Dad’s Medication Error: Follow-Up


Recently I wrote about my concern when dad’s assisted living facility ran out of his blood pressure medication in “I Must Be Doing Something Wrong” , “Dad’s Medications — Part 2” and “High Blood pressure — Dad’s and Mine“.   I wrote that dad went at least 4 days without any blood pressure medication.  In response to that post, I got a lot of valuable feedback, including Terry1954 who suggested I contact the ombuds person.

I waited a bit to deal with my own rising blood pressure and then I did contact our county Long Term Care ombuds person.  She was very sympathetic to my concerns and felt that I should talk to the Assisted Living Facility manager.  She knew the manager and thought she might not be aware of the problem.  If I failed with the manager, I should contact the state health department and she gave me a telephone number for them as well.

Almost 2 weeks ago, I did go in and talk to the ALF manager.  It appeared to me that she was very aware of the issue, but asked for a few days to get more information on exactly what happened.  We agreed to talk again the following Thursday after she got more information.  I wasn’t upset by this request as when I used to work in a hot seat type of job, I always wanted the complete outline of the problem before I had to respond to it.

When I went to see the manager the following Thursday, she was on her way out to a meeting and I was annoyed to be “blown off” like that.  I made another appointment for the following Thursday, giving myself time for the visit from my brother and sister in the intervening days.

Thursday we had that meeting.  The manager went over the details of what happened day by day.  I asked for the protocol of ordering medications and what they do when the medications don’t arrive.  She explained that the doctor (who sees residents right at the ALF) desires to have prescription renewal requests faxed to her.  So, that is what the protocol specifies.  If the resident has no medications on any day, again the protocol is to fax and notify the physician.

There were several errors in the process for my dad.  First, the doctor did call in the prescription, but to their local pharmacy rather than to Medco, the only pharmacy covered by his insurance.  Second, when it arrived from the local pharmacy with a different brand name than they expected, they sent it back.  The manager accepted responsibility for that error.

However, they also sent several faxes to the doctor requesting a replacement prescription and the doctor did not respond to those faxes until dad had been out of medication for several days already.  She felt the blame for that should go to the doctor.  I said that while I agreed that they had followed the doctor’s desired protocol, there had been a breakdown in communication.  For while they felt they were communicating with the doctor, no one was responding.

I felt there needed to be a way for them to follow up when the doctor doesn’t respond so that the resident doesn’t end up without his medications for so many days.  In the end, she agreed that they would telephone me if they didn’t get a response from the doctor.  Then I will follow up with the doctor as well, and I won’t just send a fax.  I understand that they need to work with this physician regularly; I also want someone to be responsible for following up when things don’t go smoothly.

If this were a nursing home I would expect more because the nursing home has doctors and physician’s assistants right on their staff.  I chose this ALF because it wasn’t too large, and I know this may limit how much they can do sometimes.

So, I ended up taking more responsibility for myself whereas I think the responsibility should be theirs.  Nevertheless, the bottom line is that I don’t want dad to run out of his prescription medications.  The manager didn’t think this would happen again as it had never happened before.  Either way, I want them to know I am watching and I will pick up the process if it comes to a dead-end again.

I decided not to telephone the health department to file a report at this time.  If it happens again, I probably will.  It seems to me that the health department needs to hold the doctor’s office responsible as much as the ALF.  But in the meantime, I will just stay involved in the entire process.  It isn’t the ideal solution, but it looks like the best one I can get.

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About letstalkaboutfamily

I am a retired and was the primary caregiver for both my parents before they passed. I have children and grandchildren. This blog is an attempt to connect with other caregivers and share ideas and experiences. I hope you will let me know what worked for you if you had an experience similar to mine. The main issues I am going to talk about are elder care, death and dying, assisted living, family relationships and hoarders and hoarding. Other topics will come up as I address the issues and my relationship with other family members.
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6 Responses to Dad’s Medication Error: Follow-Up

  1. frangipani says:

    You did the right things- to get to the bottom of the story AND look after your own blood pressure. 4 days without bp medicine is a bit too much. Having said that,
    I let my mom take her own medication now, and not worry if she gets it off by several hours. Because she is aware, I keep everyone calm when they spot an error. I dread the day I take this bit of independence from her.

  2. Mom was counting out dad’s pills for years now. A few years ago she realized he had taken his pills twice one Saturday evening as he took them before she put in the new pills for the week and again Fter she refilled the box. A nurse friend checked his blood pressure latr that evening to make sure it didn’t go too low. Later that year and the next, I realized mom was making serious errors counting out dad’s pills with double doses of some medications on some days and none on others. Her vision was failing and she was confused. It was those type of errors for both her medications and dads that caused the crisis that pushed them into assisted living. I lived a thousand miles away and couldn’t help. As soon as they got proper medication management, both improved for awhile until other issues led to mom’s death. Dad wouldn’t remember his medications at all without the help of the medication aides at his ALF. Usually they do a good job, but this error really got me concerned. Dad takes a high dose to keep his blood pressure under control and he missed too many days. Luckily he doesn’t seem to have any lasting effects from it!

  3. Teresa Cleveland Wendel says:

    You definitely have to watch over what’s going on. They don’t have the staff to do it. You are your father’s best advocate.

  4. Unfortunately, you are totally correct. I had hoped to hand off some responsibility and take the pressure off myself, but it really isn’t possible. No one else cares like I do and no one will watch over him like I will.

  5. Ellen Reaves says:

    There were plenty of times that I had to call and follow-up with my Dad’s physicians at the ALF and the VA in order to speed the process along. We, as caregivers, believe everything should have happened yesterday and have low tolerance for mistakes. YOU SHOULD BE THIS VIGILANT! That is the only way that problems get fixed and the lines of communication stay open. The fact that the place is small only allows the mistakes to be even that more obvious. I applaud you. Document, document, document EVERYTHING!

    • Thanks, Ellen. I try to track and document everything just because that is the way I am. I visit frequently and say hello to everyone when I get there. They know I will be there and I will know what is happening.

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