(Non-controlled, Schedule III, IV, V drugs)
1. Information regarding all prescribed medications will be documented in
the client case record on the Consent to Medication Form. This information will
include the prescribing doctor's name, name of the medication, dosage,
frequency, purpose for prescription, common risks, common benefits, and
possible alternative treatment(s). The Consent to Medication form must be
signed by the client and/or the legal guardian prior to the administration of
the medication. This includes prescribed medications that the client brings
with them to the facility.
2. When a medication is prescribed, information including the name of
medication, dosage, and frequency must be documented on the Medication
Administration Record Form and filed in the client's case record.
3. All employees are responsible for knowing the common risks and benefits
and for documenting observed side effects and/or benefits of the medication
being administered to clients they serve on the Medications Monitoring Report.
4. All medications must be stored in a locked cabinet. Medications must be
kept in original containers and clearly labeled with the client's name, date,
medication name, administering instructions, expiration date and physician's
name. If more than one client's medications are stored in the same cabinet,
they must be separated. Medications that require refrigeration must be
separated from food items. Medications marked �for external use only� will be
stored separately from other medications.
�5. A designated employee must carry
the keys to the medications storage cabinet on their person. This individual is
also responsible for administration and keeping inventory of medications during
their shift.
6. Employees shall immediately report observed or stated drug reactions,
medication errors, refusals, other concerns and/or questions to their direct
supervisor and/or the emergency pager. Medication errors include omission and
commission errors. Employees will complete a Medication Incident Report Form
for all such situations.
7. Once received by an employee, a prescription is in effect until a stop
order to discontinue medication is issued. Time limited prescriptions (i.e., 10
day prescription for antibiotics) do not require a stop order. Three
consecutive refusals to take a prescribed medication by a child that is 14 years of age or older is considered revoked consent.
If this occurs, the employee will complete the Medication Incident Report Form,
notify the guardian and prescribing doctor, and contact the residential
supervisor or on-call residential supervisor if after regular business hours.
8. When an employee transports medication, each medication label must
include the client's name, name and dosage of medication, name of prescribing
doctor, and expiration date. If an employee is transporting a client and
medication together, the employee must store the client�s medication in a
locked container, which is then locked in the vehicle�s glove compartment or
trunk.
9. A record of all appointments for review of medications will be kept in
the client's case record by the case manager, including unscheduled or
cancelled medication review appointments.
10. Disposing of medications shall be in accordance
with Community Care's procedure for disposing of prescribed medications.
11. Client complaints regarding the availability or accessibility of the
prescribing doctor will be documented on the appropriate grievance form.
Submitted grievance forms will follow Community Care's grievance policy and
procedure.
Note: Controlled drugs (Schedule II Drugs) identified by the large red
"C" on the prescription bottle or bubble pack, are medications which
have been legally designated�
�Controlled Substances.� The drugs in this category are considered
to have a high potential for abuse. Schedule II drugs will be administered
following the procedures listed above, unless contraindicated by the following:
A. For all Schedule II Drugs, there shall be an individual record
maintained, including the name of the client, prescription identification
number, date prescribed, name of medication, dosage, route of administration,
signature of the individual administering, and balance on hand.
B. There shall be a record and signed count of all Schedule II controlled
substances at least once a day, if such substances have been used that day.
C. All Schedule II Drugs on hand will be counted at least weekly, and
records kept of the inventory in a bound book, from which no pages shall be
removed.
D. All Schedule II Drugs shall be stored in a locked container, in a
separate locked box. Scheduled II controlled substances will be transported
using similar methods described in this procedure.