HELP!! Care plans on MWD orders

Specialties LTC Directors

Published

Specializes in Peritoneal Dialysis, QA.

I am new to LTC and had no real orientation I am working 24-36 hrs a week as a Clinical supervisor. Need help!!!! I was told part of my duty was to audit a MAR for missed meds. I selected the previous 10 days of an EMR and on 77 pts got 258 pages. Yikes!!!! Upon review I noticed what I think are care plans on the MAR. Things like assess pt for s/sx antipsychotic drug. Assess pt for s/sx hypoglycemia. Of course the med nurse giving meds has no time to do all these "assessments so she puts in a zero. When I requested we clean up the orders and remove these to the care plan, I was told this was SOP for a nursing home. I have 38 yrs exp as an acute RN but none in LTC. Is this true ? Or am I correct that these assessments should be on the care plan. Help!!!

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Specializes in Geriatric.

KathySandersSoffos -

I have been in LTC for 8 years now, and have never seen things like this on the MAR. This would be something that would either be included in the weekly/monthly assessment or in daily documentation if they were having a medication change. I believe, if I were you, I would clean this up. It is asking for trouble if you have a survey. It will look like you were never assessing your patient.

Wish you luck!

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The MAR and TAR having these things on them allows you to document that you did assess for behaviors, side effects and that you took preventive measures for risks. They may well be on a care plan, but no one will document that the way they do in the hospital. It is on the MAR to assure compliance.

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Specializes in Pediatric.

We have BBW monitoring on our MAR's. Nothing else like you're mentioning, though.

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