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Due to Covid, we visit with my mom at her window; a week or so ago a nurse, who just happened to be in my mom's room when my sister stopped by; told my sister that they needed a different strength of her meds to administer it according to the prescription.


I emailed the doctor about the meds not being given and recapped my conversation with her and 2 other nurses about the meds and the milligram change. The Doctor sent me med charting to show that the meds were given. 2 days later the doctor emailed me saying the meds were in fact NOT given. She apparently did not know how to read the med charting form which indicated to see the key for the form to understand what was happening. A nurse had brought it to her attention that the meds were not given per the form, after she told me the meds were being given.


It appears that the issue was not brought to the Doctor's attention directly and in a timely manner for correction. In the same email she told staff that they would need to communicate off line on how to prevent an issue like this from happening again.


A couple of days later a charge nurse and the social worker contacted me via a conference call to ask for clarification on my email; which was plainly written. I asked if their was protocol in place to catch things like this and I was told that from now on he would tell the med techs to count the meds and notify the family. I suggested a system that provided checks & balances and accountability for proper follow through, he felt that was too much work.


I am concerned that something as important as med administration has no clear chain of commands for discrepancies. I do not want to get anyone in trouble, but I am concerned that something like this could happen; for 30 days no one mentioned to anyone that one particular med was not being administered to my mom. What is the best way to move forward with this????? Thank you!

As Shane states "The proper dose was not written by the doctor; while yes the staff should have clarified it with the MD the MD should have written the proper dose."

The med techs followed procedures correctly because they are prohibited from giving a medication/supplement with a different dosage than the one ordered by the doctor. If they had given the supplement, then they would have committed a "Medication Error". (Even though they were giving the correct dosage--based on the packaging of the OTC medication--they would not have given the dosage ordered by the doctor.)

If the medication had been vital to your Mom's health, then I would have agreed that you need to report the problem to the State Board of Health and Human Services. BUT since the medication that was not given is a supplement, I suggest that you DO NOT report the incident to anyone beyond the facility. The best thing that you can do is to review the Medication Administration Record monthly and make sure that your Mom is receiving the supplement as it should be given.
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Reply to DeeAnna
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I read your response to me. I agree, let this go. A suppliment is not life threatening. I am surprised ur allowed to supply it. At Moms AL everything even OTC were ordered by a doctor and reordering handled by a Nurse.
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Reply to JoAnn29
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I have been in a situation comparable to yours for the past 5 months, and I absolutely understand your concerns.
Prior to Covid I had a very comfortable relationship with “our” AL staff, but since the whole facility’s focus has shifted towards safety and prevention, MY role in her care has sunk in their priorities.
Knowing something about the struggle that was ongoing in April and May, I’ve let the anxiety provoking gaps in communication (both ways) go by, and am now gradually rebuilding the communication lines that we all had to provide my LO’s care before this ghastly event.
Nothing can undo the horrible effects that the virus had on her, but fact is, it is just as likely that she survived largely because of the wonderful care she was receiving.
If your mom got through this unscathed, the supplementation you provided before the threat was at its most serious may have helped, or maybe not.
I’m attempting to focus forward, hoping that my LO didn’t sustain any permanent injury (she appears about the same as she was 6 months ago, with some inevitable, possibly age related losses) but knowing that time and Covid were no help.

Hoping you and your mom can continue moving forward successfully as we all continue to adjust to “New Normal”.
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Reply to AnnReid
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Mom missed a supplement provided by you? Not a blood pressure medication, or other more vital medication to her well being? I can see the confusion. Staff could have been confused about this as it’s not their normal protocol. With Covid and staffing levels where you have PRN staff unfamiliar with patients care imo it would be too confusing as it wasn’t in her med delivery to the center. The proper dose was not written by the doctor; while yes the staff should have clarified it with the MD the MD should have written the proper dose. Thus the problem here was the MD who probably doesn’t know all the doses of supplements- especially those recommended by family. The MD was probably placating you by blaming it on the staff.

While I understand your concern I would proceed with vigilance and perhaps review the “med chart” monthly to assure she is receiving her meds as prescribed.

I myself do not believe in supplements. Over 41 yrs in nursing, I have come to believe that most supplements are unnecessary. Our bodies regulate mineral levels well enough and will simply excrete excess vitamin and mineral supplements to maintain a balance. One of the only supplements I feel is needed for elderly folks is B12 by mouth and it’s really a crap shoot whether the B12 will be absorbed to be used as this depends on the person’s GI function. Many PCP’s give B12 injections monthly with is better absorbed. Additionally it’s another pill that a patient needs to take which decreases compliance.

Choose your battles. You seem to be pleased with her level of care there; I say “trust but verify”.
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Reply to Shane1124
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With Covid and families not being able to see their loved ones face-to-face, these nursing homes are working hard to keep everyone safe but they're also getting sloppy. My mom's hearing aids were thrown away by mistake by one of the caregivers at her place, and it should have been caught right away because at every shift change they have to check that she has her hearing aids, and they have to be collected at night and check into the nurses station. I figured that around 42 shift changes happened before I figured out at a window visit that she didn't have her hearing aids.

I didn't report anyone because in general I like the care she's receiving at this place, and they took full responsibility for losing them. That was a $4900 mistake on their part, so the caregivers have been reminded in the strongest possible terms that the protocol is to be followed without fail.

I'd say to pick your battles. Your mom missed vitamins if I read your post correctly. That's not life and death, so I wouldn't go above the head of the director of the facility.
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Reply to MJ1929
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Mommycare, are the meds critical for a specific medical condition, and  did the lack of them cause health conditions that are either short term or long term?
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Reply to GardenArtist
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Well, I guess this is a nuisance and maybe the supplement would be helping her but has her condition declined? I take lots of supplements so totally support them and their value just saying that hopefully she was not harmed by this oversight.

Yes they SHOULD have figured this out before 30 days went by! You've talked to them about it, etc. so I would be inclined to let it go and see if there's a way you can help keep better track of the situation in the future? Somehow? Maybe just asking if she's been being given X every day as she's supposed to be?
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Reply to againx100
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I agree, it should have been caught. My daughter, RN, says the meds are in blister packs. Pills are not given from bottles. Each time a person is given a med, its written down and the nurse or medtech signs off. The same nurse/medtech are not always handing out meds. Shifts are 8 to 12 hrs meaning that somewhere along the line a different person is doing the meds. Somewhere someone should have seen the med was not given because either they could see it on the blister pack or the sign off sheet. The other scenario would be the med was not ordered so not on the med cart. Then I would question why not?
Another scenario is someone is stealing Moms med. Does she take a drug that could be a street drug. This is how my daughter caught a friend stealing. The sign off sheet was in the same ink and handwriting. Doesn't happen since each nurse signs off with the pen they had. There are checks and balances and someone has dropped the ball.

The doctor rights up the prescription. The nurse orders it from the pharmacy. The doctor does not make sure the pills are given. Thats the nurses job. My opinion is someone is trying to cover their tracks. If you want to take it further call your Ombudsman or the State dept who oversees NHs.
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Reply to JoAnn29
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mommycare Sep 4, 2020
Thank you JoAnn29!

The meds are supplements that I supply, no street value at all! The meds were on site and everyone was aware that they were to be a part of her daily med regime, this was signed off on by her doctor. The med techs just did not give them to her due to a discrepancy in the mg of what was in the written ordered by the doctor-50mg and the actual mg listed on the bottle-60mg. It would have been real easy to bring this to someone's attention and get clarification as to what to do, the Dr. already knew about the mg difference and it was discussed in a care conference. Yet it went thirty days without anyone saying anything, they just did not give them to her! SIGH..... I really like that charge nurse, too!
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