La. Admin. Code tit. 48 § I-9865

Current through Register Vol. 50, No. 9, September 20, 2024

Section I-9865 - Medication Record Keeping

A. General Records

1. All medication administered to residents shall be recorded on a medication administration record (MAR). Each medication shall be documented to include:

a. name, strength and dosage of the medication;

b. method of administration to include site, if applicable;

c. time of administration. The time of administration is defined as one hour before to one hour after the ordered time of administration; and

d. the initials of persons administering the medication along with a legend of the initials.

2. Medication errors and drug reactions shall be reported immediately to the resident's attending physician by a licensed nurse and an entry made in the resident's record.

B. Controlled Drugs

1. The nursing facility shall establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate accounting of all controlled drugs received, administered and destroyed or otherwise disposed.

2. Control records of schedule II drugs shall be maintained. The individual resident records shall list each type and strength of drug and the following information:

a. date;

b. time administered;

c. name of resident;

d. dose;

e. physician's name;

f. signature of person administering the dose; and

g. the balance on hand.

La. Admin. Code tit. 48, § I-9865

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 24:62 (January 1998), Promulgated by the Department of Health, Bureau of Health Services Financing, LR 421922 11/1/2016).

AUTHORITY NOTE: Promulgated in accordance with R.S. 40:2009.1-2116.