This SOP defines how medications are managed, administered or assisted, stored, and documented in an assisted living community to protect resident safety and meet regulatory expectations. It emphasizes the rights of medication administration and accurate record-keeping.
Adapt the roles, medication systems, and reporting forms to your community and state rules. Copy, print, or customize it in the generator.
Purpose
To ensure residents receive the right medications safely and accurately, with proper documentation and error reporting.
Scope
Applies to nurses and trained medication aides who administer or assist with medications, and to supervisors.
Responsibilities
- Nurse / Med Aide: Administers or assists with medications and documents each pass.
- Director of Nursing: Owns this SOP, trains and evaluates staff, and reviews errors.
- Pharmacy Liaison: Manages orders, refills, and reconciliation with the pharmacy.
Step-by-Step Procedure
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1. Prepare
- Perform hand hygiene and gather the medication administration record (MAR).
- Verify the order and check for allergies and recent changes.
- Prepare one resident's medications at a time.
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2. Apply the medication rights
- Confirm the right resident (two identifiers), right medication, and right dose.
- Confirm the right route, right time, and right documentation.
- Check for the right reason and observe the right to refuse.
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3. Administer or assist
- Administer or assist per the resident's service plan and scope of practice.
- Observe the resident take the medication where required.
- Document immediately on the MAR; never pre-chart.
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4. Storage, controls & errors
- Store medications securely; count and log controlled substances per shift.
- Report and document any medication error or refusal and notify the nurse/provider.
- Follow up on missed doses and adverse reactions per protocol.
Checklist Version
- Hand hygiene performed and MAR ready
- Order verified; allergies checked
- Right resident confirmed with two identifiers
- Right medication, dose, route, and time confirmed
- Administration observed where required
- MAR documented immediately (no pre-charting)
- Controlled substances counted and logged
- Errors/refusals reported and documented