(b)

1. (1) If the facility stores and supervises a resident’s medication, a notation must be made on the individual record for each resident who refuses, either through affirmative act, omission, or silence, or is unable to self-administer his or her medications.
2. (2) The notation shall include the date, time, and dosage of medication that was not taken, including a notation that the resident’s attending physician or advanced practice nurse was notified as required by physician or advanced practice nurse’s orders.

(c) For facilities providing assistance or monitoring medications, if medications are prescribed to be taken as needed (PRN) by the resident, documentation in the resident’s file should list the:

1. (1) Medication;
2. (2) Date and time received by the resident; and
3. (3) Reason given.

(d)

1. (1) When a dose of a controlled drug that is stored for a resident by the facility is dropped, broken, or lost, two (2) employees shall record in the record the facts of the event and sign or otherwise identify themselves for the record.
2. (2) One (1) of the employees shall be the administrator or on-site manager.

(e)

1. (1) For all medications stored for residents by the facility, there shall be a weekly count of all Schedule II, III, IV, and V controlled medications.

2. (2) The count shall be:

   1. (A) Made by the person responsible for storage of medications for residents in the facility; and
   2. (B) Witnessed by at least one (1) other employee.

3. (3) The count shall be documented by both employees and shall include:

   1. (A) The date and time of the event;
   2. (B) A statement as to whether the count was correct; and
   3. (C)

(i) If incorrect, an explanation of the discrepancy.

1. (ii) When the count is incorrect, the facility shall document as required under subsection (d) of this section.