This will be a bit long so forgive me now. I am a new home health RN. I was hired by a company to do client assessments and create a care plan. That turned into administering meds. No big deal, right? I've done medication administration countless times. I went out and assessed the client. I had them sign the service plan set up by admin. They need medication administration to ensure compliance.
This is a company getting their level 2 RSA license. So I check that there is doctors orders. Was thorough in documentation. Rechecked all charts. Fully expected to do well at survey by OHQC. That is where it all went south. The surveyor stated that I was not following doctor's orders and they were incomplete due to the following:
Order stated med 25mg 1tab daily of a med. Hour of sleep for another and BID for another.
It didn't have the doctor's office stamp but it did have their signature and dose, route, frequency, person. She said it was incomplete due to lack of designated time to administer, daily is nonspecific. Lack of office stamp. List different from what patient stated they took.
So she said, also, that I was not following orders because I administered the medication at time, daily, requested by the client. Also because I was not giving medication BID. The client is able to independently take their medication. Just not compliant. That was the purpose of the two to three visits weekly.
Another issue was, although I had doctor's orders to give meds, I didn't have an order for why we were giving meds. No what each medication was taken for but that he was noncompliant.
My issue with this is that, no where in the regulations does it list that specific of details for home health medication orders. Second, the client contacted us not the physician.
Also, another thing she said was why does the clients med list have 13 meds but I only gave 3. I explained that this was all that was ordered by pcm. I also advised that I had advised the client to get un uptodate list from pcm and I would then request another medication order. The problem was he had 3 doctors and none communicated.
Also, the client ran out of medication and I advised him yo refill. She said I should have called the pharmacy used by client to get refills.
I am so frustrated because I am a diligent RN and take great pride in the care and quality of work I do. I can rationalize now why those things should be included but find it hard because of such vague regulations
Anyone else experience this problem? Any advice? Am I wrong that I feel like an inadequate nurse and fearful that she'll report me for deficiencies that I truly did not disregard or ignore?
I am not in your realm of the hh arena, but since when is the doctor's order supposed to specify a time of day to take a med? I am still seeing "daily", or "once a day", etc. This sounds too micromanaged to be real. Waiting to see what others say about this.
I think what you need to say in your documentation is that "Patient took medications as prescribed". As you state yourself, patient knows his/her meds but is non-compliant. It is common to state that patient needs reminders. You can provide teaching and reminders, but there is no need for you to administer the medication. The patient takes them him/her self.