(a)  A licensed facility shall have policies and procedures governing the administration of medications which shall be enforced and implemented by administration and staff. Policies and procedures shall include, but shall not be limited to:

(1)           automatic stop orders for treatment and drugs;

(2)           accountability of controlled substances as defined by the North Carolina Controlled Substances Act, G.S. 90, Article 5;

(3)           dispensing and administering behavior modifying drugs, such as hypnotics, sedatives, tranquilizers, antidepressants and other psychotherapeutic agents; insulin; intravenous fluids and medications; cardiovascular regulating drugs; and antibiotics.

(b)  All medications or drugs and treatments shall be administered and discontinued in accordance with signed physician's orders which are recorded in the patient's or resident's medical record.

(1)           Only physicians, registered nurses, licensed practical nurses or physician assistants, if in accordance with the assistant's approved practice, shall administer medications.

(2)           To ensure accountability, any medication shall be administered by the same licensed personnel who prepared the dose for administration. This Rule does not apply to the dispensing of medications from a pharmacy utilizing a unit of use drug delivery system.

(3)           Medications shall be administered within a half hour prior to or half hour after the prescribed time for administration unless precluded by emergency situations.

(4)           The person administering medications shall identify each patient or resident in accordance with the facility's policies and procedures prior to administering any medication.

(5)           Medication administered to a patient or resident shall be recorded in the patient's or resident's medication administration record immediately after administration in accordance with the facility's policies and procedures.

(6)           Omission of medication and the reason for the omission shall be indicated in the patient's or resident's medical record.

(7)           The person administering medications which are ordered to be given as needed (PRN) shall justify the need for the same in the patient's or resident's medical record.

(8)           Medication administration records shall provide identification of the drug and strength of drug, quantity of drug administered, name of administering employee, title of employee and time of administration.

(c)  Self‑administration of medications shall be permitted only if prescribed by a physician and directions are printed on the container.

(d)  The administration of one patient's or resident's medications to another patient or resident is prohibited except in the case of an emergency. In the event of such an emergency, steps shall be taken to assure that the borrowed medications shall be replaced promptly and so documented.

(e)  Verbal orders shall be countersigned by a physician within five days of issuance.


History Note:        Authority G.S. 131E‑79;

Eff. February 1, 1986;

Amended Eff. December 1, 1991; March 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.