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My mom lives in small assisted living residence. Her meds are managed by the on-call nurse who is an LPN. I had a concern about an Rx re-fill not happening quickly enough and was worried the med would run out before the re-fill came. The nurse was not around so I checked my mom’s mediset and found the medication had already run out. When I brought this up to the LPN she got very defensive and angry with me. She orders the re-fills and was responsible for following up. She knew when the med would run out. I think this is a pretty serious error on her part. She says I am blowing it out of proportion. Because I did what I did, we got an emergency supply from the pharmacy and mom ended up only missing one dose. If I had not audited my mom’s meds, who knows how long she would have gone without.



What should I do?

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This is not exactly relevant but a good thing to bring up in this discussion.

When I was putting my LO's pills in the pill dispensers this week, one of the pills that regulate blood pressure was larger than the others. He takes 5 mg and the larger pill was 10 mg. This bottle of pills was mail order from Express Scripts. I'm glad I caught it. because if I hadn't, he'd have taken a dose twice as much as prescribed.

Just cautioning - check and double check what's in those pill bottles.
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MammaDrama Jul 2023
Very good reminder! Thank you.
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When my mom was given the wrong dosage of meds in a rehabilitation facility, I went straight to the DON.

In our case, an LPN told my mom to take a double dose so she wouldn’t have to come back to her room. Mom asked if that would harm her. She told mom no and my mom was not one to argue with authorities and took the double dose of her Parkinson’s medication.

When I saw mom the next day she told me about it. Needless to say, I wasn’t happy about what the LPN did.

The first thing that I did was to call the pharmacist to see if mom would be okay with receiving a double dosage.

The Pharmacist said that if it only happened once, it would be okay but she strongly urged me to report the LPN to the DON because she was probably doing this to other patients with all of their medications.

The DON was responsive in investigating the situation. The nurse admitted that she had been double dosing patients due to the staff being short handed. It’s sad when nurses have to work double shifts because they are short handed but this doesn’t excuse them from over medicating patients.

The DON told me that mom would be assigned a new LPN, so I was satisfied in how it was handled. I was relieved that my mother wasn’t harmed by this nurse’s poor judgment and very glad that she wasn’t going to be caring for my mother anymore.
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MammaDrama Jul 2023
Thanks. I did make a report to the DON on Monday. We will see how that goes.

Double dosing patients? My goodness. I’m glad your mom’s DON was responsive to your complaint and assigned a different LPN.
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No big deal, huh? You are within your right to file a report to her state board of licenses, whether it is a nurse or pharmacist. The big scare comes when the state appears for an investigation. There is no need for harm to happen. The facility gets a slap on the wrist.
I reported a double dose of a diabetes drug. The pharmacist was required to take extra credit courses on diabetes in order to keep her license.
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In my Moms small AL there was no DON or SW. Not big enough to pay these type of people. The LPN should have an RN over her I would think. If so bring this to the RNs attn. I would wonder what the med was. Cholesterol no big deal. Some meds can't even be ordered until down to the last pill. The pills should be in blister pks which makes it a lot easier to keep check on.

You were not wrong, the LPN was and should have apologized. She answers to someone in that facility. RNs oversee LPNs. No RN, in my Moms AL next in line would be the Director/Admin.
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AlvaDeer Jul 2023
The LVN almost certainly has no one over her. She would be responsible, hired to do this. These days, unless dealing with narcotics and triplicate forms, even a med tech is considered sufficient (trained).
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Email the DON and Social Worker and state the facts. Ask for a meeting.

Go to the meeting and ask how they plan to prevent this from happening again.

(Examples might be that mom's meds will be audited by the DON once a week for the next 2 months; the LPN will be sent for further training or subject to additional supervision.)
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MammaDrama Jul 2023
Thanks. I like the idea of sending an email first and asking for a meeting.
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I was thrilled to have my mom's AL take over dealing with her meds. It hasn't been all roses and unicorns though. Over 8 months, they have run out of meds a few times. It's been infuriating! One was her anti-depressant and as you may know, you don't go off that without tapering down. Nope - cold turkey off of it for THREE days. She was a hot mess! Calling me crying all the time. I was pissed and did a lot of complaining and someone higher up got involved and helped solve the problem. A couple months later a different med that need to be reauthorized by a different doctor, ran out too. At least it didn't make her lose it! I think they finally implemented a system after I asked to see their process in writing! Whoops - they didn't have one. WHAT??!! Kind of horrifying. And just so stupid and lazy too!

Even with these problems, there is no way I am taking it over again.
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Do what I did I reported it to whoever is over the nurse. You aren't the only one that have found mistakes believe me. In my case with my BIL the nurses couldn't follow their med orders. I found twice that they didn't fill his medications right. First time he wasn't getting one of his seizure meds and this went on for about a week. The second time they gave him his night meds in the day time and also forgot his bp meds plus another seizure med.

The doctor ordered the nurse to come in and fill his pills which I had been filling for the last 15 years for him. So when I noticed the medication mistakes I called his POA's and reported it to them.

But watch it you might get reported to Dept of Human Services for messing with the medication. Why I say this because I was reported to DHS for taking medications from his pill boxes. But I had photos of the pills and what was missing and what was given in morning and nights. Also I had ring cameras in the apartment to show what I found out so I had proof. And yes I was unfounded. That day I found the night meds in the morning meds I called the nurse they told me to call poison control and they told me to call the pharmacy which I did. It was their mistake and it was myself taking care of their mistake. The nurses who fill these pills should check what they are filling but they didn't.

Just watch it when it comes to medications there are eyes out there watching. I was turned into DHS twice but were unfounded and I was turned into Social Security for misuse of funds that was unfounded too. When dealing with anyone they can be vicious.

Prayers
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You MUST let the charge nurse know about this. And you must check her list of meds once a week or every other week. You should also go at random times and observe what they give her. I had a huge issue with giving wrong meds and wrong quantities when my mom was in rehab. Don't let them bully or intimidate you into not looking in to this on a regular basis. That LPN can't say you're blowing this out of proportion because she's not a doctor and can't just pick and choose what meds are dispensed. You did the right thing.
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That is actually a serious Predicament . I Know My Mom always made sure she had her Xanax that is One of the worst withdrawals ever . Definitely report the error so it won't happen again .
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Talk to the administrator. This is serious.
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