N.J. Admin. Code § 10:44C-5.2 - Prescription medication

Current through Register Vol. 54, No. 7, April 4, 2022

(a) Persons served receiving medication shall take their own medication to the extent that it is possible, as assessed and determined by the TDT, documented in the person's ITP and in accordance with licensee procedure.
(b) If the person served is not responsible for or capable of taking his or her own medication, trained staff members shall assist and supervise the administration of the medication as prescribed.
(c) A written record shall be maintained of all medication administered by the trained staff members.
1. The record shall include the following:
i. The name of the person served;
ii. The date;
iii. The name of medication;
iv. The type of medication;
v. The dosage;
vi. The frequency;
vii. The initials and corresponding signatures of staff administering the medication or, in the case of electronic records, a means by which the identification of the administering staff is verified;
viii. Medication administration codes; and
ix. All known allergies.
(d) If a person served is capable of taking medication without assistance, no daily medication administration record is required.
1. A current list identifying the name of the medication(s), type of medication(s), dosage, frequency, date prescribed, and the location of the medication(s) shall be filed in the record of each person served and updated as changes occur.
(e) Written documentation shall be filed in the record of the person served indicating that all prescribed medication was re-evaluated at least annually by the prescribing physician or advanced practice nurse.
(f) Staff shall have access to medication information, either in a reference book or an online resource approved by the licensee, current within three years and written for lay persons, which shall include information on side effects and drug interaction.
(g) Any new medication or change in medication dosage by the physician or advanced practice nurse, as well as new and discontinued prescriptions, shall be immediately noted on the current written medication record by staff consistent with the licensee's procedure.
1. Verbal orders from the physician or advanced practice nurse shall be signed by the physician or advanced practice nurse within 24 hours or by the first business day following receipt of the verbal order.
2. The prescription shall be revised at the earliest opportunity.
(h) A supply of medication and prescribed nutritional supplements, adequate to insure no interruption in the medication schedule, shall be available to persons served at all times.
(i) The licensee or designee shall supervise the use and storage of prescription medication, ensuring that:
1. A storage area of adequate size for both prescription and over-the-counter medications shall be provided and kept locked for those persons served who are not self-administering their own medication;
2. Each person served who administers his or her own medication shall receive training and monitoring by the licensee regarding the safekeeping of medications for the protection of others, as necessary.
i. Medication shall be kept in an area that provides for the safety of others, if necessary;
3. Staff shall have a key to permit access to all medication at all times and to permit accountability checks and emergency access to medication.
i. Specific controls regarding the maintenance and use of the key to stored medication shall be established by agency procedure;
4. Each prescribed medication for each person served shall be separated within the storage areas, as follows:
i. Oral medications, eye drops, and ear drops shall be separated from other medications; and
ii. If necessary, medications that require refrigeration shall be maintained in a manner that provides for the safety of others, for example, by using locked boxes;
5. All medications shall be kept in their original containers from the pharmacy and shall be properly identified with the pharmacist's label.
i. A person served who is self-medicating may choose adaptive equipment that continues to assure the safe storage of medication;
6. Medications that are outdated or no longer in use shall be safely disposed of according to licensee procedure;
7. When medication is prescribed PRN (as needed), the prescription label shall include the following:
i. The name of the person served:
ii. The date;
iii. The name of the medication;
iv. The dosage;
v. The specification of the interval between dosages;
vi. The maximum amount to be given during a 24-hour period;
vii. A stop date, when appropriate; and
viii. Under what conditions the PRN medication shall be administered; and
8. The administration of PRN medication, along with the time of administration, shall be documented on the written medication record and shall be communicated to the on-coming shift of residential staff.
(j) A statement signed by the physician or advanced practice nurse regarding the usage and contraindications of over-the-counter medications shall be available for staff reference and use and shall be updated annually. This statement shall constitute a physician's order.
(k) For medications available over-the-counter, the manufacturer's label shall be sufficient for identification purposes.

Notes

N.J. Admin. Code § 10:44C-5.2
Amended by 49 N.J.R. 259(a), effective 2/6/2017

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