Trouble with MAR

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In reviewing the MAR in LTC, I noticed 2 entries on two separate blocks and apart from each other. The first block is written for Duloxetine 30 mgs with 60 mgs Cymbalta for a total of 90 mgs. (Duloxetine is Cymbalta). The next block is written as Duloxetine 60 mgs with 30 mgs Cymbalta for a total of 90 mgs. Both blocks are initialed throughout the month, as. "Given". Now it gets funky. We have CMAs giving out these meds and mid way through the month we ran out if this med. In my opinion, it should have been written as "30 or 60 mgs of Cymbalta with 30 or 60 mgs to equal one dose of 90 mgs Cymbalta. The company stated that the original way was correct and that signing twice dies not mean it was given twice (one with the 30 mg and one with the 60 mgs) and that the CMAs know to only administer one dose but to sign in both blocks (orders) in the MAR. I think this could cause a med error, and I wonder - where did half a month supply go? I questioned this with a note to my supervisor, who initially agreed with me, but then fired me because she stated that if the state came in and read that note, they could get in trouble. Any thoughts on this? Are such double entries in the MAR common? Thanks...

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Welcome to AN!

Your post was moved to ti's own thread for best response.

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Specializes in LTC,Hospice/palliative care,acute care.

We write an order like that as follows "admin 1 cymbalta 30 mg cap po-admin with 1 60 mg cap to equal 90 mg" and then the next order is "admin 1 Cymbalta 60 mg cap po-admin with 30 mg cap to equal 90 mg" . Many years ago we could write "cymbalta 90 mg (admin 1-30 mg cap with 1 90 mg cap) but someone (DOH,JCAHO?) decided that was an improper order and an accident waiting to happen.

I'm not understanding why you got fired. Did you refer to this in a resident's chart? How would "the state" read your note? You are protected as a "whistleblower" and you need to go right on up your chain of command and fight this. HALF of the meds were gone-obviously someone screwed up You should be patted on the back for discovering the issue and helping to fix it. YOU did the right thing!!!

Fight this! Your supervisor is WRONG for covering up what could have been a serious occurrence.

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Specializes in School Nursing.

I agree the supervisor was wrong firing you. If you documented your note wrong, education would be the course of action, not dismissal. I think you're right, the MAR was unclear and it appears as if they have been giving the wrong dosage. :/ You were right to question this.

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I agree that you were wrongly fired and that you were correct in questioning the MAR entries. If this is how the DON handles an administrative question where it appears you were not the erring individual(s), then I hesitate to see how she handles a real problem.

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Thank you for responding. The following day I went to the unemployment office and I told them the truth. They told me the same thing. My intent was not to get anyone in trouble. This facility was sanctioned by the state and the state was returning to see if certain wrong doings were cleared up. My intent was to help via quality assurance before the state got there. Unfortunately, these nurses preferred to not fix things but to cover it up. We are all human and no one is immune from making a mistake. What is sad is the pride and refusal to correct a mistake, not get rid of the whistleblower. Sometimes I feel like leaving this profession. What is holding me back is my Love for human life and my dedication to my God and what I feel is my calling. Perhaps private duty would be best for me. Again, thank you so much for your support. It means the world to me. :-)

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Specializes in Gerontology, Med surg, Home Health.

The proper way is: in one box Cymbalta 30 mg tab. Give one tab orally with Cymbalta 60 mg to =90mg daily

The next box: Cymbalta 60 mg tab. Give one tab orally with Cymbalta 30 mg to = 90 mg daily.

You must sign off each medication.

Stupid reason to fire someone if you want my opinion. When would the state have access to a note you wrote to the supervisor? It's not part of the medical record.

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I understand, but this is "Assisted Living" where meds are dispensed by non-licensed, certified medication aides that only had a few weeks of training (this is not their fault, of course). What alerted me was, what happened to 1/2 month's Cymbalta, and then when more was requested mid-month, the pharmacy stated it was much too early. Now half the remaining month have initials circled and in the back of the MAR is written, "not available" repeatedly for an entire half a month. This is not a drug that can be stopped abruptly, yet, it was with the above explanation. When the pharmacy came in, I showed them and they stated that this elderly and frail lady must have her med and the facility will have to foot the bill out of their pocket. BTW: when I came back after being off for the weekend, The resident was no longer there - she went into cardiac arrest - no one knows why. They just stated that it was her time. As per the super's note, you are correct. Since when does the State read a person's personal mail. This supervisor made a stupid remark when she stated, "the State could have seen that". This person was new, overwhelmed, I saw her bang on the computer because she couldn't get in (she didn't have a pin #). She seemed like one that had some impulse control issues. In any event, I checked the company out and read reviews. Employees have listed them as one of the worst places to work, where nurses are "thrown under the bus", mistakes are covered up and please don't put your mother there unless you want her to die.

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Why don't they just write "cymbalta 90 mg" and then the nurses have to figure out its a 30 mg cap with a 60 mg cap?

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I know. It doesn't seem like rocket science. I think it will be corrected. They just appeared to want to cover up the issue. I guess it's hard for a facility to agree that someone's life could have been in danger - it's what lawyers would like - an admission.

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Specializes in Pediatrics, Emergency, Trauma.
Why don't they just write "cymbalta 90 mg" and then the nurses have to figure out its a 30 mg cap with a 60 mg cap?

Because they are two different dosages given together; each dose needs be accounted for "right dose", even if it is the same med.

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because you need a box to sign each pill. if they were to have sent all 30's and said to give 3, that would have been one box. But I think it is cheaper to send the 60s. mixed dosages like this, are, in my opinion a recipe for this very problem. I think when the dosage is available as in this case, it should be done that way, ie the 3 30s instead of a 60 and a 30 . this comes up with Lasix frequently. and prednisone, however, with the prednisone, it is not always possible....

Why don't they just write "cymbalta 90 mg" and then the nurses have to figure out its a 30 mg cap with a 60 mg cap?
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