(a) The CDRH shall, with the assistance of a pharmacist, develop policies and procedures governing the management of medications for patients. Policies and procedures shall be approved by the medical director and the governing body and shall be implemented by the CDRH staff.

(b) All drugs which the CDRH staff administers or the patient self-administers shall be upon the order of a person lawfully authorized by that person's respective practice act to give such an order and shall be with the approval of the medical director, or in the absence of the medical director, the alternate physician. There shall be self-administration by patients only when the order so specifies and upon the approval of the medical director or in the absence of the medical director, the alternate physician.

(c) Medications shall be administered as ordered.

(d) Medication shall not be kept at the patient's bedside.

(e) Medications, other than those for patients who have been approved for self-administration, shall be stored in an orderly fashion in lockable cabinets or drawers accessible only to staff personnel lawfully authorized to administer medication by their respective practice act.

(f) Medications for patients who have been approved for self-administration shall be stored separately from all other medications. They shall be stored in an orderly fashion in lockable cabinets or drawers accessible only to staff personnel lawfully authorized to administer medication by their respective practice act or by other professional staff members who have been so designated in writing by the medical director, or in the absence of the medical director, the alternate physician.

(g) Professional staff members may assist patients in the self-administration of their own medications. Professional staff assistance in the self-administration of medication, by other than persons who are lawfully authorized by their respective practice act to administer medication, shall be limited to the following:

(h) Prescription drugs shall remain in their original prescription container. Non-prescription drugs shall remain in the manufacturer's original container and shall be clearly labeled with the name of the patient.

(i) A pharmacist shall review the drug regimen of each inpatient, and current outpatient, at least quarterly. The review of the drug regimen of each patient shall include all drugs currently ordered, information concerning the patient's condition relating to drug therapy, medication administration records, and where appropriate, physician's progress notes, nurse's notes, and laboratory test results. The registered pharmacist shall be responsible for reporting, in writing, irregularities in the dispensing and administration of drugs and other matters relating to the review of the drug regimen to the medical director and the administrator.

(j) Drugs shall be stored at appropriate temperatures. Drugs required to be stored at room temperature shall be stored at a temperature between 15°C (59°F) and 30°C (86°F). Only drugs requiring refrigeration shall be stored in a refrigerator between 2°C (36°F) and 8°C (46°F). When drugs are stored in a refrigerator with food, the drugs shall be kept in a lockable container clearly labeled “DRUGS.”

(k) As evidence that a drug has been administered, the patient's health record shall contain the name and dosage of the drug administered to the patient, the time at which it was administered, and the name or initial of the person administering the drug.

(l) Orders for drugs shall include the name of the drug, quantity or duration of therapy, dosage and time of administration of the drug, the route of administration, if other than oral, the date, time and name of the prescriber. PRN orders shall include the indication for use of the drug.

(m) Verbal orders for drugs shall be given only to a physician, licensed nurse, psychiatric technician, physician's assistant, or pharmacist by a person lawfully authorized to give such an order. The order shall be entered promptly in the patient health record, noting the name of the person giving the verbal order and the signature of the person receiving the order. The prescriber shall countersign the order within 48 hours.

(n) Drugs not specifically limited as to time or number of doses when ordered shall be controlled by automatic stop orders or other methods in accordance with written policies approved by the medical director.

(o) Drugs which have been discontinued or those which remain in the hospital after discharge of the patient shall be destroyed by the hospital in the following manner:

(p) Medications brought by or with the patient on admission to the hospital shall not be used unless the contents of the containers have been examined and positively identified by the patient's physician or the medical director or a pharmacist retained by the hospital.