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nursing home - how to address issues?
Posted: Friday, November 29, 2019 10:06 AM
Joined: 5/3/2013
Posts: 412

I'm looking for input on how to best address something that came to light in my first care planning meeting for my  mom who has just been placed in skilled nursing.
My mom is a brittle (hard to control) diabetic with chronic kidney disease, stage 3b.  Sodium and fluid restriction ordered from kidney doc.  She has a list of other health issues that her primary care doc has on file and also her specialists.

Without going into all the boring details unless needed, I had a care meeting earlier this week.  Present were:  Dietitian, Social Worker, Activities director and a Nurse Manager/asst nurse manager from her unit.  We went over her blood sugars because she had a few low mornings, which is unusual for her.  Come to find out - they had the wrong instructions in her med list and were giving short acting dinnertime insulin at bedtime instead of at dinner.  The instructions from the doc were correct but someone put the information incorrectly into their system.  Also -zero record of kidney disease and most of her other issues weren't included in their record.  The social worker found all of the appropriate and correct information in the binder but it wasn't in their electronic record.

I don't want to make enemies, because this is a  medicaid day one bed and other places are worse, and my mother was placed due to imminent risk of harm to herself due to refusal to go to her day program.  Taking her back home doesn't seem like an option.  But - I work in a healthcare organization (non- clinical) and I know that this is a big issue with great potential for harm.  This nursing facility has been working to overcome past issues and I see that they are advertising for a Director of Nursing, Administrator and other positions.  Maybe bought out and continuing to work on issues?  

Please advise.  I have waited to address this in a more documented and formal way so that I have a clear head and can get some input.  I'd really like to chew someone out because giving a brittle diabetic the wrong kind of insulin at the wrong time is life-threatening.  I think those present weren't the ones responsible and it seemed like they were really scrambling trying to make it right.   What do I do now?  

Posted: Friday, November 29, 2019 10:46 AM
Joined: 9/26/2012
Posts: 563

Hi Kelantol—

I haven’t been on the boards for awhile, but have had some recent experience with my mom re: skilled nursing. I too work in health care.

I think you are doing the right thing; clearly there are communication glitches at this facility for entering orders correctly into their EMR. It looks like they are trying to make things right.

If I were you, I would not wait to make this a formal complaint.  Call Mom’s nurse every morning and ask about her blood sugar. Ask her nurse if her EMR record shows her correct medications. If it doesn’t, politely bug the director of nurses until it is corrected. Don’t burn your bridges by “chewing someone out”  — chances are, this error happened due to a multitude of process errors, system errors and human errors.  

You can still do your documentation, which is always a good idea. Work with the facility, and keep close but always cordial tabs on your Mom.  Care transitions can be challenging for everyone.


Posted: Friday, November 29, 2019 11:39 AM
Joined: 12/4/2011
Posts: 18489

My experiencewith my husband;

Called 911...gave list of current meds....they wanted to see all bottles....they checked the list against the bottles....ER asks what meds, I tell them that EMSA brought the they do not have it....luckily I carry one in the glove compartment...we go over all meds and they put intothe computer....get to ICU, they ask about current meds.

You guessed it. No meds were in the computer.

I always take every thing I take to an appointment. I pull them out of the bag, one by oneand watch them enter into the system.

The next time I go the list is incorrect. Honestly, it like socks out of the dryer.

You have to check and re-check everything no matter the facility. AND do make it routine to go over the nurses charts every time you visit.

Nobody means to make a mistake but they still happen far too often.

Posted: Friday, November 29, 2019 11:55 AM
Joined: 5/16/2017
Posts: 593

This is what care meetings are find + correct issues.  I would identify who your contact/person responsible for your LO’s care(apparently this was not made clear to you) + send them a letter confirming what the errors were + verifying the corrections were made.

When you are there, make a point to meet + befriend the caretakers who are face to face with your mother + confirm with them what their instructions are on a day to day basis.

Clearly your mother needs more attention than the average patient + dont be surprised if things are not always done 100% correctly.  Staying on top of it yourself will minimize errors.  Make sure they they know you are paying attention to details + they will be more likely to double check instructions if there is ever any question about care.

Also, depending on your mother’s condition, Hospice, if appropriate will give you more eyes on her with guidance as to how to interface with staff

Posted: Friday, November 29, 2019 11:59 AM
Joined: 10/24/2018
Posts: 1077

Kelantol, I hope your mom has kept going through all of this, and sounds like you are a very level-headed daughter who will find the way to make it work. 

No experience with either multiple chronic health problems (in Mom anyway lol), nor SNF's. But I have 13 months experience with a rolling cast of Not Quite Ready For Prime Time managements. Ugh. Yuk. Grrr. Arrgghh. We are on our 5th DO"N" since January 1. The place was put on State probation in June due to the results of a February routine (I think) inspection. Corporate wants to make money. Local management has good hearts but possibly not a clue. Foot soldiers MUST follow orders. So the computer won't "release" the proper insulin unless whoever put the med in the system did it right. And where we are, only med techs can get into the computers unless there happens to be a management person around. I don't know who does the actual entering of meds. 

We had an egregious med disaster a few weeks ago, in which Mom (92, late stages, in MC) fell, was in pain, agitated, hospice was NOT called first, if at all, and no PRN pain/agitation meds were even imagined to exist. (It all turned out well, and Mom of course doesn't remember a second of it). This was a weekend so short-staffed, we had a (retired RN) companion right there who treated Mom for shock and comfort where she'd fallen while staff impersonated headless chickens, I was at work and not receiving calls until a break, at which time I was able to talk to EMS folks, hospice, and the companion. I beat Mom to the ER. 

That was a big thing. Other, smaller things occur daily. It is in her care plan to set the blinds so that daylight comes streaming in her windows. They do not seem to understand this, and SAD just takes over. I could go on but won't. Polite nudges to all levels of staff usually are not even acknowledged, even when I request the favor of a reply. As it turns out, most of the upper staff are not even aware of how to access their emails, and business cards for the most recently departed DON listed a phone number that belonged to some poor random soul miles away. 

When management is in constant flux, the foot soldiers must do their best against many odds to love and care for their charges. Love is NOT in short supply, nor is humor, thank goodness. Accuracy of records is a whole nother ball game. 

I sincerely hope that you have a better experience than we are having! 

I don't know much about kidney disease+T1D, but if it's fatal anyway, regardless, you might want to look into hospice. It doesn't mean mom is at death's door. I can mean that you have extra eyes on your mom, most of them belonging to an RN and perhaps a bath aide if you choose. 

Wishing the best to come of this!!

Posted: Friday, November 29, 2019 9:14 PM
Joined: 6/9/2016
Posts: 7

I don't know if this will be helpful, but each state typically has a long-term care ombudsman program, with ombudsman staff typically located throughout that state.  

The long-term care ombudsman staff serve as advocates for residents (and their families) of long-term care facilities (nursing, assisted living).  They seem to be pretty meek, but they can be helpful. 

I would locate the local long term care ombudsman staff and ask questions.  To locate, do a computer search on "long term care ombudsman" and also enter your state's name.  And/or go to your state government's website.



Posted: Wednesday, December 4, 2019 6:22 PM
Joined: 5/3/2013
Posts: 412

Thanks to all for your input, so helpful as always!  To hit key points - we found that aside from the mealtime insulin problem, for 18 days my mom did not receive her arthritis strength Tylenol on schedule, nor her EXELON PATCH FOR DEMENTIA (excuse my shouting but REALLY?), despite the fact that this information was included in the orders from her PCP the day she was admitted.  I was livid but I think I managed not to burn any bridges.  She is now getting everything she needs, they have gone over her record with a fine-toothed comb, I had a good conversation with the nurse manager and today met with the nurse manager, a nursing consultant, an assistant director and the director of nursing.  They were appropriately apologetic and I didn't feel like they were trying to pass the buck or diminish the importance of what I consider egregious errors in handling the medication record as well as her medical record since there were diagnoses missing there too.  Many of the staff I've met have been there for years and my mom seems like she's doing as well as can be expected. 

I can only hope now that with the exelon back on board, she will move towards her baseline cognitive levels with time.  She's confused, much more than I would have expected, and that's really hard to see.  But - one day at a time. 

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