Medication Administration Policy

Medication Administration Policy 

Purpose: To ensure the safe and effective administration of medications to residents in compliance with CMS guidelines and the State Operations Manual (SOM) for long-term care facilities. 

Procedure: 

I. Preparation: 

• Wash hands thoroughly. 

• Read the medication label three times, comparing it with the Medication Administration Record (MAR). If the label is incorrect, apply a “direction change” sticker to the medication label to notify the pharmacy. 

• Document medication administration in the MAR. 

II. Resident Identification: 

• Identify the resident before administering the medication by checking the arm band or resident photograph and calling the resident by name. Consult with other staff members if necessary. 

• Explain the procedure to the resident. 

III. Positioning: 

• Ensure the resident is appropriately positioned for medication administration. 

IV. Pre-Administration: 

• Obtain and record any vital signs as necessary prior to medication administration. 

V. Administration: 

• Wash hands again. Gloves are to be worn for injections and when there is a potential for contact with bodily fluids. 

• Administer the medication according to the physician's order and facility policy. 

• Wash hands again after administering the medication or use hand sanitizer. 

VI. Documentation: 

• Document the administration of the medication in the MAR, including the time, dosage, and any observations or resident responses. 

References: 

• Centers for Medicare & Medicaid Services (CMS), Requirements of Participation for Long-Term Care Facilities. 

• State Operations Manual (SOM), CMS.