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Zio105 Asked October 2019

Help! Mother, 84, in skilled nursing facility for a broken ankle. Medication errors. Is it time to call the ombudsman?

Mom (84) has been at SNU, Skilled Nursing facility for rehab 4 non-displaced distal fibula fracture n non-displaced distal end of 5th metatarsal, since Oct 4th.  She fell in Dad's hospice room 17th Sept. He passed 22nd. She missed him die. Couldn't get her in till Oct. 4th due to discharging from a Rehab HOSPITAL and going home so a break in chain you could say. So PCP had to order skilled nursing, but was handled. Supposed to be a good one. 3 med errors so far and it's only been 10 days.


I used to work in surgery and Dr offices, so I'm not dumb. Dealing with my Dad's rehab visits, I'm very watchful. You have to be!! They can kill u!!! They are making my Mom feel she is nuts. Never gave the meds but said they did (LVN's) & marked on computer they did. But I'm healthcare POA and statutory durable POA so I can ask to look at blister packs or punch out pack's of meds. So I did. Meds still there. Not given.


This happened Oct 10th (thyroid med not given but put in it was. Mom's word against nurse). The 11th. (Nurse said Mom asked for Hydrocodone #5 with morning meds. Mom said she didn't. Her and I talked about cutting back on it night before. Mom never lies. She hates confrontation and nicest person on planet. Nurse came in with pill cup. I was not there yet. 5 pills instead of 4. Mom asked what these meds were. Nurse says "your morn meds!" They looked different and 1 extra apparently. Again Mom says "what are the names of these meds!" Nurse says they are your morn meds take them!" So she takes them.


As she is swallowing "Nurse says" oh there's a Hydrocodone #5 in there." MOM NEVER ASKED FOR A PAIN PILL! Then Oct 14th, I got there a tad late. Mom said morning meds not given. I said are you sure. She said yes. So I go ask LVN that dishes out pills. She says "I gave them already." It was kinda early for morning meds. Usually between 8:30 - 9am. The 14th was like 8am. Again I asked if she was sure Mom got meds cause Blood pressure was high. Again Nurse states "I gave them. She just must not remember." So Mom was taken on to P.T. It nagged at me due to mess up the 10th and 11th of Oct. So I went back to nurse. I said can I look at computer. She was kinda astonished I asked. It had a checkoff that morning "meds given". Then I asked to look at blister packs or punch out packs of morning meds. She diverted situation to "pharmacist came and brought new packs. You can't tell which day is which." Stupidly I accepted that and walked off. But why should I doubt or have to freakin look over these "professionals" shoulders anyway. So all day my pour mother who just lost her husband thinks she losing her mind and not remembering. NOT THE CASE.


Night of 14th (last night) I went 4 med pass and found out through asking to look at meds and counting them that IN FACT SHE DID NOT GET HER MEDS THIS MORNING AN ONE OF THOSE BEING HIGH BLOODPRESSURE MED! I took pics of packs with pills still in them. So 3 med errors and only there 10 days! Then the facility Dr was sick last wk. So his rude female dog N.P. comes. Immediately I felt her back bow up with me there and asking questions last Wed. She comes M/W/Fri. He comes Thurs (well I'm telling them to call him to come 15th morning or at care plan meeting Wed 16th due to recent labs) N.P. goes and after she see's me leave. Mom says her nose is running horribly can she have Flonase like @ home. N.P. says can u take Mucinex, or Allegra? Mom says "I've hardly taken them. But Flonase I take alot". So she orders ALL the meds as scheduled! And didnt tell Mom or me (I asked to be told) instead of talking more about which one. Lets drug her up! And her labs had came n by 10 am. This was 2pm. GFR was 38. Extremly down from 51 10 days earlier. Mom is at stage 3 kidney disease but was very stable at 55 gfr at nephrologist appt in May or June 2019. So he didn't want to see her for a year since so good. Then all this happened. At hospital it was 48. Then SNU entry 51. Now 38. Sugars very high. Type 2 diabetes. No diabetic diet. And fast acting insulin sliding scale very lenient. So, sure Mom's sugars very high. I made one report on thyroid. Now 2 more coming. Is it ombudsmen time? I can't deal with this alone after Daddy died 22 days ago! I'm tired.

GAinPA Oct 2019
I find that my phone has proved invaluable to managing my mother’s care. That dated photo of the blister pack certainly bears witness to the meds problem. I started initialing my moms Depends before I put them on her in the morning as well as taking photos to document her personal care.

AlvaDeer Oct 2019
Yes. Call the ombudsman NOW. Give her a copy of this to read and then you can go on. This is not good, and you are correct. You know what to look for. First of all, a nurse never says to a patient "It is your medications; take it". Protocol is to explain each and every medication. Often colors in generics vary and patients don't recognize their meds. That needs explaining. I am especially concerned someone supposedly gave her an AWFUL HUGE opiate with that sly passing it off and I suspect they are pocketing opiates around there (sorry to make an accusation like that but nothing at this place sounds good). You would not believe the good care my bro got in rehab when he questioned anything. This isn't good. CALL NOW. I would if I were you, and I am in the know a bit, as well as old retired RN.

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