Chapter 3 – Health Care Operations

3.5.14 Additional Requirements Pertaining to Licensed Inpatient Facilities

• Procedure Overview

  • This procedure applies to licensed inpatient beds only.  Beds licensed under California Code of Regulations, Title 22, have additional regulatory requirements that must be met which may include, but are not limited to the following:

  • Automatic medication stop order dates (applies to all licensed beds).

  • Drug Regimen Reviews (applies to Skilled Nursing Facilities [SNF] or where otherwise required by licensing or accreditation).

  • Bedside medications (applies to all licensed beds).

• Purpose

  • To promote patient safety and comply with federal and state requirements for licensed inpatient beds.

• Procedure

  • Automatic Medication Stop Order Dates:

    • Medication orders for patients in licensed inpatient beds shall be automatically stopped after 48 hours if the duration is not specified in the order.

    • If the automatic stop date falls on a weekend or a holiday, this date shall be extended to the next regular business day unless otherwise specified by the prescriber in the original medication order.

    • Licensed health care staff shall ensure that all telephone orders for patients in licensed inpatient beds contain the required prescription elements including the duration of the order (Refer to the Health Care Department Operations Manual, Section 3.5.8, Prescription/Order Requirements and Medication Availability).

    • When pharmacy receives an order without a duration specified, the pharmacy staff shall contact the prescriber for clarification.

    • Pharmacy shall inform medical leadership of any concerns where medications have been automatically stopped due to a lack of clarification of the order duration.

  • Drug Regimen Reviews

    • The Pharmacist-in-Charge shall ensure that drug regimen reviews are completed at the appropriate interval for patients admitted to licensed SNF beds or where otherwise required by licensing or accreditation.

    • A pharmacist shall review the drug regimen of each patient at least monthly and prepare appropriate reports.  The review shall include:

      • All medications 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 pharmacist shall be responsible for reporting, in writing, irregularities in the dispensing and administration of medications and other matters relating to the review of the drug regimen to the administrator and Chief Nurse Executive (CNE).  A pharmacist shall evaluate:

      • Appropriateness of therapy (indication, route, frequency, dose, and duration).

      • Potential drug interactions.

      • Contraindications.

      • Therapeutic duplication and/or polypharmacy.

      • Unnecessary medications.

      • Documented allergy and adverse drug reactions.

      • Relevant lab results for abnormalities as required for drug monitoring.

      • Any other common parameters requiring adjustment in dose or regimen.

    • The pharmacist shall communicate the findings of the review in writing to the prescriber and the CNE or designee (e.g., the supervising nurse in charge of a licensed SNF).

    • The pharmacist shall make an entry in the progress notes indicating that the patient drug regimen has been reviewed, document any issues when identified, and sign and date the entry.

  • Bedside Medications

    • Prescribed medications permitted to be allowed for bedside shall be limited to sublingual or inhalation forms as specified on the Rescue Medications list, which has been approved by the Systemwide Pharmacy and Therapeutics Committee.

    • Prior to prescribing any medication to be allowed at bedside, providers shall evaluate the patient’s mental and physical capacity to self-administer medication.

      • If the provider has any doubt about the patient’s mental capacity to self-administer medication, bedside medication shall not be ordered until mental health services has been consulted and rendered a recommendation.

      • If a patient is deemed unable to self-administer medication, bedside medication shall not be ordered. The barriers to self-administration shall be documented in the health record.

    • Nursing staff shall:

      • Instruct the patient on the proper use and storage of the medication and document in the health record.

      • Document the frequency of use since the last registered nurse assessment and the treatment response if the patient used the medication.

      • Ascertain the reason if the medication is used more or less than prescribed and, if appropriate, discuss with the patient the importance of adherence with prescribed use and document the variance in the health record.

      • Notify the provider if the patient has not used the medication according to the instructions or is not getting expected results.

      • Document in the electronic Medication Administration Record whenever a new supply of bedside medication is provided.

• References

  • California Health and Safety Code, Division 2, Chapter 2.05, Section 1339.63

  • California Code of Regulations, Title 15, Division 3, Chapter 2, Subchapter 3, Section 3999.381, Rescue Medications

  • California Code of Regulations, Title 22, Division 5, Chapter 1, Article 3, Section 70263, Pharmaceutical Service General Requirements

  • California Code of Regulations, Title 22, Division 5, Chapter 3, Article 3, Section 72357, Pharmaceutical Service – Labeling and Storage of Drugs

  • California Code of Regulations, Title 22, Division 5, Chapter 3, Article 3, Section 72359, Pharmaceutical Service – Stop Orders

  • California Code of Regulations, Title 22, Division 5, Chapter 3, Article 3, Section 72375, Pharmaceutical Service – Staff

  • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79651, Pharmaceutical Service – Labeling and Storage of Drugs

  • California Code of Regulations, Title 22, Division 5, Chapter 12, Article 3, Section 79653, Pharmaceutical Service – Stop Orders

  • Health Care Department Operations Manual, Chapter 3, Article 5, Section 3.5.8, Prescription/Order Requirements and Medication Availability

  • The Joint Commission, Standard MM.07.01.01.004

• Revision History

• Effective: 02/2008
  Reviewed: 07/11/2023
  Revised: 11/18/2025