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 seventy-two-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 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) Assurance that the RN informs the resident or responsible person of:

(a) The name, strength and quantity of drug provided;

(b) The proper administration of the drug;

(c) Potential adverse responses to the drug; and

(d) What actions to take should adverse responses occur.

(5) Provision for documenting by the RN in the resident's health record:

(a) Date and time of unscheduled leave;

(b) Name, strength and quantity of drug provided;

(c) Name of person to whom the drug was given and by whom it was given; and

(d) Confirmation that information described in subsection (2) of this section was provided.

See WAC 246-865-070 for related regulations regarding this practice.