(a)  A facility shall establish and maintain policies and procedures governing the administration of medications which shall be enforced and implemented by administration and staff. Policies and procedures shall include:

(1)           accountability of controlled substances as defined by the G.S. 90, Article 5; and

(2)           storage, distribution, administration and monitoring the effects of medications.

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

(c)  The categories of staff that are privileged to administer medications shall be delineated by the operational policies of the facility. These policies shall be in agreement with current rules of North Carolina Occupational Boards for each category of staff.

(d)  Medications shall be scheduled and administered according to the established policies of the facility.

(e)  Variances to the medication administration policy shall be reviewed and evaluated by the nurse executive or her designee.

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

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

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

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

(j)  Medication administration records shall provide identification of the drug and strength of drug, quantity of drug administered, route administered, name and title of person administering the medication, and time and date of administration.

(k)  Self-administration of medications shall be permitted only if prescribed by the medical staff. Directions must be printed on the container.

(l)  The administration of one patient's medications to another patient is prohibited except in the case of an emergency. In the event of such as emergency, steps shall be taken by a pharmacist to ensure that the borrowed medications shall be replaced and so documented.

(m)  Verbal orders shall be signed in accordance with Rule .3707(c) of this Subchapter.


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

Eff. January 1, 1996;

Amended Eff. November 1, 2005; May 1, 2005;

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