10A NCAC 13F .1002 MEDICATION ORDERS
(a) An adult care home shall ensure contact with the resident's physician or prescribing practitioner for verification or clarification of orders for medications and treatments:
(1) if orders for admission or readmission of the resident are not dated and signed within 24 hours of admission or readmission to the facility;
(2) if orders are not clear or complete; or
(3) if multiple admission forms are received upon admission or readmission and orders on the forms are not the same.
The facility shall ensure that this verification or clarification is documented in the resident's record.
(b) All orders for medications, prescription and non-prescription, and treatments shall be maintained in the resident's record in the facility.
(c) The medication orders shall be complete and include the following:
(1) medication name;
(2) strength of medication;
(3) dosage of medication to be administered;
(4) route of administration;
(5) specific directions of use, including frequency of administration; and
(6) if ordered on an as needed basis, a stated indication for use.
(d) Verbal orders for medications and treatments shall be:
(1) countersigned by the prescribing practitioner within 15 days from the date the order is given;
(2) signed or initialed and dated by the person receiving the order; and
(3) accepted only by a licensed professional authorized by state occupational licensure laws to accept orders or staff responsible for medication administration.
(e) Any standing orders shall be for individual residents and signed and dated by the resident's physician or prescribing practitioner.
(f) The facility shall assure that all current orders for medications or treatments, including standing orders and orders for self-administration are reviewed and signed by the resident's physician or prescribing practitioner at least every six months.
(g) In addition to the requirements as stated in Paragraph (c) of this Rule, psychotropic medications ordered "as needed" by a prescribing practitioner, shall not be administered unless the following have been provided by the practitioner or included in an individualized care plan developed with input by a registered nurse or licensed pharmacist:
(1) detailed behavior-specific written instructions, including symptoms that might require use of the medication;
(2) exact dosage;
(3) exact time frames between dosages; and
(4) the maximum dosage to be administered in a twenty-four hour period.
(h) The facility shall assure that personal care aides and their direct supervisors receive training annually about the desired and undesired effects of psychotropic medications, including alternative behavior interventions. Documentation of training attended by staff shall be maintained in the facility.
History Note: Authority G.S. 131D-2.16; 131D-4.5; 143B-165;
Eff. July 1, 2005.