(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 or administered to or by the resident, 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) 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) A record shall be maintained in a bound ledger book, in ink, with consecutively numbered pages, of all controlled drugs procured or administered.

2. (2) The record shall contain:

   1. (A) Name, strength, and quantity of drug;
   2. (B) Date received and date, time, and dosage administered;
   3. (C) Name of the resident for whom the drug was prescribed or who received the drug;
   4. (D) Name of the prescribing physician or advanced practice nurse;
   5. (E) Name of the dispensing pharmacy;
   6. (F) Quantity of drug remaining after each administrated dosage; and
   7. (G) Signature of the individual administering the drug.

(f)

1. (1) For all medications stored 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 made by the person responsible for medications in the facility, and shall be witnessed by a nonlicensed 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.

(g)

1. (1) Medication administered by the facility shall be recorded in each resident's medical record no less than once each shift in which the medication is administered.

2. (2) The notation shall be in ink and shall state, at a minimum:

   1. (A) The name of the medication;
   2. (B) The dosage prescribed and the dosage taken or administered;
   3. (C) The method of administration; and
   4. (D) The date and time of the administration.