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Procedures for Residents/Patients
going on pass from Long-Term-Care 

Including Basic Care and Assisted Living Facilities

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

 The first choice in any resident medication administration scenario is for the provider pharmacy to package the medication and label 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 if administered by a licensed nurse or practitioner out of a pharmacy labeled container or a manufacturer’s original container.

This guidance is intended for instances where a proper pharmacy labeled container cannot be provided because the resident’s family or others have arrived at the Long-term-care facility wanting to take the resident out on pass and there is not time or feasibility to provide a pharmacy labeled container for their medications. 

Licensed Nurses:

In these circumstances, it is allowed that the licensed nurse may provide up to a 96 hour supply of medication in these exigent instances. 

·         These medications may be furnished to the resident, to the 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 Long-Term-Care facility.

·         The facility must designate the types of acceptable containers in their policies.

·         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 a minimum of the resident’s name, date, and time of administration.

The licensed nurse must:

·         Provide a list of the resident’s medications to the resident, the resident’s family, or caregiver. This may be accomplished by printing a list from the nursing home medication administration record or in the alternative, 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 of course, the resident’s name.

·         The name of the licensed nurse who prepared the medications and phone number for the facility, if questions arise, must be included on the medication list.

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

All of the items above must be addressed in the policies of the long term care facility, including a procedure to identify any medication returned to the facility.

The Board of Nursing will not allow delegation by nurses for repackaging of medications by Unlicensed Assistive Persons.


Approved 11/13
Reviewed 11/18