Meds on 485 don't match MAR

RN1263 · Apr 28, 2011

What do you think happened? I know, but want your thoughts on this, because my office is trying to bumble their way out of this problem by BS'ing me.

This has never happened to me before, however we don't have a protocol to fax MD regarding discontinued medications. However, If a patient was psych or had dementia (basically if I couldn't trust their word) then I would have called MD if I didn't get a response from faxing and would have spoken to MD's nurse requesting reconciliation of meds, then I would have documented speaking to nurse.

I "think" (but don't know) that the office may have put the same meds on the 485, because if the patient IS suppose to be taking those medications, but just decided not to, then it IS an issue/incident and to delete them would be saying MD approved of the discontinuation of those medications??? Just a guess.....

Isabelle49 · Apr 28, 2011

This has never happened to me before, however we don't have a protocol to fax MD regarding discontinued medications. However, If a patient was psych or had dementia (basically if I couldn't trust their word) then I would have called MD if I didn't get a response from faxing and would have spoken to MD's nurse requesting reconciliation of meds, then I would have documented speaking to nurse.
I "think" (but don't know) that the office may have put the same meds on the 485, because if the patient IS suppose to be taking those medications, but just decided not to, then it IS an issue/incident and to delete them would be saying MD approved of the discontinuation of those medications??? Just a guess.....

This doc doesn't return calls and he was faxed 3 times on this. What happened is the RN in the office who signed the 485 before submission did not check that 485 matched MAR. The problem with this is if the State Surveyor decides to visit this patient with me the meds will not add up. BIG Problem! BTW, I documented on the new mar that other meds are no where to be found in apartment and patient has no clue.

Medications written on the MAR by the SN doing OASIS assessment must match that shown on the 485, unless a new med is added before the 485 is generated, then that med would have it's own order. Thanks.

caliotter3 · Apr 28, 2011

Various offices have various levels of inattention to detail. I just correct things as I go and make certain to keep the suspense copy.

RN1263 · Apr 29, 2011

This doc doesn't return calls and he was faxed 3 times on this. What happened is the RN in the office who signed the 485 before submission did not check that 485 matched MAR. The problem with this is if the State Surveyor decides to visit this patient with me the meds will not add up. BIG Problem! BTW, I documented on the new mar that other meds are no where to be found in apartment and patient has no clue.
Medications written on the MAR by the SN doing OASIS assessment must match that shown on the 485, unless a new med is added before the 485 is generated, then that med would have it's own order. Thanks.

I think I misunderstood a bit. With the 3 computer programs I have used (maybe your on paper?) if I discontinue a medication, then it is discontinued...period. Another words if someone went to do a recert then that medication would NOT flow over to a new 485. Someone would have to re-add that medication for it to flow to 485 on recert (no checking of a MAR to 485 necessary). At my agency we still will print old 485 when doing a recert and make medication changes in red (adding, discontinuing, ect) and also make appropriate changes in computer, so they will flow over to 485 and everyone is on the same page that that change was done intentionally.

But yes I see your point...if they aren't doing their job correctly it will have a trickle down effect and you could get burned by a surveyor. However, I think you covered yourself with your documentation on MAR.

Kyasi · Apr 29, 2011

Sometimes I think my company's attention to detail is beyond the norm and some of our requirements in regards to charting seem to border on absurd. But we follow them to the letter and I guess I'd rather have that then to deal with an auditor if things were not done correctly. Our MAR's and 485's have to match exactly. We have our own chart auditors that come and check our charts frequently to make sure they do. Part of my job is to check all 485's before they leave our office for accuracy. So a lot of time and energy is spent making sure there are no errors or discrepencies. What drives me crazy is nurses who chart that Dad put Bacitracin on childs skinned knee. It was done once and the nurse will never be using it yet we have to either write an order to cover that or get the nurse to change her documentation. We can't get our field nurses to see that they don't need to mention everything a parent chose to give their child while they were not in the home. (of course something like an antibiotic that was ordered is different)

RN1263, does your company mark medication changes that are found during recertifications on the 485 as © changed DC (discontinued) or (N) new? In our company, meds don't ever just drop off but need to flow over in some way with an explanation as to whether they were Dc'd or changed. Is this not the norm?

Kyasi

caliotter3 · Apr 29, 2011

I have only just charted parent or family member given meds when I am there and see it given. Any mention of other activity that I become aware of, is done on a communication note. I think it is important that the family members inform us about what they are giving the patient, but most of them don't give a rat's behind about what information we are privy to and what is "forgotten". Some do all sorts of their own medicine when we aren't there. Makes for a topic for education.

systoly · Apr 29, 2011

'happens all the time. I call the office and document something like, "discussed form 485 with Henry the 8th, he states he will forward a new form 485 to the residence". I did have a state surveyor ask me if all the medications and dx's matched and I told her " no, but it is getting corrected" and I showed her my charting - she was ok with that.

Kyasi · Apr 30, 2011

caliotter3 This is why I think my company is sort of anal about documentation. If the family gives the med and a nurse mentions it in any way in her charting, then we are required to get an order for it. And no matter how many times I tell the nurses that if they don't give it, don't chart it.... they still do. So once it is documented, we have to address it. So I either have to make the charting disappear or I have to write an order for it. It's a pain in the arsss!

Kyasi

caliotter3 · Apr 30, 2011

But what if there is an adverse reaction to something the family gave, with your knowledge? You don't report the change of condition, or don't take action? Your charting reflects something different from what the family or the circumstances are saying? Dicey business at crisis, lawsuit, or allegations against the license time. I don't see the necessity to demand an order. All one needs

to do is to communicate with the MD and ask if they want to give an order, then act accordingly. If you oppose the action, you can give that info to the doctor too, as well as discuss anything else concerning the actions of the family members. Not all doctors are made aware of what the family members do in spite of their orders.

Kyasi · Apr 30, 2011

I'm not talking about prescription meds. In most cases, it will be something minor like Bacitracin that was used one time. In a recent case, the nurse went to great lengths to document wound care that was done once by the father weeks before. The MD had seen the wound during a routine exam and knew what the father had done. Then she failed to do a good head to toe assessment and said nothing about what the wound looked like when she was on duty. The nurses were not doing wound care and it was actually pretty much healed. (which we found when we followed up with the family.) So I asked the nurse to do a more complete assessment of the patients skin condition rather than to detail care that was done weeks before and that was irrelevant to her assessment the day she was on duty.

I am finding that many nurses today have very poor head to toe assessment skills. But that is a whole other discussion!

Kyasi

caliotter3 · Apr 30, 2011

I did not get the impression that this was about prescription meds only or about assessments done weeks before. Reread OP and it addressed meds as I read it. Families don't do assessments but they do use bacitracin without an order.