Medication management is one of the most heavily regulated and frequently cited areas in RCFE inspections. This manual covers all required elements under CCR §§87465-87476, from storage to error reporting.
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Medication administration is a clinical act that requires a licensed nurse or physician. Medication assistance - defined in CCR §87465 as handing a self-directing resident a pre-measured dose, reading a label, or opening childproof caps - can be performed by trained unlicensed caregivers. Crossing this line is a serious regulatory violation.
Medication Authorization Records (MARs) document every medication given to a resident, including date, time, dose, and staff initials. They must be current, accurate, and available for inspection. CDSS inspectors commonly check MARs for completeness and consistency with physician orders.
Controlled substances must be stored in a locked, secure location with access limited to authorized staff. A controlled substance log must be maintained, counting and verifying quantities each shift. Discrepancies must be reported immediately.
The caregiver must immediately notify the administrator and the resident's physician. If the error poses a health risk, the resident must be assessed. A written incident report must be completed. Depending on the severity, CDSS may also need to be notified within 24 hours under CCR §87211.
Medications cannot simply be discarded in the trash. DEA regulations and California law require specific disposal methods. This manual covers the facility's options including on-site medication take-back programs, authorized disposal containers, and coordination with a licensed pharmacist.