Cal. Code Regs. Tit. 22, § 79215 - Medication Management
(a) The CDRH shall, with the assistance of a
pharmacist, develop policies and procedures governing the management of
medications for patients. Policies and procedures shall be approved by the
medical director and the governing body and shall be implemented by the CDRH
staff.
(b) All drugs which the CDRH
staff administers or the patient self-administers shall be upon the order of a
person lawfully authorized by that person's respective practice act to give
such an order and shall be with the approval of the medical director, or in the
absence of the medical director, the alternate physician. There shall be
self-administration by patients only when the order so specifies and upon the
approval of the medical director or in the absence of the medical director, the
alternate physician.
(c)
Medications shall be administered as ordered.
(d) Medication shall not be kept at the
patient's bedside.
(e) Medications,
other than those for patients who have been approved for self-administration,
shall be stored in an orderly fashion in lockable cabinets or drawers
accessible only to staff personnel lawfully authorized to administer medication
by their respective practice act.
(f) Medications for patients who have been
approved for self-administration shall be stored separately from all other
medications. They shall be stored in an orderly fashion in lockable cabinets or
drawers accessible only to staff personnel lawfully authorized to administer
medication by their respective practice act or by other professional staff
members who have been so designated in writing by the medical director, or in
the absence of the medical director, the alternate physician.
(g) Professional staff members may assist
patients in the self-administration of their own medications. Professional
staff assistance in the self-administration of medication, by other than
persons who are lawfully authorized by their respective practice act to
administer medication, shall be limited to the following:
(1) Removing the container in which the
patient's medications are stored from the lockable cabinet or drawer.
(2) Handing the container, in which the
patient's medications are stored, to the patient.
(3) Observing the patient self-administer his
or her medication.
(4) Immediately
reporting to a registered nurse, licensed vocational nurse, physician or the
medical director any unusual signs, symptoms or actions on the part of the
patient that were observed.
(5)
Retrieving the container in which the patient's medications are stored and
returning the container to the lockable cabinet or drawer.
(6) As evidence that a medication has been
self-administered, the professional staff member assisting the patient in the
self-administration of the patient's medication shall record and sign, in the
patient's health record, the date and time the patient was observed
self-administering their medications.
(h) Prescription drugs shall remain in their
original prescription container. Non-prescription drugs shall remain in the
manufacturer's original container and shall be clearly labeled with the name of
the patient.
(i) A pharmacist shall
review the drug regimen of each inpatient, and current outpatient, at least
quarterly. The review of the drug regimen of each patient shall include all
drugs currently ordered, information concerning the patient's condition
relating to drug therapy, medication administration records, and where
appropriate, physician's progress notes, nurse's notes, and laboratory test
results. The registered pharmacist shall be responsible for reporting, in
writing, irregularities in the dispensing and administration of drugs and other
matters relating to the review of the drug regimen to the medical director and
the administrator.
(j) Drugs shall
be stored at appropriate temperatures. Drugs required to be stored at room
temperature shall be stored at a temperature between 15°C (59°F) and
30°C (86°F). Only drugs requiring refrigeration shall be stored in a
refrigerator between 2°C (36°F) and 8°C (46°F). When drugs are
stored in a refrigerator with food, the drugs shall be kept in a lockable
container clearly labeled "DRUGS."
(k) As evidence that a drug has been
administered, the patient's health record shall contain the name and dosage of
the drug administered to the patient, the time at which it was administered,
and the name or initial of the person administering the drug.
(l) Orders for drugs shall include the name
of the drug, quantity or duration of therapy, dosage and time of administration
of the drug, the route of administration, if other than oral, the date, time
and name of the prescriber. PRN orders shall include the indication for use of
the drug.
(m) Verbal orders for
drugs shall be given only to a physician, licensed nurse, psychiatric
technician, physician's assistant, or pharmacist by a person lawfully
authorized to give such an order. The order shall be entered promptly in the
patient health record, noting the name of the person giving the verbal order
and the signature of the person receiving the order. The prescriber shall
countersign the order within 48 hours.
(n) Drugs not specifically limited as to time
or number of doses when ordered shall be controlled by automatic stop orders or
other methods in accordance with written policies approved by the medical
director.
(o) Drugs which have been
discontinued or those which remain in the hospital after discharge of the
patient shall be destroyed by the hospital in the following manner:
(1) Drugs listed in Schedules II, III, or IV
of the Federal Control Substance Act (Title II, Public Law 91-513) shall be
destroyed in the hospital in the presence of two pharmacists, or a pharmacist
and a licensed nurse, at least one of whom is employed or retained by the
hospital. The name of the patient, the name and strength of the drug, the
prescription number, the amount destroyed, the date of destruction and the
signatures of the witnesses required above shall be recorded in the patient's
health record or in a separate log. Such log shall be retained by the hospital
for at least three years.
(2) Drugs
not listed under Schedules II, III, or IV of the Federal Control Substance Act
(Title II, Public Law 91-513) shall be destroyed in the presence of a
pharmacist or a registered nurse. The name of the patient, the name and
strength of the drugs, the prescription number if applicable, the amount
destroyed, the date of destruction and the signatures of two witnesses shall be
recorded in the patient's health record or in a log. Such log shall be retained
by the hospital for at least three years.
(p) Medications brought by or with the
patient on admission to the hospital shall not be used unless the contents of
the containers have been examined and positively identified by the patient's
physician or the medical director or a pharmacist retained by the
hospital.
Notes
2. Editorial correction of subsections (a) and (b) filed 8-31-83; effective thirtieth day thereafter (Register 83, No. 36).
3. Change without regulatory effect amending subsections (g), (g)(3) and (m) and amending NOTE filed 3-12-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 11).
Note: Authority cited: Sections 1275, 1275.2 and 131200, Health and Safety Code. Reference: Sections 1250.3, 1275.2, 1276, 131050, 131051 and 131052, Health and Safety Code.
2. Editorial correction of subsections (a) and (b) filed 8-31-83; effective thirtieth day thereafter (Register 83, No. 36).
3. Change without regulatory effect amending subsections (g), (g)(3) and (m) and amending Note filed 3-12-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 11).
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