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Long-Term Care Nursing: Medication Pass

2 Contact Hours including 2 Pharmacology Hours
This peer reviewed course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
This course will be updated or discontinued on or before Monday, September 25, 2023

The purpose of this course is to enable the participants to become familiar with a medication pass and know the rule and regulations of long-term care


By the completion of this activity, the learner will be able to meet the following objectives:

  1. Describe the duties of a long-term care nurse.
  2. Discuss the medication pass of at least 30 residence.
  3. Identify the rules of the medication pass.
  4. Discuss the different high-alert medications and how they are administered.
  5. List the resident rights for medication pass.
  6. Discuss the administration of oral medications, liquids, eye drops, ear drops.
  7. Identify the common errors that occur during a medication pass and how they are prevented.
CEUFast Inc. did not endorse any product, or receive any commercial support or sponsorship for this course. The Planning Committee and Authors do not have any conflict of interest.

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To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Sandi Winston (MSN, RN)


Long-term nursing a not an easy field, but comes with many rewards as well as challenges. Long-term care nurses care for patients in need of extended care, including geriatric, wound care, chronic diseases and disabilities.1 Nurses must be dedicated to patient care because the same patients are seen day in and day out. Although most residents are elderly, many are younger.

A long-term care nurse must have a passion for working with the special residents in a long-term care facility. The work can be difficult at times but can be rewarding. Let’s explore the duties of a long-term care nurse.

What long-term nurses do on a daily basis

Long-term care nurses focus on providing care to patients in need of extended care.1 This care may entail routine care, wound care, dementia including Alzheimer’s disease, cancer and after care following surgery or strokes. The main focus is assessing and monitoring the residents’ functional status and maintaining or restoring physical health.

Routine care involves nursing assessments, medication administration, wound care, collaboration with the team including physicians, families, pharmacy, and therapy. Also included would be daily care with ADLs as needed and proper documentation.

Responsibilities may include2:

  • Consults and coordinates with healthcare team members to assess, plan, implement and evaluate patient care plans
  • Prepares and administers and records prescribed medications. Reports adverse reactions to medications or treatments 
  • Records residents’ medical information and vital signs
  • Assesses resident’s ability to perform routine ADLs
  • Assists residents with basic needs as dressing, eating, bathing and encourages patients to do things for themselves to retain feelings of independence and self-worth
  • Recognizes and manages geriatric syndromes common to older adults including cardiovascular, respiratory, gastrointestinal, urinary, musculoskeletal, neurological, integumentary, sensory and pain problems
  • Prepares equipment and assists the physician during examination and treatment of patient
  • Facilitates older adults’ active participation in all aspects of their own healthcare
  • Involves, educates and when appropriate, supervises family/significant others in implementing best practices for older adults

These responsibilities do sound overwhelming, especially for a new nurse, but it does become easier with time and experience. A solid orientation is of the utmost importance, and the nurse must feel comfortable asking questions. The medication pass is most intimidating to a new nurse, and he/she will need assistance when first starting.

Medication Pass

The medication pass takes up the most hours of the day and evening shifts. Trying to give 30 patients their medications can be frightening for new nurses, and even the seasoned nurses have problems at times. Do NOT, under any circumstances try to pre-pour medications to save time. Pre-pouring medications is against regulations.

Scenario 1
Judy, a new Registered Nurse on the unit, has been “instructed “by the other nurses to pre-pour medications to stay in the time-limit boundaries of 1 hour before and 1 hour after. She felt pressured to follow the other nurses’ routines, afraid if she didn’t she would not get more help if needed. Unfortunately, soon after Judy finished pre-pouring the medications, State walked in. She took her cart into the med room, and emptied all the filled cups into her pockets, and dumped them in an appropriate receptacle. This action slowed her time down, and now she has to start med pass over again. When she asked the unit manager why the nurses were allowed to pre-pour medications, the manager answered “they are not allowed.” Judy learned a valuable lesson that day; do not pre-pour meds! If the state had found all those prefilled med cups, they would have been fined, and the nurse may have been fired. Pre-pouring medications is dangerous and the biggest reason for medication errors.

Medication errors are serious and can cause resident harm or even death. First, and foremost, nurses must remember the 7 Rights of Medication Pass: 

  • The right resident
  • The right medication
  • The right dose
  • The right time
  • The right route
  • The right reason
  • The right documentation

General Rules for Med Pass

Before beginning a med pass, look at the MAR, NEVER go by memory and check for allergies.

Do not bring the cart into the dining room. Do not perform blood sugar checks or administer medications in the common areas of the facility.3 This can be considered a breach of resident confidentiality.

If another nurse asks you to give a medication she has already poured, you should decline. Only administer medications you have prepared yourself. You may not be sure the medication is correct, and it may not be the correct patient. No borrowing medications from another resident’s drug drawer. If a drug is missing, use the Emergency Drug Kit and follow the specific procedure for your facility.

Look for expiration dates on all medications including over the counter drugs. Most insulins expire after 28 days after opening the vial. Metered dose inhalers expire one month after opening.

Do not use list for abbreviations

Some of the abbreviations we use for medication pass are not allowed anymore, as they can cause confusion and medication errors. Per Joint Commission, here is the newest list of abbreviations to avoid:

Official "Do Not Use" List1
Do Not UsePotential ProbemUse Instead
U, u (unit)Mistaken for "0" (Zero), the number "4" (four) or "cc"Write "unit"
IU (international Unit)Mistaken for IV (intravenous) or the number 10 (ten)Write "International Unit"

Q.D., QD, q.d., qd (daily)

Q.O.D,.QOD, q.o.d, qod (every other day)

Mistaken for each other.  Period after the Q is mistaken for "I" and the "O" is mistaken for "I"

Write "daily"

Write "every other day"

Trailing zero (X.O mg)

Lack of leading Zero (.X mg)

Decimal point is missed

Write X mg

Write 0.X mg


MSO4 and MgSO4

Can mean morphine sulfate or magnesium sulfate

confused for one another

Write "morphine sulfate"

Write "magnesium sulfate"

Because there are many medication errors involving Morphine Sulfate, never use the abbreviation!9

Now to begin the medication pass

Now to begin the med pass:

  • Wash your hands with soap and water before and after med pass
  • Ensure med cart is locked when not in use. Med room should be locked at all times
  • Keep your cart clean and organized with no personal items on the cart
  • Make sure applesauce, ice cream, and the clean water pitcher are dated
  • May use alcohol-based hand sanitizer between patients if hands not visibly soiled. After three uses, wash hands again
  • Monitor and record vital signs that are required; use apical pulse for certain medications: Digoxin, antihypertensive drugs
  • Ensure the order is correct
  • Always check the resident’s name, drug, dosage, strength, and route using the MAR for reference
  • Enter resident’s room after knocking and identify yourself
  • Make sure the resident is sitting up before giving the medications, and never leave the room until you are sure the resident has taken meds
  • Never leave the meds in the room for the resident to take later3
  • If there ever is a difference between the MAR and the medication, stop •Take Action: Review the order in the chart, check with your supervisor, call the pharmacy if needed •Do not give the medication until you know the order is correct and the order has been corrected on the MAR3

The nurse is expected to know the action of each medication, so it is imperative a med book is kept on each cart. Be sure to look up all medications with which you are not familiar!

High Alert Medications

High alert medications can be dangerous to your residents. Familiarize yourself with your facility’s list of high risk meds, check and recheck physician’s orders, ask for help when you are not sure if the order is correct, or if the resident is showing signs/symptoms of an adverse reaction.

Administering high-alert medications

  • Identify high-alert medications based on your facility's approved list. Examples of high-alert medications are anticoagulants, antidiabetic agents, sedatives, and chemotherapeutic drugs.
  • Monitor medication dosing carefully, especially if dosing adjustments are necessary because of narrow therapeutic windows.
  • Obtain and review any laboratory values required for dosing adjustments; collaborate with the practitioner if values are out of the therapeutic range; watch for adverse effects.

List of medications

  • Anticoagulants: Heparin is the most common anticoagulant used in LTC, monitor for bleeding, chest pain, rapid breathing and fast heart rate. Vital signs to be taken before administration. Vitamin K to be given for critical level INR per physician’s orders.
  • Hypoglycemics: These are used to correct low blood sugar. Perform blood sugar test before giving Insulin to avoid low blood sugar. The most common signs/symptoms of low blood sugar include sweating, confusion, weakness, headache, and dizziness.4 Always have a tube of Glucagon on your cart to help reverse these symptoms.
  • Opioids: The drug that nurses have trouble with is liquid morphine. Be sure to check and recheck the concentration. All forms of opioids are considered high risk. Pay attention to the frequencies and dose.5 Be sure to watch the resident swallow the narcotic, and if timed release, ensure resident does not chew the pill.
  • Digoxin: Vital signs must be taken before the dose, pay attention to the pulse! If the pulse is below 60 or above 100, do not administer and document findings.
  • Chemotherapy: Only given in oral doses in long-term care. Follow instructions carefully, and do not touch the drug.

Residents’ rights and the med pass

Before we continue with the med pass, let’s review residents’ rights regarding medications:

  • Residents have the right to be treated with dignity and respect
  • Residents have the right to privacy
  • Residents (and families) have the right to refuse medication6

Keeping these rights in mind while passing medications helps the residents keep their dignity.

Preparing Oral Doses

When preparing oral doses, be sure to follow facility guidelines as well as CMS and pharmacy guidelines:

  • If you must touch a pill, use gloves
  • Always pop pills from bubble pack over the cart
  • If you drop a pill, throw it away. If it is a narcotic, have another nurse waste it with you. You always need a witness when wasting narcotics
  • Be sure only to split pills that are allowed to be split, no pills that are not scored!
  • If you have an order to crush medications, use a pill crusher or mortar and pestle, crush meds into fine powder, mix in applesauce or other item (water for enteral tubes)   –FYI: not all medications that are scored can be crushed [e.g., Toprol XL (metoprolol succinate)]3
  • Be certain to shake liquids before pouring, pour at eye level, wipe any drips from bottle afterward. Ensure the resident swallows the entire dose

There are certain medications with AHCA/CMS guidelines:

  • Metered Dose Inhalers: are used to treat asthma and COPD, wait one minute between puffs, have resident rinse mouth after doses are administered
  • Fentanyl patches: Used for severe pain, is time released. CMS has determined that some of the drug remains on the pad after removal and is a potential for diversion and abuse. Be sure to document time patch is removed, and waste with another nurse, place in sharps container
  • Medication Administration via Feeding tube:  Most time consuming! Always check placement before administering the drug. Administer each medication separately, flushing the tube between each medication7

Eye Drops

Always use a tissue, put on gloves and ask the resident to look up. Do not touch the eye with the dropper. Count the drops as they are being administered. Have the resident close the eye to help wash the drop over the entire eye. Wait at least five minutes before administering another drop.3

Ear Drops

Always use gloves when administering ear drops. Have the resident lie down with the affected ear up. Pull up and back on the earlobe. Instill the drops without touching the dropper to the skin, earlobe, etc.3

Common Medication Errors

Every new nurse will think they won’t have a medication error, but they will, especially with the time constraints for med pass in long-term care. Remember the phrase “to err is human.” Slowing down, ensuring the correct medication is being given, remembering the 7 rights of medication pass can help reduce medication errors.

"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional.” Antipsychotics, antidepressants, sedatives/hypnotics and anticoagulants were most common drugs for errors. The most common errors are giving medications at the wrong time, dose or route. Sound familiar? Remember the 7 rights!

Scenario 2:
Jane, a new graduate, was doing her first med pass alone after one week of training on the cart. She was passing the morning meds, the heaviest med pass of her day, when one of her residents began to “act out.” After trying to calm her down, to no avail, Jane went to her cart to look at the MAR to see what medication she could give. She found the order for Lorazepam 1 mg to be given I.M. every 12 hours and verified it had not been given for almost 36 hours. After Jane retrieved the Lorazepam from the refrigerator, she drew up the entire 2 ml of drug thinking that the concentration was 1 mg equals 2 ml. The actual concentration was 1 mg equals 1 ml. She gave the resident the injection, and the resident finally calmed down and fell asleep. At the end of the shift, during report and narcotic counting, the on-going nurse asked Jane where the other ½ of the Lorazepam was as she did not see that it was wasted. When Jane realized what happened, she went to the shift supervisor to report the error. The resident was monitored throughout the night. There were no adverse reactions, and the resident slept well. Jane learned a valuable lesson, and will always remember her first med error.

Documentation for the Med Pass

The right documentation during and after a med pass is of the utmost importance. Remember, if it is not documented, it is not done! Always document the meds given AFTER they have been given. If you document before, and the resident refuses or spits out the med, you have a lot more steps to completing your paperwork.

Remember to use the Nursing Process (nursing 101): Assessment, Diagnosis, Planning, Implementation and Evaluation. The assessment includes vital signs, lung and abdominal sounds, and adverse reactions to medications. Your documentation is your proof of care provided to each resident.

The nurse has two hours to complete the medication pass. Ask the floor staff to go to the supervisor with questions as med nurses should not be interrupted during the pass. Check the MAR for the times medications are due. After each patient, enter the drugs given. If you have a missed dose, wait until the end of the pass to get the med. If a PRN is given, mark the time, dose, reason and then go back after 1 hour to recheck the effectiveness. For pain medications, don’t forget to document the level of pain, as well as the pain level after 1 hour.


Long-term care nursing is a rewarding and challenging career, and the nurse must have a passion for working with the special residents in long-term care. The nurse wears many hats and the days are hectic. When the medication pass is thrown into the mix, the new nurse may become frantic and worried about getting the pass done in a timely fashion. This does sound overwhelming, especially for a new nurse, but it does become easier with time and experience. A solid orientation is of the utmost importance, and the nurse must feel comfortable asking questions.

Following the rules and regulations of the facility helps the new nurse with all the duties and responsibilities of the day, including an error-free medication pass.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)


  1. What is a Long-term Nurse. Everynurseorg. 2017. (Visit Source) . Accessed July 18, 2017.
  2. GHR Job Description: Geriatric Nurse. GHR , Inc. 2014. (Visit Source). Accessed July 20, 2017.
  3. Med Pass Fundamentals. mmlearn. 2012. (Visit Source). Accessed July 27, 2017.
  4. Hypoglycemia (Low Blood Glucose). American Diabetes Association. 2015. (Visit Source). Accessed August 3, 2017.
  5. High Alert List of Medications. PSNET. 2016. (Visit Source). Accessed August 6, 2017. 
  6. Resident Rights. MedicareGov. (Visit Source). 
  7. CMS Medication Administration and Pharmacy Guidelnes. Frandsen, B. 2017. (Visit Source).
  8. Mitchell J. Medication Errors in Long-Term Car. Medication Errors. (Visit Source). Accessed August 8, 2017.
  9. Official "Do Not Use" List. Joint Commission. 2017. (Visit Source). Accessed August 11, 2017.