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Comments on: Nursing Home MAR’s sent to the ED with all times removed: A new and horrible trend

Ramblings of an Emergency Physician in Texas

Last Build Date: Sat, 02 Dec 2017 13:18:31 +0000



Fri, 10 Oct 2008 07:10:26 +0000

First off, finding and reading this blog made my evening... This practice of not giving us (EMS/ER) times on the MARs has been happening in my county at the 3 nursing homes for atleast the last 3-4 years. We recently started demanding the full MARs, threatening to report the facility to the State Board of Health if they wound't give them to us. Since then we have started getting MARs with times a little easier now. :-) DNR/POLST (Physician Orders for Life-Sustaining Treatment) status problem are also the same here. Personally, I love the new POLST forms as they specifically state what should/should not be done for the patient, in great detail. The DNR forms we used to see were fairly limited in their application to our day to day struggles with the nursing homes. We have one facility that has actually told us they can't use the POLST forms because their a "Skilled Nursing Facility, and that's not what they were designed for.."

By: PharmaGhost

Tue, 29 Apr 2008 17:58:39 +0000

Doc, I understand your concern and you are correct that this nursing home behavior is a problem. I think I know the reason behind the behavior and it probably is due to nursing home policies and procedures in meeting Joint Commission standards for Medication Reconciliation. Joint Commission standard MM.1.10 EP#2 and National Patient Safety Goal #8 address this. Also, on the discharge side there is an additional standard: Provide the Discharge List of Current Medications to the next provider(s) (PC.15.30, EP #1) and to the patient (PC.15.20, EP #9). The basic requirement is a list of the patient's medications is to be provided to the next provider of care. There is no requirement that the list includes the time of the last dose. Depending on facility policies, the time of the last dose may or may not be included. If the nursing staff is incapable of fully completing a form with all the information, the facilities tend to take the short cut approach. In actuality, a full copy of the patient's MAR meets the JC standard. The medication list doesn't have to be on a specific form, but facilities don't want to send patients home with copies of their MARs for multiple reasons, so they have a separate medication reconciliation form for this information. It appears the nursing homes in your area, in consultation with their consultant pharmacist, LTC pharmacy policies and procedures, Director of Nursing, and Medical Director cooked up the interpretation of medication reconciliation you are seeing. In order to fix the problem, you are going to need the help of all the ER docs and the group will need to talk or meet with all of the above individuals or directors and recommend that they change their policies and procedures. Of course, you can also contact Joint Commission and report all of this. Below is taken directly from the Joint Commission website: Joint Commission requirements and recommendations. In July 2004, the Joint Commission announced 2005 National Patient Safety Goal #8 to "accurately and completely reconcile medications across the continuum of care." During 2005, accredited organizations were required to develop and test processes for medication reconciliation to be implemented by January 2006. The requirements of the Goal for 2006 are: 8a) Implement a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. [Note: While this safety goal does not require a separate form for the medication list, many organizations have found it useful to develop and implement one or more forms to support the medication reconciliation process.] 8b) A complete list of the patient's medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.** Implementation Expectations for Requirement 8b state: At a minimum, reconciliation must occur any time the organization requires that orders be rewritten and any time the patient changes service, setting, provider or level of care and new medication orders are written. For transitions not involving new medications or rewriting of orders, the organization should determine whether reconciliation must occur. On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications* that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with him or her and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists and other caregivers. End of [...]

By: Paramedic NWF

Thu, 24 Apr 2008 05:13:49 +0000

Well, the practice of cutting out the administration times, dates, of M.A.R.s has ben happening in Northwest Florida for the past 4 years at least. It is exasperating to try and fingure the cause of why a patient may have altered mental status, hypotension, low blood sugar, low blood pressure, in congestive heart failure... get the picture... when the actual date and time of the medication prescribed was last given is removed from the information. For the area I work in, I can relate it to an episode where a poor pt (I am being careful to not provide information to violate HIPAA) was stripped of their rights/declared incompetent, all possessions were placed in someone elses' care, the patient continued on a downward spiral, edema to the lower extremities, confusion, low blood pressure, borderline low-normal respirations, and swallowing problems to name a few of their symptoms - Any guesses what their problem was? They had a thyroid problem (it was also documented clearly in the H&P) and hadn't received their medication from the nursing home for many months that was traceable back by using the M.A.R. I pointed this out to the facility who ignored me then brought it to the attention of the pt's physician's office so it could be fixed and the pt have what's left of their health back. I didn't throw the facility or the doctor under the proverbial "bus" but sought to be a patient advocate. The result, a complaint from the doctor to my medical director (no, I didn't get into any trouble from the director) to talk with his paramedics about telling a doctor what to do with their patient and M.A.R.s from many of the nursing homes in our area that no longer provide EMS or the ER with the administration part of the M.A.R. What is acceptable today from anyone in the removal of vital health information will come back to haunt those who may have to rely on these same systems for their care or care for their loved ones at some point in the future. How about fixing the problem before you or someone you may love falls victim to the insane practice? Karma can really bite!

By: nurseexec

Mon, 14 Apr 2008 15:32:38 +0000

JC Jones--the New York Times article neglected to say that SNFs in Florida have the best staffing in the nation--we are not allowed, by law, to "understaff". Last year, our CNA staffing was actually increased by the Legislature. In my SNF I staff 1 CNA for every 6-7 residents and 1 nurse for every 20. In other states, CNA staffing is still at 1 to 15, and nursing staff 1 to 40 or 50. SNFs are NOT all bad, and using a broad brush to say so is doing the public a disservice.

By: p a boies

Sat, 05 Apr 2008 13:50:55 +0000

this is what you are getting, because that is what those nurse's are allowed to give need to complain up the food chain, not to the nurses....i work agency, and when i went to copy a MAR to send patient out, i thought the charge was going to faint....alledgedly the hospitals have been trying to crucify the NH for the occassional missed med.....SO, you will no longer get that info.....always remember to think of the unintended sequelae of YOUR actions

By: JC Jones MA, RN

Mon, 31 Mar 2008 17:18:14 +0000

I have worked on both sides of the equation and John Harris, J.D. has hit the target. Health professionals - stop attacking each other & attack the corporate greed responsible for understaffing the SNF's! SNF's receive $72 billion in FEDERAL funding! That's our tax dollars. Private EQUITY firms purchase & control SNF's, maxizing profits, minimizing care. For more information, read my blog & this article in the NYT and make sure you have a plan to for your own "retirement".

By: A Paramedic who knows

Thu, 27 Mar 2008 00:58:29 +0000

You are right, there are some damn good NH around. Yet, they are very few and far between. If I was to end up in a NH (which I won't cause those bullets are still cheaper). There has never been a meeting with a NH and ER and Paramedics here, I know I've tried. There are some good nurses, but at the same time they're so busy they can't see patients! I wish we had more of the good ones like yourself, but they're hard to find, let alone at what the NH will pay them. Also I've noticed more and more of LPN's and CNA's just don't understand or care about the patient. Just yesterday I got sent for the "low o2 sat's" I get there and the patient is fine, with a recent Dx of PNA. I check with my Sat probe and get 99% even after I d/c'd the O2 and the patient talking a 1000 words a min. I told the staff that the patient had PNA and that a lower SpO2 is expected. I even took thier SpO2 and proved that it was the batteries! After all even though I smoke my SpO2 should not be 70%! They didn't care. This is what we deal with day in and day out and it's BS and needs to be fixed, but it won't be. oh well.

By: nurseexec

Thu, 27 Mar 2008 00:21:05 +0000

As a DON in a FL SNF/Rehab, I am appalled at the practice of removing times from the MARs being sent to you. I am also with geridoc--we shouldn't be bashing each other, rather, working together to provide the patient with the best care possible. Have you considered talking to the DON at the facility? Yes, there are crappy SNFs. But there are also good ones, with positive, caring nurses and CNAs. Yes, there are crappy LPNs, but I've met quite a few who could dance circles around some RNs in their sleep. Bitching gets us nowhere. I have spent countless hours meeting with ER docs and attendings at our local hospital, and with paramedics from EMS. We have set up education for my staff with both EMS and the hospital docs. They get to come to our facility and see great care, and my staff gets to learn from great professionals. Our returns to hospital have plummeted since implementing the program. I spent 12 years as a ICU charge nurse, 3 years in the ER, and 3 years in the OR before taking on my current job. As a DON, I want to be part of a solution, not perpetuating a problem.


Fri, 21 Mar 2008 03:04:51 +0000

A huge pet peeve I have with the NH is that they never ever have their phone number on any of the documentation that they send with the patient. I know that I can look it up but I shouldnt have to. It is like they dont want you to call them to ask about their patients.


Thu, 06 Dec 2007 04:04:29 +0000