ALS covering up med error? Advice please

[bershaw]

Hi - here's hopefully a short version of the scenario i'm facing. I'm not sure what to do, if anything.

I am a brand new CNA- just certified. I'm working in an assisted living facility on NOC shift, where i am doing mostly paperwork. I only work two days a week.

Last weekend I got a call from my ASL (she's an LPN) at about 11:30pm. She asked me to check the MAR to see if Prednisone had been added for a new resident. I looked and it had not been added. She asked me to add it and we hung up.

I did some digging and discovered that the order was recieved on 1/26, the day the resident arrived. Her meds had come with her, including a full bubble card of prednisone. The residents discharge papers had an order to step down the Prednisone over 7 days. New cards with the dosing for the step down came on the evening of 1/27. Two of my co-workers had been entering the meds into the MAR and had missed the Prednisone and an order for Tylenol too.

After reviewing the discharge papers, I noted the order stated the step down was to have been started on 1/27. It was 1/30when she called. The order specifically said 1/27. The resident had missed 3 days of medication.

I wrote the orders in the MAR exactly as written. Then I texted my ASL to ask what should be done since the res. had missed 3 doses of the medication. Then I let the a.m. med tech know what was going on and went home. I had 5 days off in between.

When I came back I looked in the prog notes to see what had happened. My Asl had noted in the prog notes that the discharge orders had been "unclear" and that they hadn't recieved an answer about what to do about the med. The MAR pages I had written were completely gone, replaced by newly written orders. Half of the discharge paperwork is now gone. The ASL noted that the Dr. and family had been notified, but there is no supporting documentation of any of this (fax, ect.) The medication was given the a.m. of 1/31 per the ASL direction, at the starting point. Basically the Dr's orders had been changed. Since the ASL made this call to me on 1/30, she knew about the original error of not including it in the MAR. I asked where the MAR page was that I had written and was told that the ASL "took care of it" and that since that was the only med on the page it was replaced.

This situation scares me, if nothing else the fact that such a cover up is happening over a mistake. What if it had been a med that was more vital to the resident? I'm not sure if it should be reported, or to whom. All the answers I am getting are vague and everyone seems nervous about it. I was told that this is not the first time this LPN has made an error and covered it up.

Thoughts?

[npeters]

Definitely sounds like something a supervisor needs to be aware of. Is there any way of reporting it anonymously?

[jb2u, ASN, RN]

Unfortunately this falls under "seeking legal advice." According to the terms of service for this website, seeking legal advice is not allowed. Thread closed.