Utah Admin. Code 432-300-15

Current through Bulletin 2024-23, December 1, 2024

Section R432-300-15 - Medications

(1) A licensed healthcare professional shall assess each resident upon admission and at least every six months thereafter to determine what level and type of assistance is required for medication administration. The licensee shall ensure level and type of assistance provided is documented on a department approved form in each resident's service plan.

(2) The licensee shall ensure each resident's medication program is administered in one of the following methods:

(a) if the resident is assessed to be able to self-administer medications:

(i) the resident may keep prescription medications in their rooms; and

(ii) if more than one resident resides in a unit, the licensee shall ensure each resident is assessed for the ability to safely have medications in the unit, if safety is a factor, the licensee shall ensure medications are kept in a locked container in the unit;

(b) if the resident is assessed to require assistance in medication self-administration, facility staff shall assist residents by:

(i) reminding the resident to take the medication;

(ii) opening medication containers;

(iii) reading the instructions on container labels;

(iv) checking the dosage against the label of the container;

(v) reassuring the resident that the dosage is correct;

(vi) observing that the resident takes the medication;

(vii) reminding the resident or the resident's responsible person when the prescription needs to be refilled; and

(viii) documenting any staff assistance with medication administration including the type of medication and when it was taken by the resident;

(c) if the resident's family or designated person is responsible for resident self-medication, they may set up medications in a package that identifies the medication and time to administer;

(d) the licensee shall ensure the family or designated person assisting with a resident's medication signs a waiver indicating that they agree to assume the following responsibilities:

(i) filling prescriptions;

(ii) administering medications; and

(iii) documenting the following:

(A) type of medication;

(B) the time administered; and

(C) the amount taken by the resident.

(3) The licensee shall ensure that medication records include the following information:

(a) the resident's name;

(b) the name of the prescribing practitioner;

(c) the name of the medication, including prescribed dosage;

(d) the times and dates administered;

(e) the method of administration;

(f) signatures of staff or responsible persons administering the medication; and

(g) the review date.

(4) A resident's licensed practitioner shall order any change in the dosage or schedule of medication administration and document it in the medication record. The licensee shall ensure that any facility staff or persons assisting with medication administration are notified of the medication change.

(5) The licensee shall ensure a current pharmacological reference book is available in the facility that contains information on possible reactions and precautions to any medications taken by a resident.

(6) The licensee shall ensure the following:

(a) the resident's family and licensed practitioner are notified if medication errors occur; and

(b) medications are stored in a locked central storage area to prevent unauthorized access, this includes;.

(i) If medication is stored in a central location, residents have timely access to the medication, and medications are administered according to the prescribed order;

(ii) Medications that require refrigeration are stored separately from food items and at temperatures between 36 - 46 degrees F;

(c) the administration, storage, and handling of oxygen comply with the requirements of the plans review as outlined in Section R432-4-12;

(d) facility policies address the disposal of unused, outdated, or recalled medications;

(e) the resident's medication is returned to the resident or to the resident's responsible person upon discharge;

(f) the return of medication to the resident or the resident's responsible person is documented by a healthcare professional; and

(g) disposal of controlled substances complies with Section 26B-2-229.

Utah Admin. Code R432-300-15

Amended by Utah State Bulletin Number 2023-10, effective 5/9/2023