When a resident of a long term care facility has the opportunity for an unscheduled therapeutic leave that would be precluded by the lack of an available pharmacist to dispense drugs prescribed by an authorized practitioner, a registered nurse designated by the facility and its consultant or staff pharmacist and who agrees to such designation, may provide the resident or a responsible person with up to a 72-hour supply of a prescribed drug or drugs for use during that leave from the resident's previously dispensed package of such drugs. The drugs shall only be provided in accordance with protocols developed by the pharmaceutical services committee and the protocols shall be available for inspection. These protocols shall include the following:

(1) Criteria as to what constitutes an unscheduled therapeutic leave requiring the provision of drugs by the registered nurse;

(2) Procedures for repackaging and labeling the limited supply of previously dispensed drugs by the designated registered nurse that comply with all state and federal laws concerning the packaging and labeling of drugs;

(3) Provision to assure that none of the medication provided to the resident or responsible person may be returned to the resident's previously dispensed package of such drug or to the facility's stock.

(4) A record-keeping mechanism that will provide for the maintenance of a permanent log that includes the following information:

(a) The name of the person to whom the drug was provided;

(b) The drug and quantity provided;

(c) The date and time that the request for the drug was made;

(d) The date and time that the drug was provided;

(e) The name of the registered nurse that provided the drug;

(f) The conditions or circumstances that precluded a pharmacist from providing the drug.

Refer to WAC 246-839-810 for related regulations on this practice.