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Medication Procedures for Residents going on pass
from Long Term Care  

Including Basic Care and Assisted Living Facilities 

Developed by the North Dakota Board of Pharmacy in collaboration with the North Dakota Board of Nursing and the North Dakota Department of Health 

The provider pharmacy should package and label the medication for long term care (LTC) resident medication administration. The pharmacy labels it with a complete pharmacy label according to North Dakota Administrative Code 61-04-06 and North Dakota Century Code 19-02.1-14.1 subsection 2. It is the standard of practice for those administering medications to administer them out of a pharmacy labeled container; or a manufacturer’s original container. 

This guidance is intended for instances when the resident’s family/others have arrived at the LTC facility requesting to take the resident out on pass, and there is not time/feasibility to provide a proper pharmacy labeled container for their medications.  

Licensed Nurses: 

  • In these urgent instances, the licensed nurse may provide up to a 96-hour supply of medication.  
  • These medications may be furnished to the resident, resident’s family, or caregiver who will accompany them during the pass.  
  • The medication can be provided in containers provided by the provider pharmacy or the LTC facility. 
  • The facility policy must designate the types of acceptable containers.  
  • Multiple medications may be provided in the same container if they are to be administered to the same resident and at the same time.  
  • The container must be labeled with the resident’s name, date, and time of administration. 

The licensed nurse must: 

  • Provide a list of the resident’s medications to the resident, resident’s family, or caregiver. This may be accomplished by printing a list from the nursing home medication administration record or, if that is not possible, a typed or handwritten list of medications. 
  • The written list must include the name of the medication, the dosage, time of administration and the resident’s name. 
  • The name of the licensed nurse who prepared the medications and phone number for the facility must be included on the medication list for questions as they arise. 

Child resistant packaging should be utilized unless the resident or their family requests an easy open container. This request must be documented by the licensed nurse. 

The LTC facility should address the above requirements in their policy and include a procedure to identify any medication returned to the facility. 

A licensed nurse may not delegate the repackaging of medications to Unlicensed Assistive Persons or Nurse Aides. 


Approved 11/13 
Reviewed 11/18, 10/22 

Page Updated: 11/1/2022 2:35:09 PM