Am I Wrong? - page 2

........or isn't Ambien 5 mg., Sonata 10 mg, and Rozerem (a new sleep medication) just a bit much to give a 90-something-year-old patient every night at bedtime? Here's my concern. The patient in... Read More

  1. by   Halinja
    My 77 year old mother had begun to show troubling signs of dementia. I had talked to my Dad about it, and he had talked to their PCP. It was a slow decline and I was feeling so sad that such a sharp woman should now be losing those faculties. She was one ONE sleeping pill (ambien, 5mg) and an antidepressant.

    She went in for surgery and they d/c'd everything. When she recovered from the surgery they still kept her off of the previous meds. And wow, my Mom's mind was back, sharp as ever.

    I can only imagine how bad it would have been had she been on three! I think you are definitely right to be concerned. Sounds like you are doing a great job of being the patient's advocate, don't stop.
  2. by   VivaLasViejas
    Thanks to all of you who have responded so far.

    I did fax the NP who ordered two of the medications to notify her that the resident is already on Ambien; next step will be talking to the physician and asking him to speak with the daughter, as she has so little respect for my knowledge and seems to think I'm just being picky. I'm NOT going to wash my hands of this and simply sign off on a managed risk agreement. I'm still not sure exactly how I'm going to proceed, but I'm definitely not letting this one go without a fight.
  3. by   kukukajoo
    Stick to your guns! If you are looking for information to back up your claims of all this being unsafe, I would fax the pharmacy that is prescribing and ask for an opinion. They will know what should and shouldn't be administered at her age/weight/cognitive ability, etc....

    Where I live, the pharmacy will fax the doc asking for clairification on the orders and letting them the know the norms, etc. for the meds above.

    You are doing what is right and the fact that you care enough to go against the grain that has been set just goes to show what a good nurse you are!

    Keep us posted, I would like to know the outcome. I'll be keeping my fingers crossed that you get some help for this woman!
  4. by   Jolie
    My administrator and I have drawn up a managed-risk agreement that essentially makes the daughter assume responsibility for any bad outcomes, but I still don't feel right about it.......I mean, it's partially about covering our behinds, but it's also about NOT giving in to what I feel is over-medication. I've been in geriatrics too long not to know what happens to frail elderly folks who take too much and too many meds, and even though both the resident and her daughter want all of this, I feel a responsibility to protect her from herself here.
    Quote mljrn97

    I am not a legal expert, but I question whether this would hold any water. I don't think it is legally possible for a person (the daughter) to "waive" his/her right to sue in advance of an incident or negative outcome. So I don't think this agreement would protect you or your facility should the mother be injured due to overmedication. It also does nothing to address your valid concerns that the mother's best interests are not being served, which is your responsibility as a registered nurse and patient advocate.

    Please get your facility's attorney involved.

    Best of luck to you, and thank you for your sincere desire to do right by this resident!
  5. by   rita359
    Quote from DDRN4me
    Marla, though i do agree that she may have taken many meds over her lifetime and been ok, it is obvious that this is just bad practice and also probably contributing to the womans declining health. Do you have a medical director or ethics committee that you can get on board with you? Perhaps a case conference with the primary md, yourself, and the daughter is in order. good luck...this woman is lucky she has you looking out for her!! Mary
    Also, is there a pharmacist or consulting pharmacist who is aware of this pt taking three sleepers. I can't imagine that the pharmacy who dispenses these meds is aware that she is taking 3 sleepers and doing nothing about it. Make them aware and let them call NP or Dr.
  6. by   subee
    Quote from RNAnnjeh
    I agree. Leaving meds at the bedside is one big no-no. I'm curious...does she even take the meds that the daughter leaves at the bedside? Just to play devil's advocate for a minute....does the patient take these meds or do they mysteriously disappear in the night....or are they still there in the morning.

    My first position was in LTC (in Florida), and we had to have a diagnosis/rationale for every medication otherwise the pharmacy wouldn't fill the prescription. The pharmacists often called us when there was more than 1 sleep aid prescribed, and we had to give a darn good reason why.

    Wonder what the daughter's use of sleep aids is like.

    Best of luck. I'd be questioning this as well.

    RNAnnjeh

    For all we know the daughter could be selling them on the street - never mind taking them herself. Obviously this LOL is not taking all these meds and imagine how this scenario would look in court or a newspaper. An institution that didn't nip this problem in the bud would look awfully culpable (and mis-managed).
  7. by   VivaLasViejas
    I heard back from the NP a little while ago, and just as I suspected, she did NOT intend for all three sleepers, plus a sub-therapeutic dose of Remeron, to be given! She D/C'd the Ambien and the Remeron, thanked me for my attention and concern, and stated she would follow up with the resident's primary care MD on another recommendation she made.

    Now, of course, I get to tell the daughter to take that Ambien out of the apartment because it's been discontinued, and of course she's going to be upset because I have, for the second time, "gone over her head" to change medications. But dang it, I'M the professional here, I'M the one who knows better, and it's MY responsibility to make sure people don't come to any harm while under my care. So there.........PFFFFFFFFFFFFT!!

    I know, yeah, THAT was real grown-up. But having laypeople treat me as though I went to school for four years to know NOTHING is one thing that really chaps my cheeks, and the worst part of it is, this is not in the resident's best interests. Sooner or later, she'd fall and break a hip or something else, or she'd take too many at once and overdose, and guess who would be left holding the bag.........that daughter would probably be on our doorstep with her attorney first thing the next morning.

    Once again, thanks to all who have offered advice thus far; I'll keep you posted as to the unfolding drama.
  8. by   kukukajoo
    I am SOOO glad the NP got back to you! I had an idea she could not have known!

    As for the daughter, um, be firm but decisive and remind her that if she feels that you are not working in the best interest of the patient, her mom, then she has every right to go to the office of the ombudsman. Document everything and you are covered!

    As for the managed risk agreement, if something did happen in the future all that would do is show that you knew there was an issue and did nothing about it but pass it off. Ultimately it would be you and your license if something horrilbe were to happen. It is like in real estate, they say the lease always protects the tenant more than the landlord!

    You did the right thing!
  9. by   billable
    I am not a nurse, but I own an assisted living. I can tell you that family members like this are common. We handle situations like these by faxing the MAR to the primary MD and ask him to sign off on it.

    You have done 2 things with this. You have brought it to the primary MD's attention to be addressed and you have passed the liability on to the right person--the doctor. He is and should be responsible for deciding what medications his patient is taking.

    Since assisted living is regulated by the state, regulations vary from state to state. I, however do not allow any medications in my building that we don't keep, hand out and document--even tylenol.
  10. by   anne74
    You can explain to the daughter that it's not personal, but it's your professional license is on the line here. You wouldn't be doing your job if you didn't provide her this information.

    It seems like you are doing everything in your power to protect this woman. I think it's great you pressed an investigation, and great to have the doc and the NP talk to this daughter. Also, document that you've explained to the daughter the consequences, yet she is unwilling to accept your education.

    Work on what you can control, such as what meds are dispensed to her by your facility. But you can't fault yourself if this daughter continues to sneak meds to her mother. You can't be there 24/7. You can only do so much, so if something happens to this elderly woman, you should still remember that you did everything in your power to protect her.

    Another thought - isn't there some way you can site elder abuse? If this were being done to a child, you better believe the state would get involved ASAP. This elderly woman has impaired thinking, and therefore can't stand up for herself - just like a child. Good luck.
  11. by   VivaLasViejas
    This is just getting better and better: I got a call from the PCP's office about two hours after hearing from the NP, and they were VERY happy to follow up with me and have us all be on the same page.:spin: I love it when I get cooperation---not only that, but now everyone is onto the daughter (the MD said "Well, she should have understood........she was there with Mrs. XX when I D/C'd the Ambien at the last appointment").

    I have also thought better of the managed-risk agreement; now that the sleeping meds have been straightened out, there's no need for all this pussyfooting around---either we take control of all the meds, or the daughter comes three times a day to administer them. None of this let-the-chips-fall-where-they-may stuff: I worked too flippin' hard for my license, and I'm not going to risk my livelihood to accommodate someone who doesn't even respect the fact that I'm trying to keep her mother safe. Thanks again, to all of you!!
  12. by   txspadequeenRN
    You go girl!!!!



    Quote from mjlrn97
    This is just getting better and better: I got a call from the PCP's office about two hours after hearing from the NP, and they were VERY happy to follow up with me and have us all be on the same page.:spin: I love it when I get cooperation---not only that, but now everyone is onto the daughter (the MD said "Well, she should have understood........she was there with Mrs. XX when I D/C'd the Ambien at the last appointment").

    I have also thought better of the managed-risk agreement; now that the sleeping meds have been straightened out, there's no need for all this pussyfooting around---either we take control of all the meds, or the daughter comes three times a day to administer them. None of this let-the-chips-fall-where-they-may stuff: I worked too flippin' hard for my license, and I'm not going to risk my livelihood to accommodate someone who doesn't even respect the fact that I'm trying to keep her mother safe. Thanks again, to all of you!!
  13. by   neneRN
    Quote from suemom2kay
    Any chance daughter is diverting? Smells like diversion to me.

    This was my first thought as I read this post!

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