411-086-0260 Pharmaceutical Services (1) Consulting Pharmacist. Each facility shall have a consulting pharmacist who shall ensure compliance with ORS Chapter 689, facility policy (OAR 411-085-0210) and this rule. (2) Pharmaceutical Services Review. The Quality Assessment and Assurance Committee shall: (a) Develop written policies and procedures for safe and effective drug therapy, distribution and use; (b) Oversee pharmaceutical services in the facility, monitor the service to ensure accuracy and adequacy and make recommendations for improvement; and (c) Meet at least quarterly and document its activities, findings and recommendations. (3) Drug Supply, Storage and Labeling: (a) Drug Room. Facilities without a pharmacy shall have a drug room as defined in ORS Chapter 689, supervised by the consulting pharmacist. Drug rooms shall contain only prescribed (legend and non-legend) drugs, non-prescription (non-legend) stock drug supply and the emergency medication kit authorized pursuant to this rule. Locked carts or locked cupboards shall be used to prevent pilferage; (b) Labels: (A) All medications purchased or designated for specific residents shall be labeled as prescribed for such resident; (B) If facility policy allows medications accompanying the resident on admission to be used, the medication must be identified as to the resident and medication and shall be authorized for use only on the written order of the attending physician. (c) Storage. Except as provided in subsection (4)(b) of this rule, all medications shall be stored in the facility pharmacy, a drug room, or in a locked medication cart; (d) Stock Supply: (A) Except as provided in section (6) of this rule, a stock supply of prescription (legend) drugs may be maintained only within a licensed pharmacy; (B) A stock supply of non-prescription drugs may be maintained in a drug room or locked medication cart, but there must be a doctor’s order for administering such drugs. A stock supply of non-prescription drugs means those non-legend medications supplied in the manufacturer’s original package or repackaged by a registered pharmacist and labeled in accordance with ORS Chapter 689. (e) Resident Discharge. Medication to accompany the resident upon discharge must be on the written order of the physician; (f) References. References regarding use, dosage, contraindications, drug interactions, and adverse reactions shall be available on drug products used in the facility. (4) Drug Administration: (a) Medications prescribed to one resident shall not be administered to another; (b) Self-administration. Facilities shall have written policies and procedures allowing self-administration of medication: (A) All bedside medications, except nitro-glycerine, shall be stored in closed, locked cupboards or drawers; (B) The consulting pharmacist shall specify maximum quantities of medications to be stored at bedside to ensure prevention of poisoning by confused or suicidal residents. (c) Stop Order Policy. An automatic stop order policy shall be adopted and enforced. This policy shall provide guidance when medications ordered are not specifically limited as to time or number of doses. The policy shall be developed by the Quality Assessment and Assurance Committee. (5) Medication Review. Medications shall be reviewed monthly by the consulting pharmacist and reordered by the physician as necessary, but no less often than quarterly. The pharmacist shall alert the DNS when drugs designated “less-than effective” (“DESI” drugs) by the Federal Food and Drug Administration have been ordered and what alternative medications may be available. The DNS shall notify the physician. (6) Emergency Medication Kit: (a) An emergency medication kit shall be prepared and authorized by a registered pharmacist for use in the facility in accordance with written facility policy. The contents shall be selected by the Quality Assessment and Assurance Committee; (b) The kit shall be sealed and stored in a manner to prevent loss of drugs, but available to authorized personnel. The vendor pharmacist shall be notified when the seal is broken. A record shall be made that identifies each use of an emergency drug. The contents shall be plainly indicated on the outside of the container; (c) Any drug removed from the kit shall be covered by a prescription and signed by the physician within 72 hours. (7) Charges for Drugs; Choice of Supplier. See OAR 411-085-0340. (8) Documentation. The nursing staff shall clearly and accurately document administration of pharmaceuticals and the response thereto. Statutory/Other Authority: ORS 410.070, 410.090 & 441.055 Statutes/Other Implemented: ORS 441.055 & 441.615 History: SSD 19-1990, f. 8-29-90, cert. ef. 10-1-90