7.8.2.35                 MEDICATIONS:  Administration of medications or staff assistance with self-administration of medications shall be in accordance with state and federal laws.  No medications, including over-the-counter medications, PRN (when needed) medications, or treatment shall be started, changed or discontinued by the facility without an order from the physician, physician assistant or nurse practitioner and with entry into the resident’s record.

  1.             State board of nursing licensed or certified health care professionals are responsible for the administration of medications.  Administration may only be performed by these individuals.
  2.             Facility staff may assist a resident with the self-administration of medications if written consent by the resident is given to the administrator of the facility or the administrator’s designee.  If the resident is incapable of giving consent, the surrogate decision maker named in accordance with New Mexico law may give written consent for assistance with self-administration of medications.  All staff that assist with self-administration of medications shall have successfully completed a state approved assistance with self-administration of medication training program or be licensed or certified by the state board of nursing.
  3.             PRN (pro re nada) medication.

                                (1)           Physician or physician extender’s orders for PRN medications shall clearly indicate the circumstances in which they are to be used, the number of doses that may be given in a 24-hour period and indicate under what circumstances the primary care practitioner (PCP) is to be notified.

                                (2)           The utilization of PRN medications shall be reviewed routinely.  Frequent or escalating use of PRN medications shall be reported to the PCP.

  1.             Only a licensed nurse (RN or LPN) shall administer any medications or conduct any invasive procedures provided by the following routes: intravenous (IV), subcutaneous (SQ), intramuscular (IM), vaginal or rectal.  Only a licensed nurse shall administer non-premixed nebulizer treatments.
  2.             The facility shall have medication reference material that contains information relating to drug interactions and side effects on the premises.  Staff that assist in the self-administration of medications shall know interactions or possible side effects that might occur.
  3.             Medications prescribed for one resident shall not be used for another resident.
  4.             Medication assistance record (MAR).  For residents who are not independent and require assistance with self-administration, the facility shall have a MAR that documents the details of the residents’ medication, including PRN and over-the-counter medication that is assisted with self-administration by qualified staff or administered to the resident by licensed or certified staff.  The information in the MAR shall include:

                                (1)           the resident’s name;

                                (2)           any known allergies to medication that the resident has;

                                (3)           the name of the resident’s PCP or the prescriber of the medication;

                                (4)           the diagnosis or reason for the medication;

                                (5)           the name of the medication, including the drug product brand name and the generic name;

                                (6)           notation if the medication is a schedule II-IV drug;

                                (7)           the dosage of the medication;

                                (8)           the strength of the medication;

                                (9)           the frequency or how often the medication is to be taken or given;

                                (10)         the route of delivery for the medication (mouth, eye, ear, other);

                                (11)         the method of delivery for the medication (pills, drops, IM injection, other);

                                (12)         the date that the medication was started or discontinued;

                                (13)         any change in the medication order;

                                (14)         pre-medication information (i.e., pulse, respiration, blood pressure, blood sugar) as required by the medication order;

                                (15)         the date and time that the medication is self-administered, administered with assistance or is administered;

                                (16)         the initials and signature of the person assisting with or administering the medication;

                                (17)         the desired results obtained from or problems encountered with the medication (pain relieved, allergic reaction, etc.);

                                (18)         any refused dose of medication;

                                (19)         any missed dose of medication; and

                                (20)         any medication error.

  1.             No medication shall be stopped or started without specific orders from the primary care physician.
  2.              If a resident refuses to take a prescribed medication, it shall be documented and the facility shall report it to the prescriber.
  3.              A suspected adverse reaction to a medication shall be documented on the MAR and reported immediately to the PCP and the resident’s surrogate decision maker. If applicable, emergency medical treatment shall be arranged.  Documentation of the event shall be kept in the resident’s record.
  4.             Prescription medication, other than blister packs and unit dose containers, shall be kept in the original container with a pharmacy label that includes the following:

                                (1)           the resident’s name;

                                (2)           the name of the medication;

                                (3)           the date that the prescription was issued;

                                (4)           the prescribed dosage and the instructions for administration of the medication; and

                                (5)           the name and title of the prescriber.

  1.             Any medication that is removed from the pharmacy container or blister pack shall be given immediately and documented by the staff that assisted with the medication delivery.
  2.            The facility shall report all medication errors to the physician, documentation of medication errors and the prescriber’s response shall be kept in the resident’s record.
  3.             The facility shall develop and follow a written policy for unused, outdated, or recalled medications kept in the facility in accordance with 16.19.11.10 NMAC.

[7.8.2.35 NMAC – Rp, 7.8.2.36 NMAC, 1/15/2010]

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