Description The primary purpose of this position is to assist in the administering of medications to residents as ordered by the attending physician, under the direction of the attending physician, the nurse supervisor or charge nurse, and the Director of Nursing Services. The administration of medications shall be in accordance with established nursing standards, the policies, procedures, and practices of this facility, and the requirements of this state. Requirements Accurately and safely prepare, administer, and document the oral and/or topical medications that are commonly used in this facility and that may be ordered for resident use by the attending physician or the Medical Director. Verify that any medications brought into the facility by a newly admitted resident are examined and identified by the attending physician or the facility pharmacy or pharmacist. Follow the labeling policies and practices of the facility. Ensure that all medications administered are properly labeled. Assist with medication charting as directed by the Nurse Supervisor/Charge Nurse. Follow facility procedures in regard to charting of medications. Follow facility policies and procedures regarding the destroying of medications; assist in carrying out these rules under the direction of the facility pharmacist or Director of Nursing Services, including the documentation requirements. Assist in documenting and removing medications that are discontinued by the attending physician. Follow facility procedures governing drug receipt errors, including notifying the delivery source and the Director of Nursing Services. Ensure that medication is returned and reordered except emergency drugs. Ensure that documentation of the drug receipt error includes a written error report, signed by an observer/witness and you. Follow facility procedures in holding medications for residents who are transferred from the facility or when the attending physician discontinues medications. Accurately measure, record, and report the vital signs of residents. Observe and verify that medication is ingested or applied as directed. Document any instance where prescribed medication is not administered, including reason(s) for refusal. Promptly notify the Charge Nurse, Nurse Supervisor, or Director of Nursing Services of any errors or reactions to medications by residents. Follow the medication card practices of the facility. Ensure that no medication is administered without a written, signed, dated order from an attending licensed physician. Follow the facility procedure for recording the order in the resident’s clinical record, including the type, route, dosage, frequency and strength of each medication. Verify the identity of the resident before administering the medication treatment. Follow the facility’s procedures allowing residents to self-administer his or her medications. Assist the Nurse Supervisor/Charge Nurse in monitoring and documenting all aspects of such self-administering. Promptly notify the Nurse Supervisor/Charge Nurse of any failure of a resident to properly take any “self-administered” medications. Follow established guidelines concerning the storage of drugs and biologicals. Be familiar with the meaning and usage of common medical abbreviations, symbols, and terms relative to the administration of medications as used by the facility, pharmacists, and physicians. Participate in the development and implementation of the resident’s comprehensive assessment as necessary.