Section 116.70 Medication Administration Record and Required Documentation

Section 116

Section 116.70  Medication

Administration Record and Required Documentation

a)         All medications, including patent or proprietary medications

(e.g., cathartics, headache remedies or vitamins, but not limited to those)

shall be given only upon the written order of a physician, advanced practice

nurse, or physician assistant.  All orders shall be given as prescribed by the

physician and at the designated time.  Telephone orders may be taken by a

registered professional nurse or licensed practical nurse.  All orders shall be

immediately written on the individual's record or a "telephone order

form" and signed by the nurse taking the order.  These orders shall be

countersigned or documented by facsimile prescription or electronically signed by

the physician within 10 days.

b)         Medication Administration Record

1)         Except as provided in Section 116.60(g), an individualized MAR

shall be kept for each individual for medications administered, including PRN

medications, and shall contain at least the following:

A)        the individual's name;

B)        the name and dosage form of the medication;

C)        the name of the prescribing physician, physician assistant,

dentist, podiatrist or certified optometrist;

D)        dose or quantity to be taken;

E)        frequency or times of administration;

F)         route of administration;

G)        date and time given;

H)        most recent date of the order;

I)         allergies to medication; and

J)         special considerations, including special directions and

precautions for the medication's preparation and administration and

contraindications for the medication.

2)         PRN medication must be documented on the MAR in accordance

with Section 116.70(b)(1).  In addition, the following information must be

included on the MAR:

A)

conditions for which the medication may be given; and

B)        maximum

or stop dosage

g special directions and

precautions for the medication's preparation and administration and

contraindications for the medication.

2)         PRN medication must be documented on the MAR in accordance

with Section 116.70(b)(1).  In addition, the following information must be

included on the MAR:

A)

conditions for which the medication may be given; and

B)        maximum

or stop dosage.

3)         The MAR for the current month shall be kept with the

medications or in the individual's record.

4)         The MAR shall be completed and initialed immediately after

medication is administered by the registered professional nurse, licensed

practical nurse, or authorized direct care staff.  Each MAR shall have a

section that contains the full signature and title of each individual who

initials the MAR.

5)         All changes in medication shall be noted on the MAR by a

licensed practical nurse, registered professional nurse, advanced practice

nurse, pharmacist, physician, physician assistant, dentist, podiatrist, or

certified optometrist and reported to the Nurse-Trainer prior to the next dose.

Upon the direct instruction of a Nurse-Trainer, authorized direct care staff

may indicate on the MAR completion of the following actions:

A)        discontinuation

of a medication;

B)        change

in medication schedule; and/or

C)        application of a medication information label issued with a

medication by a licensed pharmacy.

6)         Individual refusal to take medications shall be noted on the MAR.

Authorized direct care staff shall document in the individual's record the

reasons for refusal and notify the registered professional nurse,

Nurse-Trainer, or person licensed to prescribe medication in Illinois to

receive direction on any action to be taken.  Refusal of medication by an individual

is not considered a medication error.

7)         For individuals who are independently self-administering

medications, no MAR shall be required

the individual's record the

reasons for refusal and notify the registered professional nurse,

Nurse-Trainer, or person licensed to prescribe medication in Illinois to

receive direction on any action to be taken.  Refusal of medication by an individual

is not considered a medication error.

7)         For individuals who are independently self-administering

medications, no MAR shall be required.  However, any medication that

individuals take shall be listed in their records, including dosage, frequency

and identity of the prescribing physician, physician assistant, dentist,

podiatrist or certified optometrist.  Each agency shall develop and implement a

quality assurance system to ensure that self-administered medications are taken

in accordance with prescribed orders.

c)         In the event of a medication error, authorized direct care

staff shall immediately report the error to the registered professional nurse, Nurse-Trainer

or person licensed to prescribe medication in Illinois to receive direction on

any action to be taken.  All medication errors shall be documented in the

individual's record and a medication error report shall be completed within

eight hours or before the end of the shift in which the error was discovered,

whichever is earlier.  The medication error report shall be sent to the Nurse-Trainer

for review and further action within 7 calendar days after the occurrence.  A

copy of the medication error report shall be maintained as part of the agency's

quality assurance program.  Medication errors must be documented and are

subject to review by DHS or DPH, whichever is applicable.  Medication errors

that meet the reporting criteria of DHS' rules on Office of Inspector General

Investigations of Alleged Abuse or Neglect or Deaths in State-Operated and

Community Agency Facilities (59 Ill. Adm. Code 50) shall be reported to the

Office of Inspector General

urance program.  Medication errors must be documented and are

subject to review by DHS or DPH, whichever is applicable.  Medication errors

that meet the reporting criteria of DHS' rules on Office of Inspector General

Investigations of Alleged Abuse or Neglect or Deaths in State-Operated and

Community Agency Facilities (59 Ill. Adm. Code 50) shall be reported to the

Office of Inspector General.

d)         In the event of suspected drug reaction, authorized direct

care staff shall immediately report the signs and symptoms to the registered

professional nurse, advanced practice nurse, physician, physician assistant,

dentist, podiatrist, or certified optometrist to receive direction on any

action to be taken.  All adverse drug reactions shall be documented in the

individual's record and an adverse drug reaction report shall be completed

within eight hours or before the end of the shift in which the reaction was

discovered, whichever is earlier.  The adverse drug reaction report shall be

sent to the prescriber and the Nurse-Trainer for review and further action.  A

copy of the adverse drug reaction report shall be maintained as a part of the

agency's quality assurance program.

e)         An inventory and a record of use of controlled substances

shall be maintained by the registered professional nurse in the program, and

each substance shall require a separate sheet indicating the:

1)         name of the individual;

2)         name of the prescriber;

3)         prescription number;

4)         name of the drug and strength;

5)         amount used;

6)         amount remaining;

7)         time and date administered;

8)         name of the individual who administered the medication; and

9)         documentation of a shift count done by authorized direct care

staff.  Any discrepancies shall be reported to the Nurse-Trainer for review and

action in accordance with written policy

4)         name of the drug and strength;

5)         amount used;

6)         amount remaining;

7)         time and date administered;

8)         name of the individual who administered the medication; and

9)         documentation of a shift count done by authorized direct care

staff.  Any discrepancies shall be reported to the Nurse-Trainer for review and

action in accordance with written policy.

A)        A shift count must be completed when the responsibility for

administering medications changes from one authorized direct care staff or

nurse to another authorized direct care staff or nurse.

B)        The authorized direct care staff or nurse passing on responsibility

for medication administration will count the controlled substances with the

authorized direct care staff or nurse assuming responsibility for medication

administration.

C)        The count completed when a controlled substance is administered

is not considered a shift count.

f)         Host Family Community Integrated Living Arrangements as

described in 59 Ill. Adm. Code 115 must develop a quality assurance procedure

to ensure accurate inventory and record of use of controlled substances.