Enteral formulas, equipment, route of administration, and rate of flow are selected based
on an assessment of the resident’s condition and need.
e. When new medication orders are received from the prescriber, the intended route of
administration is also obtained. The provider pharmacy is informed that the resident is
receiving medications through the enteral tube. Medications for enteral administration
are obtained in easily pulverized or liquid form. The provider pharmacy is consulted to
determine the best method for preparing dosage forms for enteral tube administration
when liquid formulations are not available.
f. Enteral tubes are flushed before administering medications and after all medications have
been administered with at least 30 ml of water.
g. Prior to crushing tablets for administration through the enteral tube, the Crushing
Guidelines and list are consulted.
1) A mortar and pestle are preferable to a tablet crusher, since they can reduce the
tablet to a finer powder than can the tablet crusher.
2) Crushed medications are not mixed together. The powder from each medication
is mixed with water, or other suitable diluent if water is unacceptable, before
administration. Each medication is administered separately to avoid interaction
and clumping.
3) The medication cup is rinsed with water to get all of the medication.
4) The enteral tubing is flushed with at least 5 ml of water between each medication
to avoid physical interaction of the medications.
64
h. The provider pharmacy or consultant pharmacist is consulted when changing to a
different formulation or when initiating enteral therapy for necessary dose scheduling
adjustments of the medications or feeding schedule adjustments.
1) If on continuous feeding, it may be necessary to change to intermittent feeding to
avoid an interaction between enteral solution and some medications.
2) If on intermittent feeding, it may be necessary to delay feeding up to two hours to
avoid a medication interaction (for example, phenytoin) with enteral solution.
i. Medications that are GI irritants (such as potassium chloride solution) are diluted as
recommended for oral administration, since there is a high potential for gastric irritation
when medications are administered directly into the stomach through enteral tubes.
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SPECIFIC MEDICATION ADMINISTRATION PROCEDURES
a. Note any allergies or contraindications the resident may have prior to drug
administration.
f. Medication cart is to be kept locked at all times unless in use and within nurse’s sight.
g. Cleanse hands before handling medication and before contact with resident.
i. Obtain and record any vital signs as necessary prior to medication administration.
l. Observe for medication actions/reactions and record on the PRN effectiveness sheet
when appropriate.
m. Once removed from the package or container, unused doses should be disposed of
according to facility policy. If the medication is a controlled substance, the medication is
given to the director of nursing for disposal as per regulations.
These guidelines refer to all medications, in addition to specific procedures for each type of
medication.
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2. ORAL MEDICATION ADMINISTRATION PROCEDURE
Purpose
To administer oral medications in an organized and safe manner.
Equipment Required
1. Medication cart with medications
2. Medication book containing Medication Administration Record
3. Medication cups
4. Drinking cups
5. Mortar and pestle/tablet crusher/tablet splitter
6. Pitcher of water
7. Controlled substances records (if appropriate)
8. Towelettes or handwashing solution
Special Considerations
1. Refer to crushing guidelines prior to crushing any medication for assurance that it can be
pulverized.
2. Refer to medication reference text for administration of any medication when added to
any substance such as applesauce, juice, milk, etc.
3. Mortar and pestle/tablet crusher/tablet splitter should be cleaned after each use.
Procedures
1. Pour the correct number of tablets or capsules into the medication cup.
2. If medication is liquid, pour correct amount directly into a graduated medication cup or
measuring device provided with liquid.
3. Crush medications if indicated for this resident only after checking the Crush List. Crush
in tablet crusher or mortar and pestle or with other appropriate device and clean
immediately after use.
4. Wipe rim and sides of bottle with tissue or towelette and replace cap after pouring.
5. Liquid medications may be diluted in any fluid indicated by the physician’s order. Liquid
potassium supplements, bulk laxatives, and liquid stool softener may be diluted in juice at
nurse’s discretion.
6. Administer medication and remain with resident while medication is swallowed.
7. If resident is in bed, head of bed should be elevated to greater than 45 degrees prior to
administration of medication and for at least two minutes after.
8. Follow all medication with 4 to 8 ounces of water.
67
3. SUBLINGUAL AND BUCCAL MEDICATION ADMINISTRATION PROCEDURE
Purpose
To administer sublingual medications under the resident’s tongue safely and accurately. To
administer buccal medications in the resident’s cheek safely and accurately.
Equipment Required
1. Medication administration cup
2. Medication administration record (MAR)
3. Medication
4. Towelettes or handwashing solution
Procedures
1. Pour proper number of sublingual/buccal tablets/capsules into medication cup.
2. Have resident take a sip of water to moisten his or her mouth, and instruct resident to
swallow water.
3. Place medication in the resident’s mouth or help resident to do so if capable, following
the directions shown below.
a. Place buccal tablet in the pouch between cheek and upper or lower gum.
b. Place sublingual tablet under the tongue.
4. Instruct resident to close his/her mouth and to not swallow or chew until the tablet has
completely dissolved. Eating, drinking, and smoking should be avoided while the tablet is
dissolving.
5. Instruct the resident to avoid rinsing the mouth for several minutes after the tablet has
dissolved.
6. Wash your hands.
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4. NASAL INHALERS, SPRAYS, AND PUMPS ADMINISTRATION PROCEDURE
Purpose
To administer nasal medications in a safe and accurate manner.
Equipment Required
1. Inhalation or spray medication
2. Medication Administration Record (MAR)
Procedures
1. Determine that an adequate amount of medication is remaining in the aerosol canister or
pump.
2. Have resident blow his/her nose gently to clear the nostrils.
3. Shake the medication container.
4. Administer medication to resident or help resident to do so if capable, following the
directions shown below.
a. Have resident keep head upright. Press a finger against the side of the nose to
close one nostril. Keeping mouth closed, tip of pump, spray or inhaler is inserted
into the nostril. Have resident sniff in through open nostril while pump or inhaler
is quickly and firmly squeezed or activated.
b. Instruct resident to hold his/her breath for a few seconds and then breathe out
through mouth.
c. Repeat for other nostril if indicated.
5. Wash your hands.
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5. NOSE DROPS ADMINISTRATION PROCEDURE
Purpose
To relieve inflammation and/or congestion of the mucous membranes through the administration
of medications into the nasal cavity.
Equipment Required
1. Prescribed Solution
2. Tissues or Sterile Gauze
3. Medication Administration Record (MAR)
Procedures
1. Have resident gently blow his/her nose to clear the nostrils.
2. Have resident lie on a bed with the head tilted back and the neck supported, as shown.
3. Shake the nose drops container.
4. Insert the dropper tip into the nostril about 1/3 inch, and place the prescribed dose or
number of drops in the nostril. Avoid touching dropper tip to nose.
5. Instruct resident to remain in the same position for at least five (5) minutes.
6. Repeat with other nostril if indicated.
7. Wash your hands.
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6. EYE DROPS ADMINISTRATION PROCEDURE
Purpose
To administer ophthalmic solution into and around the eye in a safe and accurate manner.
Equipment Required
1. Bottle of Eye Drops
2. Sterile Gauze Pad
3. Medication Administration Record (MAR)
Procedures
1. Shake the eye drops container.
2. Remove the cap, taking care to avoid touching the dropper tip.
3. Have resident tip his/her head back slightly.
4. Pull the lower eyelid down and away from the eyeball to form a pocket, as shown.
5. Hold the dropper tip directly over the eye, taking care to avoid touching the eye or eyelid.
6. Instruct resident to look upward, and place one drop into the pocket, continuing to hold
the eyelid for a moment to allow the medication to distribute.
7. Release the eyelid and instruct the resident to close the eye for one or two minutes. Do
not allow the resident to squeeze the eye shut or rub the eye. If stinging or burning
occurs, reassure the resident that this is temporary.
8. Use gauze to remove any excess drops on the resident’s face.
9. Replace the cap on the eyedrops container.
10. Wash your hands.
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7. EYE OINTMENT AND GEL ADMINISTRATION PROCEDURE
Purpose
To administer ophthalmic ointment or gel into and around the eye in a safe and accurate manner.
Equipment Required
1. Tube of Ophthalmic Ointment or Gel
2. Sterile Gauze Pad
3. Medication Administration Record (MAR)
Procedures
1. Remove the cap from the medication tube, taking care to avoid touching the tip of the
tube.
2. Have the resident tilt his/her head back slightly.
3. Pull the lower eyelid down and away from the eyeball as shown, to form a pocket.
4. Squeeze the tube and apply the prescribed amount of ointment or gel to the inner surface
of the lower eyelid. Do not touch the tip of the medication tube to the eye or the eyelid.
5. Release the eyelid and instruct the resident to gently close the eye, and to keep it closed
for one (1) to two (2) minutes. While the eye is closed, it may be gently rotated to
distribute the medication.
6. Instruct the resident to avoid squeezing the eye shut or rubbing the eye.
7. Replace the cap on the medication tube.
8. Wipe off any excess gel or ointment with the gauze pad.
9. Inform the resident that eye ointments/gels can temporarily blur the vision.
10. Wash your hands.
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8. EAR DROPS ADMINISTRATION PROCEDURE
Purpose
To administer medication into the auditory canal.
Equipment Required
1. Medication in Dropper Bottle
2. Cotton Balls
3. Medication Administration Record (MAR)
Procedures
1. Warm the ear drops, if cold, by holding the container in your hand for a few minutes. Do
not warm the container in hot water, since instillation of a hot liquid into the ears can
cause pain, nausea and dizziness.
2. Shake the container.
3. Have the resident tilt his/her head to one side, or lie down with the affected ear facing up.
4. Open the container and position the dropper tip near, but not inside, the ear canal
opening, to avoid contamination.
5. Pull the resident’s ear backward and upward to open the ear canal.
6. Place the proper number of drops into the ear canal, and replace cap on container.
7. Gently press the small, flat skin flap over the ear canal to force out air bubbles and
encourage drops down the ear canal.
8. Instruct resident to stay in the same position for at least five (5) minutes. If the resident is
unlikely to be able to comply with this requirement, place a clean piece of cotton ball into
the ear canal opening to prevent medication from draining out.
9. Repeat the procedure for the other ear if indicated.
10. Gently wipe any excess medication off the outside of the ear.
11. Wash your hands.
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9. ORAL INHALATION ADMINISTRATION PROCEDURES
Purpose
To allow for correct administration of oral inhalers to residents, and for instruction in proper
technique for those residents able to administer the medication to themselves.
Equipment Required
1. Metered Dose Inhaler
2. Aerochamber or Spacer Device
Procedures
1. Determine that an adequate amount of medication is remaining in the aerosol canister.
2. Remove the cap and hold the inhaler upright.
3. Shake the inhaler.
4. Attach the aerochamber or spacer device.
5. Instruct the resident to tilt his/her head back slightly, stand or sit up as straight as
possible, and breathe out through mouth.
6. Place aerochamber with inhaler attached into mouth.
7. Instruct resident to inhale slowly as you depress the canister to release the medication.
8. Breathe in and out normally for one (1) minute, keeping aerochamber in place in the
mouth.
9. Repeat doses as prescribed (see below for general guidelines on spacing of
doses/medications).
10. Have resident rinse his/her mouth and spit out the rinse water.
11. Wash your hands.
*Aerochambers or spacers should be used with most inhalers to facilitate proper dosing in this
patient population.
Spacing and Proper Sequence of the different inhalers is important for maximum drug
effectiveness. If more than one inhaler is used, following the sequence below provides the
most benefit to the patient.
1. Bronchodilators/Beta Agonists
(albuterol/Ventolin, Proventil; metaproterenol/Alupent; pirbuterol/Maxair;
bitolterol/Tornalate)
• These agents work by promoting bronchodilation by relaxing bronchial smooth
muscle
2. Anticholinergic Agents
(ipratropium/Atrovent)
• Antagonizes the action of acetylcholine with resulting bronchodilation
• Minimal systemic activity
• Is used for maintenance therapy only, not acute episodes
• May be more useful than traditional bronchodilators in chronic bronchitis
74
3. Miscellaneous Agents
(cromolyn/Intal; nedocromil/Tilade)
• Stabilizes mast cells and inhibits the release of histamine from these cells
• Must be used on a regular basis, not useful on a PRN basis
• May be used prophylactically prior to exercise
4. Corticosteroids
(beclomethasone/Beclovent, Vanceril; triamcinolone/Azmacort; flunisolide/AeroBid;
dexamethasone/Decadron)
• Anti-inflammatory agents that may have a variety of actions useful in
management of COPD
• Must be used on a regular basis, not PRN agents
• Minimal systemic activity
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10. RECTAL SUPPOSITORY ADMINISTRATION PROCEDURE
Purpose
To administer medication rectally in a safe and accurate manner; to maintain and regulate a
therapeutic regimen of bowel evacuation.
Equipment Required
1. Rectal Suppository as ordered
2. Disposable Glove
3. Lubricant
4. Tissue
5. Paper Towel
6. Medication Administration Record (MAR)
7. Bedpan or Commode where applicable
Procedures
1. Assist resident in turning to left side with knees bent.
2. Remove wrapper from suppository.
3. Put glove on right or left hand.
4. Lubricate index finger and suppository.
5. Separate buttocks.
6. Insert suppository gently into rectum beyond sphincter about 3 inches.
a. Ask the resident to take a deep breath, to relax the anal sphincter.
7. Apply pressure with tissue over anus briefly until desire to expel suppository has passed.
a. Instruct resident to retain suppository for 10–15 minutes if possible.
8. Place tissue and glove in paper towel.
9. If suppository was for bowel evacuation, assist resident onto a bedpan, commode, or
toilet. Make the resident comfortable.
a. Leave call signal with resident or check back at intervals.
10. Elevate head of bed to Fowler’s position if the resident remains in bed.
11. Remove soiled articles. Place in covered, plastic-lined container in utility room.
12. Wash your hands.
13. Document effect of suppository if for bowel evacuation.
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11. RECTAL ENEMA ADMINISTRATION PROCEDURE
Purpose
To administer medication rectally in a safe and accurate manner; to maintain and regulate a
therapeutic regimen of bowel evacuation.
Equipment Required
1. Rectal enema as ordered
2. Disposable Gloves
3. Lubricant
4. Tissue
5. Paper Towel
6. Medication Administration Record (MAR)
7. Bedpan or Commode where applicable
Procedures
1. Assist resident in turning to left side with knees bent.
2. Prepare enema for administration.
3. Put gloves on.
4. Separate buttocks.
5. Insert enema tip gently into rectum beyond sphincter about 3 inches.
a. Ask the resident to take a deep breath, to relax the anal sphincter.
6. Slowly empty the contents of the enema into the colon.
a. Instruct resident to resist urge to expel colon contents while enema is being
administered, and afterward for as long as possible.
b. If resident is uncomfortable, flow may be too fast.
c. Enema solution should be retained until definite lower abdominal cramping
is felt.
7. Remove gloves and discard appropriately.
8. If enema was for bowel evacuation, assist resident onto a bedpan, commode, or toilet.
Make the resident comfortable.
a. Leave call signal with resident or check back at intervals.
9. Elevate head of bed to Fowler’s position if the resident remains in bed.
10. Remove soiled articles. Place in covered, plastic-lined container in utility room.
11. Wash your hands.
12. Document effect of enema if for bowel evacuation.
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12. VAGINAL MEDICATION ADMINISTRATION PROCEDURE
Purpose
To administer vaginal medication safely and accurately for therapeutic effect.
Equipment Required
1. Medication
2. Sterile Glove
3. Water-Soluble Gel, if appropriate
4. Applicator, if appropriate
5. Tissue
6. Paper Towel
7. Medication Administration Record (MAR)
Procedures
1. Place tablet/suppository in applicator or draw cream/gel into applicator.
2. Have resident lie on back with knees flexed and legs spread apart, or on left side with
knees bent.
3. Wearing sterile gloves, examine perineum.
a. Clean area if discharge is noted.
4. With one hand, spread apart the labia.
a. Place applicator into vagina and advance the plunger to instill gel or cream or to
release tablet or suppository.
b. If without applicator, insert lubricated tablet or suppository approximately 3-4
inches into vaginal area.
5. Wipe lubricant from vaginal area with tissue.
6. Advise resident to remain lying down for about 30 minutes.
7. Place tissue and glove in paper towel.
8. Place wrapped, soiled articles in covered, plastic-lined container in utility room.
9. Wash your hands.
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13. ENTERAL TUBE MEDICATION ADMINISTRATION PROCEDURES
Purpose
To safely and accurately administer oral medications through an enteral tube.
Equipment Required
1. Medication(s)
2. Feeding (50cc) Syringe
3. 75–100 ml water
4. Clamp
5. Stethoscope
6. Drinking cup
Procedures
1. If resident is in bed, elevate head of bed to 45-degree angle.
2. Inflate trach cuff if necessary.
3. Verify tube placement.
a. Unclamp tube and use either of the following procedures:
1) insert a small amount of air into the tube with the syringe and listen to
stomach with stethoscope for gurgling sounds; or
2) aspirate stomach contents with syringe.
4. Reclamp tube to maintain a closed system. Check that breathing tube is not clamped.
5. Prepare medications for administration.
a. Mortar and pestle are preferable to tablet crusher for preparing tablets for enteral
administration to allow smaller particle size.
b. Consult “Crush Guidelines” before crushing tablets
c. Crush tablets and dissolve in 10–15 ml of water or other appropriate liquid.
d. Empty capsule contents into 10–15 ml of water or other appropriate liquid.
e. Dilute liquid with 10–15 ml of water, using up to 60 ml of water as for oral
administration.
f. Dilute gastric irritants in water for highly concentrated solutions.
6. Flush the tube with 30ml of water prior to medication administration.
7. Administer each medication separately, flushing tube with 5 ml of water after
each dose.
a. Administer liquid medications first, then those that need to be diluted. Reserve
thick medications, e.g., antacids, for last.
b. Allow medication to flow down tube via gravity.
c. Give gentle boosts with the plunger (approximately 1 inch down) if the
medication will not flow by gravity. Repeat if necessary. Do not push medications
through the tube.
8. Flush the tube with 30 ml of water and clamp for 30 minutes before reattaching.
9. Leave head of bed elevated for 30 minutes to prevent aspiration of stomach contents.
10. Leave trach cuff inflated for 30 minutes.
11. Clean feeding syringe and return to bedside stand.
12. Wash your hands.
79
14. TRANSDERMAL DRUG DELIVERY SYSTEM (PATCH) APPLICATION
PROCEDURES
Purpose
To administer medication through the skin for continuous absorption while the patch is in place,
through proper placement of the patch and care of the application sites.
Equipment Required
1. Medication Patch
2. Alcohol Wipes
Procedures
1. Identify the location on the body for patch placement.
2. Remove old patch from body.
3. Cleanse area of old patch with alcohol wipe.
4. Remove new patch from package and envelope.
5. Apply new patch firmly against skin.
6. Wash your hands.
7. Document placement site on MAR as follows:
SITE CODE
Left upper arm LA
Right upper arm RA
Left upper thigh LT
Right upper thigh RT
Left chest LC
Right chest RC
Left upper back LB
Right upper back RB
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15. INTRAMUSCULAR MEDICATION ADMINISTRATION
Purpose
To administer an aqueous suspended medication into the intramuscular tissue.
Equipment Required
1. Medication as ordered, reconstituted if appropriate.
2. Syringe capable of holding the medication.
3. Sterile needle (size depends on the size of the resident, viscosity of drug, comfort of the
drug).
4. Alcohol wipes.
Sites of Administration
1. Ventriogluteal (front of hip area).
2. Deltoid (arms).
3. Dorsogluteal (back buttock).
4. Vastus lateralis (upper lateral area of leg).
5. Rectus femoris (medial upper leg).
Procedures
1. Prepare medication as follows:
a. Calculate correct amount of medication.
b. Shake well if required.
c. Prepare syringe and needle.
1) Swab rubber cap with alcohol sponge.
2) Pull back plunger to draw a volume of air into the syringe equal to volume
of medication to be given. Inject air into vial.
3) Withdraw correct amount of medication.
4) Create air lock in syringe.
5) Recap needle.
2. Select an appropriate site for injection.
3. Adjust resident’s position.
4. Cleanse skin with alcohol sponge, using circular motion from center of chosen site until
an area about 3 inches in diameter has been prepared
5. Expel air from syringe.
6. Expose site to be injected.
7. Gently tap the area to stimulate nerve endings and minimize initial pain.
8. Stretch the skin so that it is taut, to ease needle insertion.
9. Using the other hand to hold the syringe, insert the needle at a 90-degree angle; use a
quick, dart-like thrust.
10. Pull back on plunger to see if needle is in a blood vessel. If so, withdraw needle, secure
new equipment and medication, and repeat procedure.
11. Hold the needle steady and inject the medication at slow, even rate.
12. Withdraw needle rapidly.
13. Swab the area with an alcohol wipe in a circular motion.
14. Discard syringe and needle in designated area. Do not recap needle.
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15. Wash hands.
16. Document the injection on the MAR along with site used, as follows:
SITE CODE
Left Buttock LB
Right Buttock RB
Left Arm LA
Right Arm RA
Left Thigh LT
Right Thigh RT
82
16. SUBCUTANEOUS MEDICATION ADMINISTRATION PROCEDURES
Purpose
To administer a parenteral medication into the subcutaneous tissue in order to promote slow
medication absorption and prolong medication action.
Equipment Required
1. Sterile syringe and appropriate gauge needle
2. Alcohol wipes
3. Medication container
Procedures
1. Prepare medication as follows:
a. Calculate correct amount of medication.
b. Shake well if required.
c. Prepare syringe and needle.
1) Swab rubber cap with alcohol sponge.
2) Pull back plunger to draw a volume of air into the syringe equal to volume
of medication to be given. Inject air into vial.
3) Withdraw correct amount of medication.
4) Create air lock in syringe.
5) Recap needle.
2. Select an appropriate site for injection.
3. Adjust resident’s position.
4. Cleanse skin with alcohol sponge, using circular motion from center of chosen site until
an area about 3 inches in diameter has been prepared.
5. Expel air from syringe.
6. Expose site to be injected.
7. Gently tap the area to stimulate nerve endings and minimize initial pain.
8. Grasp and pinch a cushion of flesh.
9. Hold needle with bevel side up and insert at a 45-degree angle.
10. Insert needle quickly.
11. Pull back on plunger to see if needle is in a blood vessel. If so, withdraw needle, secure
new equipment and medication, and repeat procedure.
12. Inject medication slowly.
13. Remove needle quickly.
14. Wipe area with alcohol sponge. Apply pressure over the injection site for 2 minutes.
15. Discard syringe and needle in designated area. Do not recap needle.
16. Wash hands.
17. Document the injection on the MAR along with site used, as follows:
SITE CODE
Left Buttock LB
Right Buttock RB
Left Arm LA
Right Arm RA
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Left Thigh LT
Right Thigh RT
Left Abdomen LS
Right Abdomen RS
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17. INFUSION THERAPY MEDICATION ADMINISTRATION PROCEDURES
Purpose
To provide for the safe and accurate administration of parenteral medications through the vein.
Equipment Required
1. Infusion therapy medication prepared by provider pharmacy.
2. Emergency or unstable IV medication prepared in the facility, if not prepared by provider
pharmacy.
3. Alcohol wipes.
Procedures
1. Obtain infusion therapy medication.
2. Draw required amount of medication into syringe.
3. Complete “Infusion Therapy Solution/Additive” label and place on IV bag or bottle
4. Clamp tubing.
5. Wipe rubber stopper of infusion therapy solution container with alcohol swab.
6. Follow procedures for adding medication directly to solution or via “piggyback”
according to type of system in use.
7. Unclamp tubing and allow fluid to flow through.
8. Regulate flow of medication infusion as prescribed.
9. Discard syringe and needle in designated area. Do not recap needle.
10. Wash hands.
11. Document in Nursing Progress Notes:
a. type of solution and medication
b. duration of medication infusion
c. any untoward reactions
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MEDICATION MONITORING
Policy
The facility supports pharmacy services that promote quality care including drug regimen review
(DRR). DRR is defined as the systematic evaluation of drug therapy viewed within the context of
resident-specific data. The consultant pharmacist reviews the medication regimen of each
resident at least monthly and a medication review must be performed for any resident whose
length of stay is less than 30 days. Findings and recommendations are reported to the
administrator, director of nursing, the attending physician, and the medical director, where
appropriate.
Procedures
a. The facility assures that the consultant pharmacist has access to residents and the
residents’ medical records; the provider pharmacy’s resident medication profiles, if
requested; the facility’s records of medication receipt and disposition; medication storage
areas; and controlled substances records and supplies.
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a) The resident’s response to drug treatment is evaluated through the use of
laboratory data, physical assessment, medication administration record,
and other data to determine if therapeutic goals are achieved.
b) Side effects, adverse reactions, and interactions (drug–drug, drug–diet,
drug–lab test and drug–disease) are evaluated, and modifications or
alternatives are considered.
c) Medical condition and response to drug therapy are used to evaluate the
drug regimen for unnecessary medications.
d. Resident-specific DRR recommendations and findings are documented and acted upon by
the facility and/or physician.
e. The consultant pharmacist compiles and analyzes data collected during DRR and presents
findings to the (Quality Assessment and Assurance Committee or Pharmaceutical
Services Subcommittee) as a part of the facility continuous quality improvement (CQI)
program.
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2. MONITORING OF MEDICATION ADMINISTRATION
Policy
The consultant pharmacist evaluates medication administration to verify that the resident has
received medications in accordance with the prescriber’s orders and facility policy. Procedures,
personnel, and techniques are monitored, and intervention is provided when necessary.
Medication monitoring includes, but is not limited to, medication pass observation, which is
conducted by the consultant pharmacist or other designated facility or pharmacy personnel.
Procedures
a. The consultant pharmacist reviews written records to determine that:
1) Medications are administered at the frequency and times indicated in the
prescriber orders.
2) “Stop order” policies, where utilized, are observed.
3) “Standing orders,” where utilized, are implemented appropriately.
4) Refusal or inability of the resident to take medications is evaluated, documented
and responded to appropriately.
5) Alteration of dosage forms, such as pill crushing, has not impaired therapeutic
response.
6) Administration of medications is documented, including the frequency and reason
for administration of as needed (PRN) medications.
7) Residents who self-administer medications are counseled regarding technique.
The consultant pharmacist routinely evaluates the resident’s response to therapy,
refill frequency, storage conditions, and medication information needs.
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3. PSYCHOACTIVE DRUG MONITORING
Policy
Residents who receive antidepressant, hypnotic, antianxiety, or antipsychotic medications are
monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that
residents receiving these medications obtain the maximum benefit with the minimum of
untoward effects.
Procedures
a. Residents receive a psychoactive medication only if designated medically necessary by
the prescriber. The medical necessity is documented in the resident’s medical record and
in the care planning process.
b. The continued need for the psychoactive medication is reassessed regularly by the
prescriber and the care planning team. If continuation is deemed necessary, this is
indicated in the medical record. Effects of the medications are documented as a part of
the care planning process. Unless medically contraindicated, periodic dosage reductions
are attempted and the results documented.
d. Therapy with psychoactive drugs is initiated at a low dose and gradually increased as
necessary whenever possible.
e. Dose scheduling of the psychoactive medications takes into account the resident’s
lifestyle and habits; for example, a resident should not be awakened to receive a
medication for insomnia.
f. Initiation and dosing of the psychoactive medication follows recommendations from the
medical literature, clinical practice guidelines, and regulations and standards.
g. All of the following conditions are satisfied prior to initiation and/or continuation of
therapy:
1) Possible reversible causes for the resident’s distress have been ruled out.
2) Use results in maintenance or improvement in the resident’s functional status.
3) Long-term daily use has been accompanied by unsuccessful gradual dosage
reductions.
4) The need for and response to therapy are monitored and documented in the
resident’s medical record.
h. For deviation from the recommended dosage and dosage reduction criteria, the clinical
record contains evidence to support justification for use of a drug not meeting the dosage
criteria but considered clinically appropriate by the physician. Examples include:
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1) a medical or psychiatric consultation or evaluation supporting confirming
physician’s conclusion.
2) physician, nurse, or other health professional documentation that the resident is
being monitored for adverse consequences or complications of therapy.
3) documentation that previous dosage reductions have been unsuccessful.
4) documentation of resident’s subjective or objective improvement or maintenance
of function while on the regimen in MEDICINE CHEST ion.
5) documentation that a resident’s decline or deterioration is evaluated by the
interdisciplinary team to determine that the regimen in MEDICINE CHEST ion is
not the cause.
6) documentation that the resident’s age, weight, or other factors require a unique
drug dose or duration.
7) other evidence that may be used to justify the regimen in MEDICINE CHEST
ion.
i. The consultant pharmacist compiles, analyzes, and presents data related to psychoactive
drug use in the facility as a component of the CQI process.
j. The facility utilizes the data presented by the consultant pharmacist (and others) to
formulate and monitor psychoactive drug use improvement plans.
k. Psychoactive drug monitoring guidelines include but may not be limited to:
Antianxiety/Sedative Drugs
DRUG RECOMMENDED
DOSE/DAY (mg)
FOR THE ELDERLY
Short-acting Benzodiazepines
Alprazolam 0.75
Estazolam 0.5
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Lorazepam 2
Oxazepam 30
Long-acting Benzodiazepines
Chlordiazepoxide 20
Clonazepam 1.5
Clorazepate 15
Diazepam 5
Flurazepam 15
Halazepam 40
Quazepam 7.5
Antidepressants
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Antipsychotics
1) Antipsychotics are given only if the resident has been diagnosed with one of the
following indications, as defined by the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV) or subsequent editions and the
diagnosis is documented in the medical record, or if the resident is under
psychiatric care for a diagnosis not included on the list:
a) schizophrenia
b) schizo-affective disorder
c) delusional disorder
d) psychotic mood disorders (including mania and depression with psychotic
features)
e) acute psychotic episodes
f) brief reactive psychoses
g) schizophreniform disorder
h) atypical psychosis
i) Tourette’s disorder
j) Huntington’s disease
k) organic mental syndromes (including dementia, delirium, and amnestic
and other cognitive disorders) with associated psychotic and/or agitated
behaviors
2) Residents receive antipsychotic medication only for behaviors that are
quantitatively and objectively documented through the use of behavioral
monitoring charts or a similar mechanism.
3) Residents receive antipsychotic medication only for behaviors that are persistent,
that are not caused by preventable reasons, and are causing the resident to:
a) present a danger to self or others
b) continuously scream, yell, or pace
c) experience psychotic symptoms (such as hallucinations, paranoia,
delusions)
4) The above guidelines and recommended dosages below do not apply to the
following conditions:
a) Short-term symptomatic treatment (7 days) for residents with hiccups,
nausea, vomiting, or pruritus.
b) Residents with nausea and vomiting secondary to cancer or cancer
chemotherapy.
5) Antipsychotics are not used solely for the following conditions if there is no other
indication:
a) wandering
b) poor self-care
c) restlessness
d) impaired memory
e) anxiety
f) depression without psychotic features
g) insomnia
h) unsociability
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i) indifference to surroundings
j) fidgeting
k) nervousness
l) uncooperativeness
m) agitated behaviors that do not represent danger to the resident or others
6) Antipsychotic drugs are not used in excess of the doses shown for residents with
“organic mental syndromes” as shown in 1) k) above, unless higher doses are
necessary to maintain or improve the resident’s functional status:
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justification appears somewhere in the resident’s medical record.
The justification includes:
(a) a diagnosis with description of symptoms
(b) a discussion of the psychiatric and medical differential
diagnosis
(c) a description of the rationale for the choice of a particular
treatment(s)
(d) a discussion of why the present dose is necessary to
manage the resident’s symptoms
8) Residents who are receiving antipsychotic drug therapy are adequately monitored
for significant side effects of such therapy, through the use of the AIMS, or
DISCUS and other appropriate tests.
Hypnotics
Alprazolam 0.25
Chloral hydrate 500
Diphenhydramine 25
Estazolam 0.5
Hydroxyzine 50
Lorazepam 1
Oxazepam 15
Temazepam 7.5
Triazolam 0.125
Zolpidem 5
2) A gradual dosage reduction is attempted at least three times within six months
before a clinical contraindication is documented.
3) The drugs listed below are not initiated for any resident. If a resident is admitted
to the facility using one of these drugs, a gradual dosage reduction is attempted.
Barbiturates Ethchlorvynol
Glutethimide Meprobamate
Methprylon Paraldehyde
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4. DOCUMENTATION AND COMMUNICATION OF CONSULTANT PHARMACIST
RECOMMENDATIONS
Policy
The consultant pharmacist works with the facility to establish a system whereby the consultant
pharmacist observations and recommendations regarding residents’ drug therapy are
communicated to those with authority and/or responsibility to implement the recommendations,
and responded to in an appropriate and timely fashion.
Procedures
a. A record of the consultant pharmacist’s observations and recommendations is made
available in an easily retrievable form to nurses, physicians, and the care planning team.
This should include:
1) Documentation of the date each medication regimen review is completed on the
appropriate form and notation of the findings in the medical record or other
designated site.
2) A standard format utilized by clinical care providers, such as SOAP or FARM
notes may be used to record and/or communicate pharmacist findings.
3) The consultant pharmacist documents potential or actual medication therapy
problems and other drug regimen review findings appropriate for prescriber
and/or nursing review.
f. (A copy of the drug regimen review notification form is sent to each attending physician
new to the facility, with an explanatory cover letter.
g. The consultant pharmacist compiles, analyzes, and presents aggregate data about
recommendations, response to recommendations, and outcomes as part of the pharmacy
CQI program in the facility.
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APPENDIX 1: TABLE OF WEIGHTS AND MEASURES
96
APPENDIX 2: MEDICAL ABBREVIATIONS
97
Mcg. Microgram ml. Milliliter
mm. Millimeter mm Hg Millimeters of
mercury
M mol Millimole Mosm Milliosmole
Mg. Milligram m. Minim
ss. One half Ng. nanogram
Abbreviations associated primarily with the history and admission of the patient
Abbreviation Meaning Abbreviation Meaning
ADM Admission, admit NKA No Known
Allergies
O Objective P Plan
A&W Alive and Well PTA Prior to admission
CC Chief complaint RXN Reaction
C/O Complaints of SH Social History
D/C, DC Discontinue, discharge S&S Signs and symptoms
PMH Past medical history TPR Temperature, pulse,
respiration
DX Diagnosis UK Unknown
ER Emergency Room WM White male
FH Family history WNL Within normal
limits
F/U Follow up W/U Work up
S Subjective YO Year(s) old
H/O History of WDWN Well developed,
well nourished
H&P History & physical VS Vital signs
HPI History of present illness WF White female
Hx History NEF Negative
N Normal NC Non-contributory
NA Not applicable NAD No acute distress
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transaminase
K Potassium TIBC Total iron binding
capacity
LFT Liver function tests SGPT Serum glutamic-
pyruvic
transaminase
Lytes Serum electrolytes MCH Mean corpuscular
hemoglobin
RBC Red blood cell MCHC Mean corpuscular
hemoglobin
concentration
WBC White blood cell Chol Cholesterol
Na Sodium CO2 Carbon dioxide
Cl Chloride MCV Mean corpuscular
volume
PFT Pulmonary function tests PMN Polymorphonuclear
monocyte
Plt Platelets PT Prothrombin time
PTT Partial thromboplastin time Retic Reticulocyte
RF Rheumatoid factor Fe Iron
Sp. Gr. Specific gravity RFT Renal function tests
Segs Polymorphonuclear leukocytes SMAC Sequential multiple
analyzer computer
BCP Blood chemistry profile SR Sedimentation rate
T3 Triiodothyronine T4 THYROXINE
TBG Thyroid binding globulin TNTC Too numerous to
count
UA Urinalysis TP Total protein
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VO Verbal order SO Standing order
Medical Conditions
Abbreviation Meaning Abbreviation Meaning
AF Atrial fibrillation PA Pernicious anemia
AI Aortic insufficiency PAC Premature atrial
contraction
AKA Above knee amputation PAT Paroxysmal atrial
tachycardia
ARF Acute renal failure PND Paroxysmal
nocturnal dyspnea
ASCVD Arteriosclerotic coronary PUD Peptic ulcer disease
vascular disease
ASHD Arteriosclerotic heart disease PVC Premature
ventricular
contraction
BBB Bundle branch block PVD Peripheral vascular
disease
BPH Benign prostatic hypertrophy RA Rheumatoid arthritis
CA Carcinoma RF Renal failure
CAD Coronary artery disease RSR Regular sinus
rhythm
CHF Congestive heart failure RVH Right ventricular
hypertrophy
CLL Chronic lymphocytic leukemia SIADH Syndrome of
inappropriate ADH
secretion
CML Chronic myelogenous leukemia SLE Systemic lupus
erythematosus
COLD Chronic obstructive lung disease SOB Shortness of breath
COPD Chronic obstructive pulmonary SVT Supraventricular
disease tachycardia
CRF Chronic renal failure TB Tuberculosis
CVA Cerebrovascular accident TIA Transient ischemic
attack
DJD Degenerative joint disease URI Upper respiratory
infection
DM Diabetes mellitus UTI Urinary tract
infection
ECG Electrocardiogram VF Ventricular
fibrillation
FX Fracture DVT Deep vein
thrombosis
HH Hiatal hernia FUO Fever of unknown
origin
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IHSS Idiopathic hypertrophic subartic HA Headache
stenosis
MI Myocardial infarction HTN Hypertension
IDDM Insulin dependent diabetes LAH Left atrial
mellitus hypertrophy
LES Lower esophageal sphincter NIDDM Non-insulin
dependent diabetes
mellitus
GERD Gastroesophageal reflux disease
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Reg Regular insulin SSKI Saturated solution
of potassium iodide
102