N.H. Admin. Code § He-M 1201.07

Current through Register No. 50, December 12, 2024

Section He-M 1201.07 - Documentation

(a) Documentation of medication administration shall be performed and maintained by authorized providers or licensed persons only.

(b) Authorized providers and licensed persons shall document medication administration only for those medications that they administered themselves.

(c) With the exception of (f) below and within the scope of Nur 404, the nurse trainer shall remain the single authority over compliance with (d)-(j) below.

(d) The authorized provider or licensed person shall document all medication administration on the individual's medication log as soon as possible following administration including, at a minimum, elements specified in Nur 404.05(c)(1)-(3).

(e) Each authorized provider or licensed person who administers medications to an individual shall enter his or her full signature and initials on a cover sheet annually in the individual's current medication log.

(f) When a controlled drug is prescribed for an individual, authorized providers or licensed persons shall maintain an inventory that includes:

(1) The name of the drug and strength;

(2) The amount used;

(3) The amount remaining;

(4) The signature of the authorized provider or licensed person who administers the controlled medication;

(5) Documentation of a daily count; and

(6) If applicable, documentation of disposal in the presence of 2 people, at least one of whom is a licensed person.

(g) When an over-the-counter medication is prescribed, authorized providers shall consult with a licensed person to:

(1) Ensure the over-the-counter medication is:

a. The right brand-name or generic drug;

b. The right dosage;

c. Appropriate for the right route of administration; and

d. Administered in keeping with a PRN protocol pursuant to He-M 1201.04(h)(2); and

(2) Review any special considerations in administering the medication, as directed by the licensed person.

(h) Documentation pursuant to (g)(1) and (2) above shall include the name of the licensed person the authorized provider consulted with and the date of the consultation.

(i) Upon discovery of each medication error, and each time an individual refuses medications, except as noted in He-M 1201.04(l), the authorized provider or licensed person shall document, at a minimum, the following:

(1) The individual's name;

(2) The date and time of medication error or individual's refusal;

(3) The drug name, dosage, frequency, and route of administration;

(4) A description of the medication error or individual's refusal;

(5) Date and time of consultation of a licensed person, pursuant to He-M 1201.04(k);

(6) Actions recommended by the licensed person;

(7) Actions taken by the authorized provider; and

(8) Date and time of notification of a nurse trainer.

(j) The nurse trainer shall submit a written report to the area agency or subcontract agency within 5 business days regarding any authorized provider or licensed person who demonstrates a pattern of noncompliance with He-M 1201 as determined by Nur 404.06(e)(2), and include documentation from (i) above.

(k) The requirements of (a)-(j) above shall not apply to individuals who self-administer medications pursuant to He-M 1201.05(b).

N.H. Admin. Code § He-M 1201.07

(See Revision Note at part heading for He-M 1201) #4809, eff 5-1-90; ss by #6000, eff 3-21-95; ss by #7836, INTERIM, eff 3-22-03, EXPIRES: 9-18-03; ss by #7956, eff 9-19-03; ss by #9982, eff 9-19-11 (from He-M 1201.06 )

Amended by Volume XXXIX, Number 41, Filed October 10, 2019, Proposed by #12876, Effective 9/25/2019, Expires 3/23/2020.

Amended by Volume XL Number 28, Filed July 9, 2020, Proposed by #13057, Effective 6/17/2020, Expires 6/17/2030