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I am doing quality reviews for an insurance co, and I had a case where the mom of a child alledged the nurses gave her child a wrong dose of a med.
I read through 6 months of 487's, notes, etc...but I found the documentation very confusing.
In this situation, the child rec'd 7-3 and 11-7 nursing care. Parents did 3-11. So, there was no med kardex where nurses signed out daily doses, I guess because parents would not be expected to do so, and that makes sense.
I did find med lists, but they were very often not updated with the latest orders, and D/C of meds was documented only once out of 20+ changes. I never saw any documentation of dressing/treatment changes in the care plan, only on the 487, and when 485/orders updated every cert period.
Can you tell me how you track this info? I have to call the child's mother to see if she can give me a specific example of the errors she is referring to, but I suspect the chart has been sanitized. For example, there was one eve when the nurse documented she was refused access to the home. But no follow up call by a supervisor the next day? And mom requests a new agency with absolutely no indication of a problem documented? And a month of nurses notes is missing.
I see the mom signs the nurses notes each shift, so I can understand why nurses would be hesitant to chart negative social issues, but wouldn't there be some kind of documentation in the office record, if you informed your sup about a situation in the home? When I was a sup, I documented calls from the nurses.
I find it odd. What do you think? And how do you track med/treatment changes? What records do you keep in the home, and is there a duplicate record in the office?