The hospital safely administers medications.

(1)

Drugs and biologicals are prepared and administered in accordance with the following: - Federal and state laws - The orders of the licensed practitioner or practitioners responsible for the patient’s care - Accepted standards of practice Note 1: Drugs and biologicals are administered by, or under supervision of, nursing or other personnel when permitted by Federal and State laws and regulations (including applicable licensing requirements) and with the approved medical staff policies and procedures. Note 2: For hospitals that use Joint Commission Accreditation for deemed status purposes: Drugs and biologicals may be prepared and administered as follows: - On the orders of other practitioners not specified under 42 CFR 482.12(c) only if such practitioners are acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. - On the orders contained within preprinted and electronic standing orders, order sets, and protocols for patient orders only if such orders meet the requirements of 42 CFR 482.24(c)(3).

(3)

The hospital develops and implements policies and procedures that guide the safe and accurate self-administration of medications by the patient or their caregiver or support person, where appropriate. Note 1: This applies to hospital-issued medications and the patient’s own medications brought into the hospital. Note 2: The term "self-administered medication(s)" may refer to medications administered by a family member.

(4)

If the hospital allows a patient to self-administer specific hospital-issued medications, the hospital has policies and procedures in place that address the following: - Making certain that an order is issued by a licensed practitioner responsible for the patient’s care and that it is consistent with the hospital’s self-administration policy - Determining that the patient or the patient’s caregiver or support person is capable of administering the specified medication(s) - Instructing the patient or the patient’s caregiver or support person, where appropriate, in the safe and accurate administration of the specified medication(s) - Addressing the security of the medications for each patient Note: The term "self-administered medication(s)" may refer to medications administered by a family member.

(5)

If the hospital allows a patient to self-administer medications not issued by the hospital, the hospital has policies and procedures in place that address the following: - Making certain that an order is issued by a practitioner responsible for the patient’s care and that it is consistent with the hospital’s self-administration policy - Determining that the patient or the patient’s caregiver or support person is capable of administering the specified medication(s) - Instructing the patient or the patient’s caregiver or support person, where appropriate, in the safe and accurate administration of the specified medication(s) - Addressing the security of the medications for each patient - Identifying the specified medication(s) and visually evaluating the medication(s) for integrity Note: The term "self-administered medication(s)" may refer to medications administered by a family member.