the medication audit trail (ordering, receiving and...

15.1

CHAPTER 15

F425 - PHARMACY SERVICES

THE MEDICATION AUDIT TRAIL

(ORDERING, RECEIVING AND

DISPOSITION OF MEDICATION)

15.2

NURSING HOME

THE PRESCRIPTION AUDIT TRAIL

I. Regulatory Overview

STATE

59A-4.112 Florida Nursing Home Regulations involving Pharmacy Services

1) The facility shall adopt procedures that assure the accurate acquiring, receiving,

dispensing, and administering of all drugs and biologicals, to meet the needs of each

resident.

2) The consultant pharmacist shall establish a system to accurately record the receipt and

disposition of all controlled drugs in sufficient detail to enable an accurate

reconciliation.

3) The pharmacist shall determine that drug records are in order and that an account of all

controlled drugs is maintained and periodically reconciled.

4) All controlled substances shall be disposed of in accordance with State and federal laws.

All non-controlled substances may be destroyed in accordance with the facility’s

policies and procedures. Records of the disposition of all substances shall be maintained

in sufficient detail to enable an accurate reconciliation.

FEDERAL

F425 (Rev. 9/20/2006)

§483.60 Pharmacy Services (Complete regulation available in Section II of this manual)

The facility must provide routine and emergency drugs and biologicals to its residents, or

obtain them under an agreement described in §483.75(h) of this part. permits, but only under

the general supervision of a licensed nurse.

(a) Procedures. A facility must provide pharmaceutical services (including procedures that

assure the accurate acquiring, receiving, dispensing, and administering of all drugs and

biologicals) to meet the needs of each resident.

(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who--

(1) Provides consultation on all aspects of the provision of pharmacy services in the facility;

(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

15.3

NURSING HOME

II. THE AUDIT TRAIL CONSISTS OF:

1) Records that show when medications were ordered.

a. Telephone Orders

b. Physician Orders (ex RX from outside prescriber)

c. Refill order sheets

d. copies of faxes at the Pharmacy

2) Delivery of Medication

a. documentation should show which nurse received the medication

b. copies of delivery documents (i.e. delivery logs or delivery manifests) should be

retained by the facility and the vendor Pharmacy

3) Administration of Medication

Doses administered are recorded on the facility’s medical records forms including:

a. the MAR (Medication Administration Record)

b. the PRN Sheet

c. the Treatment Sheet

4) Disposition of Medication

a. Documentation showing drug was destroyed in the facility (non-controls can be

destroyed on the nursing unit)

b. Documentation of controlled substances destruction showing disposition by the

Consultant Pharmacist, the D.O.N. and the Administrator or their designee

c. Documentation of medications released with a patient when they are discharged

d. Documentation of medications returned to the Pharmacy for credit.

III. THE GOAL OF THE AUDIT TRAIL

The audit trail should allow the Consultant Pharmacist to track a medication throughout the

Facility.

EX. 30 doses of Percocet ordered and delivered on 4/1/2007 by vendor pharmacy

Received by Nurse L. Smith LPN on 4/1/2007 3pm

MAR indicates 15 doses were administered between 4/1/2007 and 4/20/2007 (per

MAR)

15 doses sent to the DON for destruction on 4/20/2007

15 doses actually destroyed by the Consultant Pharmacist on 5/30/2007

audit shows all doses are accounted for

15.4

NURSING HOME

Medication Orders in the Nursing Home

1. Who can prescribe in the nursing home?

Anyone who can prescribe in Florida can also prescribe in the nursing home

2. Identify prescribers who are problematic in the nursing home?

(1) Physician Assistants – Consultant must look at how P.A. orders are approved by

their Physician

(2) ARNP’s – prescribing or altering doses of controlled substance

15.5

NURSING HOME

3. What is the process for ordering medications for a new admission?

a. Hospital transfer

b. Transfer from another facility

c. Transfer from resident’s home

4. The use of Telephone Orders vs In-house Orders

5. What is the process for transferring orders from Nursing to Pharmacy personnel?

a. via phone

b. via fax

6. Compare the new order process in the Nursing Home vs an ALF

7. What makes an order “legal” in the nursing home?

a. Specific Frequency (1 tab q4h)

b. Route of administration

c. Duration of therapy

d. PRN orders must have reason for use

8. The standard of practice requires the primary physician for each resident to renew orders

every 30 days.

a. Physician Order Sheet – signed and dated every 30 days.

Federal Indicators and state regulations do not require this process.

9. No medications can be administered without an order

15.6

NURSING HOME

FEDERAL PHYSICIAN REQUIREMENTS

F333 – Prescriber’s Orders –

The latest recapitulation of drug orders is sufficient for determining whether a valid

order exists provided the prescriber has signed the “recap” The signed “recap”, if the

facility uses the “recap” system, and subsequent orders constitute a legal authorization to

administer the drug.

F386 – Physician’s visits – The Physician must:

1) review the resident’s total program of care, including medications and treatments,

at each visit required by paragraph © of this section;

2) write, sign and date progress notes at each visit and

3) sign and date all orders

Under Guidance to surveyor: “There is no requirement for physician renewal of

orders”

F387 - Frequency of Physician visits

1) The resident must be seen by a physician at least once every 30 days for the first 90 days

after admission, and at least once every 60 days thereafter

2) A physician visit is considered timely if it occurs not later than 10 days after the date the visit

was required

F388 – At the option of the physician, required visits in SNF’s, after the initial visit, may

alternate between personal visits by the physician and visits by a physician assistant, nurse

practitioner or clinical nurse specialist in accordance with paragraph (e) of this section

15.7

REVISED FLORIDA PHARMACY REGULATIONS

64B16-27.1003 Transmission of Prescription Orders. Prescriptions may be transmitted from prescriber to

dispenser in written form or by any means of communication. Prescriptions may be transmitted by facsimile

systems as provided in Section 465.035, F.S., and federal law. Any direct transmission of prescriptions, including

verbal, facsimile, telephonic or electronic data transmission, shall only be with the approval of the patient or

patient’s agent. The pharmacist receiving any such transmitted prescription shall not participate in any system that

the pharmacist knows or should have reason to know restricts the patient’s choice of pharmacy. The pharmacist

shall take such measures necessary to ensure the validity of all prescriptions received. Specific Authority 465.005,

465.0155, 465.022 FS. Law Implemented 465.022, 465.026, 893.07 FS. History–New 11-18-07.

64B16-27.103 Oral Prescriptions and Copies. (1) Only a pharmacist or registered pharmacy intern acting under the supervision of a pharmacist may, in the State

of Florida, accept an oral prescription of any nature.

(2) Only a pharmacist or registered pharmacy intern acting under the supervision of a pharmacist may, in the State

of Florida, prepare a copy of a prescription or read a prescription to any person for purposes of providing reference

concerning treatment of the person or animal for whom the prescription was written, and when said copy is given a

notation shall be made upon the prescription that a copy has been given, the date given, and to whom given.

Specific Authority 465.005, 465.0155, 465.014, 465.022 FS. Law Implemented 465.003(13), 465.014, 465.022, 893.07(1)(b) FS.

History–Amended 5-19-72, Repromulgated 12-18-74, Formerly 21S-1.18, 21S-1.018, 21S-27.103, 61F10-27.103, Amended 9-

19-94, Formerly 59X-27.103, Amended 10-15-01, 11-18-07.

Podiatric Residents

461.014(1)(f), Florida Statutes - Residency

(f) A person registered as a resident podiatric physician under this section may, in the normal course of his or her employment, prescribe medicinal drugs described in schedules set forth in chapter 893 and pursuant to s. 461.003(5) if:

The person prescribes such medicinal drugs through use of a Drug Enforcement Administration number issued to the hospital or teaching hospital by which the person is employed or at which the person's services are used;

1. The person is identified by a discrete suffix to the identification number issued to such hospital; and 2. The use of the institutional identification number and individual suffixes conforms to the requirements of the federal Drug Enforcement Administration.

15.8

NURSING HOME

Receiving Medications in the Nursing Home

1. Records of receiving a medication:

a. Who and when ordered?

b. Who and when received?

2. Record of source:

a. From the pharmacy?

b. From home?

c. Other?

3. Records of medication delivery (delivery log or delivery manifest) should be maintained

by the facility and vendor Pharmacy for at least 2 years.

These may be used during an AHCA investigation, a DEA investigation or a Medicaid

Audit

NURSING HOME

SAMPLE OF A DELIVERY LOG

Quality Care Pharmacy

6499 38th

Ave N

St.Petersburg Fl 33710

Shady Rest Nursing Home 8/1/2007

11440 49th Street N

Clearwater Florida

8/1/2007 Rx 711000 Mary Smith Furosemide 40mg #30

8/1/2007 Rx 711001 Mary Smith Ibuprofen 400mg #30

8/1/2007 Rx 711002 Mary Smith Slow K 8meq #30

8/1/2007 Rx 683722 Tom Jensen Isosorbide Mononitrate ER 60mg #30

8/1/2007 Rx 711009 Gus Adams Phenytoin ER 100mg #30

__________________________________ ______________________

Nurse Signature Date

15.9

The Disposition of Medication in the Nursing Home

1. Methods of disposition

a. Proof of use (administered to resident as documented on the MAR)

b. Transfer of control drugs to the D.O.N. for Destruction

c. Waste (dropped doses or refused doses)

d. Returned to family or resident

e. Returned to the pharmacy for credit

f. Pilferage (will your audit trail catch missing meds??)

2. Discontinued Medications

a. When a drug order is discontinued the drug must be removed from the normal drug

storage area (i.e. drug cart) and placed in an area clearly marked for discontinued

medications

b. The facility policy will indicate whether the medication can be returned to pharmacy

for credit, destroyed in-house by nursing or if a controlled substance transferred to

the D.O.N. for destruction

c. The facility should have a standard format for logging in these discontinued

medications and identifying what happened to the remaining doses. (see sample

form)

d. The disposition records becomes part of the patient’s permanent chart

3. Discharge Medications in the Nursing Home

a. All medications of discharged residents must be removed from the nursing

drug cart in a “timely manner”.

b. Upon discharge, all medications may be sent home with the resident if so

ordered by the physician.

c. Under certain per diem contracts the meds may need to be returned to

Pharmacy unless the family or facility wishes to pay for the remaining

doses.

d. The disposition records becomes part of the patient’s permanent chart

15.10

NURSING HOMES

4. Compliance issues to be reviewed by the Consultant Pharmacist Monthly

a. Verbal orders not written in the chart

b. New orders were never sent to Pharmacy for processing

c. Discontinued orders still in use

d. Discontinued medications stored with active medications

e. Doctors signatures in place renewing orders in a timely manner (every 30 days)

f. Evidence of primary doctor involved in P.A. prescriptions and controlled

substances orders written by an ARNP

g. All orders have complete directions as described above

h. The audit trail from order (or reorder) to destruction is intact

15.11

NURSING HOME

THE RETURN OF UNIT DOSE MEDICATION TO THE PHARMACY

Note: This regulation does not address the type of facility that can return medications.

The board has taken the position that only facilities with a Pharmacy license and

a Consultant Pharmacist are allowed to return medications for credit.

This would prohibit ALF’s (without a Special ALF license), Group homes, ADT’s,

FACT programs, Juvenile Detention Centers and Correctional facilities without an

Institutional Modified license from returning medication even if they are in unit dosed

packaging and stored centrally.

15.12

NURSING HOME

SAMPLE FORM

Discharge Drug List Form

Patient Name __________________________________________ Room # ______________

Physician __________________________________________________________________

I certify that the following drugs have been delivered to and received by:

1. _____________________________________________________________________

Signature of Charge Nurse Date

I acknowledge that these medications are not currently packed in child resistant packaging and

that I waive this special packaging requirement Yes ( ) No ( )

I request that these medications be repackaged by the Pharmacy in child resistant packaging

prior to my receipt of this medication. Yes ( ) No ( )

2. _____________________________________________________________________

Signature of Patient or Responsible Party Date

Prescription Name Quantity

_____________________________________________________________________________

_________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_______________________________________________________________________

___________________________________________________________________________

Drugs reviewed and evaluated by pharmacist:

3. _____________________________________________________________________

Signature of Pharmacist Date

4. Disposition of Drugs:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

WMC-308

15.13

NURSING HOME

SAMPLE POLICY & METHODS

Medications to Resident on Discharge

POLICY:

It is the policy of this facility to send home the resident’s medications upon discharge if

the physician orders it.

METHODS:

1. The physician must authorize the release of the medication and the nurse must

document his request on the chart.

2. The nurse will complete and sign the disposition of medication form including

the quantity sent with the patient and have the patient or another responsible

person sign as receiving the medications. A copy of this form will be made a

part of the patient’s chart.

3. Control drugs will also be included on the disposition form. Also the proof of

use form for the control drug shall have a notation written on it by the nurse

stating that these drugs have been returned to the patient and this form will also

be signed by the person receiving the control drugs.

4. If the medication being sent with the patient does not have a safety closure

package (i.e., unit dose packaging) the patient must state in writing that they

request a non-complying package.

15.14

NURSING HOME


Ordering Drugs

POLICY:

Drugs are to be administered only upon the order of a person lawfully authorized to

prescribe. All such orders are to be in writing and signed by the person giving the order.

Each order is to specify the name and strength of the medication, the amount or duration

of therapy, the dosage, the time or frequency of administration, the route if other than

oral, and the site of the injection if so ordered.

There are to be no standing orders for medications or treatments. Telephone orders may

only be given to a pharmacist or licensed nurse and are to be recorded immediately in

the patient’s medical record and signed by the prescriber in a timely manner.

Unless otherwise specified by the prescriber or limited by automatic stop orders, drugs

are to be prescribed for thirty (30) days, dispensed in thirty (30) day quantities. Daily

drug order and receipt records are to be maintained on file in the facility for one (1) year.

METHODS:

1. 9:00 AM medication nurse will be responsible for re-ordering all refill

prescription except HS medications, and all new orders received during her shift

(7-3).

2. The responsible charge nurse on each wing after 3:00 PM will order medications

for new admissions, STAT orders, new orders received during that shift, and HS

renewal orders.

3. When to order:

Prescriptions should be re-ordered when at least four (4) days medication supply

remains. When making a pass only a four day supply of medication remains,

place container on the side shelf for re-ordering when pass is completed. When a

medication has been re-ordered it should be indicated on the Unit-Dose card in

the space indicated. Always check storage bin before re-ordering. Medication

dispensed in containers other than unit-dose cards, shall have a notation placed

on the container that the medication has been re-ordered, the date, and the initials

or name of the person re-ordering. Tape may be used to accomplish this.

15.15

4. A record of medications order transmitted to pharmacy will be kept on each

wing. All new orders will be written on ASCO reorder form #M-1080 and a

Xerox copy will be maintained in the medication room. All new or renewal

order transmittals should be reordered on this form regardless of the pharmacy

supplying the medication. For new prescriptions, the charge nurse at each station

writes in the specifics of the prescription as per the information requested on the

ASCO order form with the notable exception of the prescription number. For

refill prescriptions of any kind, she merely peels off the re-order portion of the

label on the Unit-Dose card and attaches it to the order being sure to specify

whether it is:

a. Notification that is an order previously phoned in:

b. A request for a label change only.

When a peel off label is not affixed to a medication, the nurse will write all

appropriate reorder information directly on the ASCO reorder form.

5. Upon receipt of prepared prescription from a pharmacy, the nurse receiving the

medication will initial, date, and mark the order received on the previously

completed ASCO order form where the original order to the pharmacy was

written. These records shall be retained in an orderly and retrievable manner in

each medication room. The 7-3 medication nurse shall check whether the

previous day reorders have been delivered. The pharmacy should be notified on

that shift if orders have not been received from the previous days orders and an

incident report shall be fined with the director of nursing. The director of

nursing shall report these incidents to the pharmacy consultant and the

Pharmaceutical Services Committee.

6. ONLY a physician, a dentist, a podiatrist, an optometrist or an ARNP may

prescribe drugs. All such orders are to be in writing and signed in writing by the

person giving the order. For the purposes of these procedures, all prescription

and non-prescription medications, vitamin and mineral supplements, intravenous

and irrigating solutions, biologicals and vaccines, and alcohol-containing

beverages are considered to be drugs.

7. EVERY drug order MUST specify all of the following:

a. The name of the medication

b. The strength of the medication, if any.

c. The dosage.

d. The time or frequency of administration.

e. The route of administration, if other than oral

f. The quantity or duration of therapy. (If not specified by the prescriber or

limited by automatic stop orders, drugs are to be prescribed for thirty (30)

days, dispensed in thirty (30) day quantities.

g. PRNs should specify the condition for which they are to be administered.

For example, s needed for painor as needed for sleep.

15.16

8. Each new drug order is to be acknowledged by the charge nurse on duty at the

time the order is received, or by the licensed nurse receiving the order, by

entering the word noted, the nurse’s signature, and the time and date immediately

below the order.

9. There are to be no standing orders for medications or treatments. Nurses may

NOT accept standing orders from any physician for his/her patients in this

facility.

10. The charge nurse on duty at the time the order is received, or the licensed nurse

receiving the order is responsible for ALL the following:

a. Telephoning the new order into the pharmacy exactly as prescribed, and as

soon as possible after receiving and noting it on the physician’s order sheet.

Each medication prescribed for a patient MUST be ordered and

must be available for use regardless of how infrequently it may be used. Stat

orders and orders for emergency drugs not in the emergency drug supply

MUST be telephoned into the pharmacy immediately upon receiving them.

ONLY a licensed nurse or pharmacist may telephone medication orders to

the pharmacy.

b. Entering each newly prescribed medication in the daily drug order and

receipt record and indicating in the record that the medication order has

been telephoned to the pharmacy.

c. Entering each newly prescribed medication on the patient’s current

Medication administration record. When a new order changes the dosage

or dosage interval of an already prescribed medication, the previous entry

on the patient’s current medication administration record is discontinued

by writing “Dc” and the date following the last documented

administration. The new order is then to be entered in the space

designated for medication names and directions.

11. Daily drug order and receipt records and medication re-order forms are to

originate at each nursing station. Medication orders from different nursing

stations are not to be listed on the same order sheet. Each daily drug order and

receipt record and medication reorder form is to be clearly marked as to the

station from which the orders originate, and are to be delivered.

12. Each newly prescribed and re-ordered medication must be entered on that

nursing station’s daily drug order and receipt record. The nurse making the entry

is to include all of the following information and initial the entry:

a. The date ordered.

b. Whether the order is a new order or a re-order.

c. The patient’s name.

d. The name of the drug and the strength, if any, or the prescription number,

if it is a re-order.

15.17

e. The directions for use.

f. The prescriber’s name.

g. The name of the pharmacy, if other than the usual pharmacy. If the

patient or his/her responsible party request the medication be ordered by

telephone from a pharmacy of their choice, in accordance with the

procedures for ordering drugs from other pharmacies, the entry may be

made on the same daily drug order and receipt record. The nurse making

the entry must, however, mark the pharmacy’s name prominently on the

entry line.

The original (top) copy of the daily drug order and receipt record is to be

forwarded to the pharmacy and the carbon is to be kept as a record of

what was ordered. The pharmacy is to return the original with the re-

ordered medications and in accordance with the procedures for receiving

drugs, the original and the carbon are to be stapled together and the

completed record filed at the business office in the log designated for that

purpose. The billing clerk is responsible for maintaining a log of

completed daily drug order and receipt records on file for one (1) year.

13. There are only four (4) kinds of drug orders. They are:

a. New, handwritten orders, entered on a physician’s order sheet and signed

by the prescriber.

b. New orders, received verbally over the telephone or received verbally in

person, such as when the prescriber is leaving the facility.

c. New, signed orders on a transfer sheet from a hospital or other health care

facility.

d. Drug re-orders.

14. In addition to the standard procedures for ordering drugs, the following

procedures apply to:

NEW HANDWRITTEN ORDERS, ENTERED ON A PHYSICIAN’S

ORDER SHEET AND SIGNED BY THE PRESCRIBER.

a. The director of nursing services is responsible for instructing ALL

Nursing and administrative staff to inform the director of nursing and/or

all charge nurse(s) when any physician enters the building.

b. The charge nurse on duty at the time the order is received is responsible

for clarifying the order BEFORE the physician leaves the nursing station.

c. The nurse receiving the order is responsible for sending the pharmacy a

transcription of the physician’s order each time he/she is in facility and

signs an order for medications.

15.18



NEW ORDERS RECEIVED VERBALLY OVER THE TELEPHONE

OR IN PERSON

a. Verbal orders for medications are to be handled in the same manner

whether received over the telephone or in person such as when the

physician is leaving the facility. Only a licensed nurse or registered

health care practitioner in the course of their responsibility may receive a

verbal order for a drug. The practitioner receiving the order should enter

the order into chart and other entries for the medication record keeping

system, including physicians orders, a telephone order verification form

(when applicable), the MAR and the monthly update record.

b. The licensed practitioner receiving the verbal order is required to enter

each medication ordered on a telephone order form:

Copy of Telephone Order Form in this space

The telephone order form is a three-part NCR (carbonless) form. The

original copy of the form must be mailed to the prescriber for signing.

The second duplicate copy is to be taped on the page designated for that

purpose located just behind the physician’s order sheet in the patient’s

chart. The third copy is placed in the consultant pharmacist mail box.

When the signed copies are returned to the facility by the doctor, the

original is to be taped in the patient’s chart replacing the duplicate second

copy which may be discarded. When the physician signs the charted

order at the time of his next visit, the signed, original telephone order

may be discarded.

c. Verbal orders for Schedule II drugs are permitted only in the case of a

bona fide emergency situation.



NEW, SIGNED ORDERS, ON A TRANSFER SHEET FROM A HOSPITAL

OR OTHER HEALTH CARE FACILITY.

15.19

a. When a transfer sheet containing medication orders (1) bears a

physician’s signature, and (2) indicates the medication(s) is to be

continued in this facility, the charge nurse on duty at the time the order is

received, or the licensed nurse receiving the order, is responsible for

verifying the order over the telephone with the patient’s physician before

drugs are administered. The nurse is responsible for documenting the

telephone verification on the admission orders by entering the phrase,

Admission orders verified per telephone, the nurse’s signature, the time

and date.

b. Where NO physician’s signature appears on the transfer sheet, admission

orders must be verified over the telephone with the patient’s physician

before drugs are administered, and then signed by the patient’s physician

within forty-eight (48) hours according to the procedures for a telephone

order.



DRUG RE-ORDERS

a. Each medication prescribed for a patient must be available for use at least

twenty four (24) hours in advance of exhausting the supply on hand

regardless of how infrequently it may be used. Routinely administered

drugs are to be re-ordered three (3) to four (4) days before the last dose

on hand is expected to be given.

b. Re-orders can be made by removing the special peel-off label from the

medication container and placing it in the space provided on the

medication re-order form.

c. The nurse re-ordering the medication is responsible for identifying any

error which appears on the label, or noting any change in directions for

use which have occurred since the medication was originally dispensed.

d. In the event the special peel-off label from the container is not available,

re-orders can be made by entering the patient’s name, prescription

number, name and strength of the medication, current directions for use,

and the physician’s name in the spaces provided on the daily drug order

and receipt record, and indicating it is a re-order without a reorder label.

e. Regardless of whether the peel-off label is available, all re-ordered

medications must be entered on that nursing station’s daily drug order

and receipt record. This is the only permanent record of re-ordered drugs

kept in the facility and it must be kept for each re-ordered medication.

f. When the medication re-order form and the daily drug order and receipt

record are completed, they are to be placed in the pharmacy pick up

basket for pick up by the pharmacy messenger service at the next

regularly scheduled pick up and delivery.

15.20

NURSING HOME


New Orders to Begin on Arrival

POLICY:

It is the policy of this facility to provide residents with new medication orders in a

timely manner.

METHODS:

1. Nurses receiving medication orders from the physician shall determine how

quickly the medication should be started.

2. If the order is of a STAT nature, to begin immediately, the pharmacy shall

immediately be notified and asked to provide the drug as quickly as possible.

3. If the order is of a routine nature, the medication shall be ordered from the

pharmacy using the usual procedures for ordering.

4. All routine new orders shall be written to include the phrase may begin on

arrival.

5. The routine order shall be administered as soon as received if appropriate with

the directions.

15.21

NURSING HOME


Receiving Drugs

POLICY:

Medications are to be received from the issuing pharmacy on a prompt and timely basis.

For each medication ordered, a record is to be maintained by the licensed nursing staff

showing the name of the patient, the drug’s name and strength, the quantity ordered and

received, the date ordered and received, and the name of the issuing pharmacy. The

record is to be maintained on file in the facility for one (1) year.

State Survey Manual

59A-4.112 (3) The consultant pharmacist shall establish a system to accurately

record the receipt and disposition of all controlled drugs in sufficient detail to

enable an accurate reconciliation.

59A-4.112 (4) The pharmacist shall determine that drug records are in order and

that an account of all controlled drugs is maintained and periodically reconciled.

59A-4.112 (7) All controlled substances shall be disposed of in accordance with

state and federal laws. All non-controlled substances may be destroyed in

accordance with the facility’s policies and procedures. Records of the

disposition of all substances shall be maintained in sufficient detail to enable an

accurate reconciliation.

METHODS:

1. Prompt and timely availability is interpreted as follows:

a. All new drug orders are to be received and available for administration on

the day they are ordered by the physician unless the drug would not

usually be started until the next day, in which case it is to be received

before the first dose would ordinarily be administered.

b. Drugs ordered from the pharmacy during their regularly scheduled

business hours on an emergency or stat basis should be received and

administered within one (1) hour.

c. Drugs ordered from the pharmacy after their regularly scheduled business

Hours on an emergency or stat basis are to be received and

administered not more than two (2) hours after the order is received from

the prescriber.

d. The reason(s) for deviating from the above procedures should be

documented in the patient’s chart.

15.22

2. Medication delivered to the facility from any pharmacy must be received by a

licensed nurse.

3. The receipt of each medication is to be recorded on the original or copy of the

daily drug order and receipt record. The licensed nurse checking in the

medication is to record the quantity of the medication received, and date and

initial the record, thereby documenting that the medication was received.

4. If an ordered medication is not received and there is no explanation from the

pharmacy, the pharmacy is to be contacted by telephone as soon as possible to

determine why the medication was not sent.

5. The licensed nurse receiving the medication is responsible for verifying

medication received and the directions for use with the medication ordered and

with the physician’s order in the patient’s medical record.

6. Disposition of Orders Once Received: To put an order away, first determine via

the pharmacy order book if it is a new or a refill prescription, and if refill, what

kind. If it is new, place one card in each dosage drawer.

Example: If medication is given QID, and if you are using a time pass method,

place one card in each of the 9:00, 1:00, 5:00, and 9:00 bins in front of that

patient’s divider card.

On refills, place the entire prescription in a storage bin under that Patient’s name

(or immediately behind the correct patient’s in use card in the medication bins)

and leave there until old card in the dosage bin is utilized. Once again:

ALWAYS CHECK STORAGE BIN BEFORE RE-ORDERING.

If the refill is a PRN box replacement, you will want to immediately put it in the

PRN box.

When a card on a pass is emptied and the cart is returned to the nursing station

the storage bin should be immediately checked for a replacement medication

card or an emergency re-order should be made (for delivery the next day).

15.23

NURSING HOME


Ordering and Receiving Drugs from Other Pharmacies

POLICY:

Medications brought into the facility by or with the patient or by the patient’s family are

to be used only upon a written order by the patient’s physician and only when the

contents of the medication container are known to be consistent with that which appears

on its label.

Patients or their responsible parties, who want to purchase medications from a pharmacy

other than the facility’s contractual pharmacy supplier, may do so provided:

(1) They and their pharmacist sign a notice of intent to purchase medications

from an outside pharmacy; and

(2) They and their pharmacy adhere to the facility’s policies and procedures

for drug labeling, packaging, prompt and timely delivery of medication,

emergency service, drug regimen review, etc.

The facility retains the right to terminate the agreement for cause and, in the event of an

emergency, to order any drug, medication, or related supply for the patient from the

facility’s regular pharmacy supplier.

METHODS:

1. Medications brought into the facility by or with the patient or by the patient’s

family are to be used only if ALL of the following conditions are met:

a. The drug has been ordered by the patient’s physician and the order

entered in the patient’s medical record.

b. The medication container or prescription vial is clearly and properly

labeled in accordance with the facility’s procedures for drug labeling.

c. The contents of the container or prescription vial have been examined

and positively identified after its arrival in the facility by a physician or a

pharmacist, unless the medication has come directly from another health

care facility. For example, discharge medications from an acute hospital

which have come in the ambulance with the patient or those delivered

directly by an outside pharmacy need not be identified by the physician

or pharmacist unless the nurse has reason to question the contents.

2. If the patient’s physician is not available to identify the contents of medication

brought into the facility by the patient or member of the family, the medication is

to be entered on the daily drug order and receipt record and the words verify

contents written. The medication is then to be sent to the pharmacy for

identification with the regularly scheduled pick-up.

15.24

3. Patients or their responsible parties who want to purchase medication from a

pharmacy other than the facility’s contractual pharmacy supplier may do so

provided:

a. The patient or their responsible party and their pharmacist sign a notice of

intent to purchase medications from an outside pharmacy.

b. The patient or their responsible party and their pharmacy adhere to the

terms of the notice, and the facility’s policies and procedures for drug

labeling, packaging, prompt and timely delivery of medication,

emergency service, drug regimen review, etc.

4. When the patient or their responsible party indicate that they wish to purchase

drugs from a pharmacy other than the facility’s regular pharmacy supplier, the

administrator, billing clerk, or the charge nurse on duty at the time is to provide

them with a copy of the notice of intent to purchase medications from an outside

pharmacy. A supply of notices is stored at the nursing station and the business

office. A copy of all relevant policies and procedures is to be provided to the

outside pharmacy upon request. The completed and signed copy of the notice is

to be maintained in the Patient’s medical record.

5. When the completed and signed copy of the notice is received and placed in the

patient’s chart, the charge nurse on duty at the time is to mark the patient’s

current medication administration record and drug storage box with the name of

the outside pharmacy to indicate the proper order source. Thereafter, drug orders

are to be telephoned to the outside pharmacy, and each order is to be entered in

the daily drug order and receipt record, prominently indicating the name of the

outside pharmacy.

6. In order to avoid delays associated with verifying the contents of medications, all

drugs and related supplies ordered from an outside pharmacy are to be shipped

directly from the pharmacy to the nursing station. Shipment may be carried

ONLY by:

a. A licensed pharmacist;

b. An agent of the pharmacy;

c. An independent bonded delivery;

d. A licensed physician;

e. Parcel delivery; or

f. The patient’s responsible party (or delegated family member).

Medication delivered in any other way must be verified by the regular pharmacy.

Under no circumstances shall medications, whether prescription or non-

prescription be brought to the patient’s bedside.

7. If a situation occurs where the delivery of the patient’s medication from the

outside pharmacy is delayed or uncertain, the medication nurse is to order by

telephone a seven (7) day supply of all drugs needed for administration from the

regular pharmacy. If this is done, the nurse placing the order is to notify the

billing clerk of the situation for clarification in the next billing.

the medication audit trail (ordering, receiving and...

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