Medication Administration Release

Each resident’s medication program must be administered by means of one of the methods
described below. Resident’s ability to administer medications will be determined during the
resident assessment and the appropriate method will then be selected.

 The resident in able to self-administer medications and is thereby solely responsible to

obtain and administer their own medications.

 The resident is able to self-direct medication administration, i.e. facility staff may
assist residents with medication administration by:
o Reminding the resident to take the medication;
o Opening medication containers; and
o Reminding the resident or the resident’s responsible person when the prescription
needs to be refilled.
Again, the resident is held responsible to obtain and administer the medications.

 The resident requires significant (total) assistance with administration and as such the
facility assumes responsibility to administer medications according to a predetermined
service plan.
OR
 Family members or a designated responsible person may administer medications from
a package set up by a licensed practitioner or licensed pharmacist which identifies the
medication and time to administer. Responsible party also agrees to assume the
responsibility to fill prescriptions, administer medication, and document that the
medication has been administered.
I, ______________________________ (designate), agree to assume the responsibility to
obtain and administer medications from a package set up by a licensed practitioner or
licensed pharmacist. I also agree to refill prescriptions and document that the medications
have been administered. In so doing, I release The Inn on Barton Creek from any and all
responsibility dealing with medication administration.
______________________________
(Address)
______________________________
(Telephone)
______________________________ ___/___/___
(Signature) (Date)

Please sign below to acknowledge you have read and understood the Medication Administration
Release which defines the party that will be responsible to obtain and administer medications.
__________________________________ ___/___/___
(Resident or Responsible Party Signature) (Date)