(a)
- (1) No medication or treatment shall be given without the written order of the physician or dentist.
- (2) Drugs shall be administered in accordance with orders.
(b)
- (1) If it is necessary to take physician's or dentist's orders over the telephone or verbally, the order shall be immediately written on the physician's order sheet in the medical record and signed by the nurse who took the order.
- (2) Documentation shall include the name of the physician or dentist who gave the telephone or verbal order and the date and time of the order.
- (3) The order shall be countersigned by the attending physician or dentist on his or her next regular visit or no more than seven (7) days from the time the telephone or verbal order was given.
- (4) There shall be indication made by the nurse that the orders were transcribed (signature and time).
- (c) Each resident shall be identified prior to administration of medication.
- (d) Each resident shall have an individual medication record.
- (e) The dose of a drug administered to a resident shall be properly recorded by the person who administered the drug except in established self-medication programs.
- (f) Medications shall be administered only by licensed nursing personnel except in established self-administration programs.
- (g) Treatment of a lesion or open wound shall be done only by licensed nursing personnel.
(h)
- (1) Medication setups may be prepared one (1) shift at a time.
- (2) The medication must be administered on the same shift on which they are prepared.
- (3) Liquids and injectables shall not be set up more than one (1) hour in advance.
- (i) Medications shall be administered by the same person who prepared the doses for administration, except under single unit-dose package distribution systems.
- (j) The attending physician shall be notified of an automatic stop-order prior to the last dose so that the physician may decide if the administration of the medication is to be continued or altered.
(k)
- (1) There shall be written policies and procedures for the development of any self-administration program.
- (2) These policies must include qualifications of clients to participate in the program and procedures for monitoring the program.