Medication in a care home is signed for on a tablet, resident by resident, tablet by tablet, and the stock count at the end of every round has to match. There is no four in the morning round. Every night one appears on the record, every resident visited, every dose signed, by the PIN of a nurse who retired seven years ago, and in the morning the count in the trolley is right for the doses she gave.
I am the registered nurse in charge of nights at a nursing home and the medication trolley is locked to my belt.
How the record works.
A tablet on the trolley. Each resident's medicines are listed with the times they are due. You give the dose, you sign with your PIN, the stock count goes down by one, and at the end of the round the count on the tablet has to match the count in the drawer, and if it does not you do not go home until it does.
There are rounds at eight, midday, six and ten. There is no round at four.
There is a round at four.
The four o'clock round.
It appears on the record overnight. Every resident. Thirty eight of them. Each one visited, according to the record, in the order of the rooms along the corridor, at about two minutes each, which is the pace of a nurse who has done it a long time. Each one signed, with a PIN, and the PIN belongs to a nurse who retired in 2019 and whose PIN was removed from the system when she left.
What is signed for is not what is prescribed. It is, for each resident, one thing. A single tablet, from a drug that the home does not stock and has not stocked since 2019, which is a mild sedative that was taken off the formulary, and which she used to give, in her time, to the ones who could not sleep.
The stock count in the trolley, in the morning, is right. For the doses she gave. From a stock we do not have.
What has been checked.
The tablet, replaced. The round appears.
Her PIN. Removed again, by the software company, who confirmed it was removed, and who then watched it sign a round at four from their office and have not been in touch since.
The trolley. Locked, to my belt, at four, in the nurses' station, with me. The record on the tablet updates in front of me. Room one, signed. Room two, signed. The trolley does not move and its drawers do not open and the record says she is in room eleven.
The residents. I have gone into rooms during the round, with the record saying she was in them. They are asleep. They are all asleep, every one, on the nights of the round, which in a home of thirty eight people is not a thing that happens, and the ones who are usually awake at four, and there are a few, are asleep, and comfortable, and in the morning they say they slept well.
Who.
She ran nights here for twenty six years. The carers who knew her say she was strict about the record and soft about everything else, and that she would do a round at four that was not a round, that she called the settle, where she went into every room and looked, and gave a tablet to the ones who needed one, off the record, which was wrong, and which she knew was wrong, and which she did anyway for twenty six years because a person who cannot sleep in a care home at four in the morning is a person who is frightened, and she did not hold with it.
She retired in 2019 and died in 2021 and the home sent flowers.
What is done about it.
The four o'clock round is on the record and the record is the legal document and the inspectors read it, and I have flagged it, and the manager has flagged it, and the software company has flagged it, and the inspectors have read it, and they have written in the report that the home should investigate an anomalous medication round, and that the residents appear well settled at night, which they do.
What I do.
I run nights.
I cannot stop her round and I have stopped trying. I do something else. At four I go with her. I take the tablet off the trolley and I walk the corridor at her pace, two minutes a room, and I go into each room as her signature lands on it, and I look. That is all. I look, and the resident is asleep, and I say goodnight, and I go to the next.
The record has changed since I started. The signature at four is still hers, and then, a second later, there is a second signature on each one, and it is mine, and I have not signed anything, and the record shows a dose given by her and witnessed by me, which is the way a controlled drug is signed, two nurses, one to give and one to see it given, and it is the first time in seven years that her round has been witnessed, and it is the correct procedure, and I think that is what she was waiting for.