Chemical restraint and lazy nurses

[Veronica.c]

Ok so I work as an lpn in LTC. We hae a resident who is a bother so to speak. He continually tries to get out of bed at night and has had a few falls. I know he is worrisome BUT

I worked 7-3 this week (I'm PRN so I work all the shifts) an I started to notice that in the mornings, this man was heavily medicated. He has an order for Klonopin 0.5mg QHS which evening shift is happy to give just to help keep him in bed. I've worked the shift. I've given it to him myself. But I wasn't aware of the level of sedation he was under until I worked day shift this week.

Hes so over medicated in the AM that the first day I worked, I thought he was in a coma and had had a stroke. Did neuro checks and watched him closely. He didn't fully wake up until around lunch. Which means he didn't eat breakfast and apparently NEVER does due to the over sedation....not a good thing.

So I approach the NP about my concerns. She D/C the Klonopin to my relief. The next morning he was awake, alert and verbal and ate ALL of his breakfast meal! Wonderful!

Well the 3-11 shift throws an outright fit about the Klonopin DC. They call the NP at home and have her reinstate it. All bc they didn't want to have to run to his room and put him to bed every time he tried to get up.

I know now it's annoying. I've worked that shift and gotten frustrated with him myself BUT I was unaware how sedated he was in the AM also.

Im upset that the Np gave in to the pressure from the nurses and gave this med back! I informed her that they were wrong. That it is illegal to sedate someone just bc they are annoying....apparently she needed reminding!!!!! This is abuse! There are laws protecting this man. But no one cares. My DON, the ADON, the NP. I feel like the nurses threw a fit and she gave them what they wanted bc she favors them. Sorry if I'm not here to discuss manicures with you. I don't kiss ass. I care about my patients and that is all.

what is the deal??? Why am I the only one who cares??? What should I do? Opinions welcome.

[morte, LPN, LVN]

clonazepam has a very long half life, why not suggest something else? Perhaps lorazepam?

also, what else, if anything is he getting during the noc?

[Veronica.c]

You do have a say. You are one of his nurses! As we have pointed out timing is an issue, that morning dose is an issue, and heron also brought up the dangers of stopping a benzo so abruptly. You can always start out with discussing discontinuing just the morning dose. I'm still concerned about the lack of a care plan for this gentleman and for all the other residents. Care plans are required for every resident of a SNF that accepts Medicare or Medicaid payments. Care plan meetings should occur every 90 to 120 days for each resident, with notices sent to POAs. These are federal regulatory requirements![/quote']

My complaints fall on deaf ears.....my hands are tied. Believe me I want to help so bad. I've been there a year and have yet to cry at work....but I did over this man. A full on melt down and even grabbed my ADON and let her know how upset I was....nothing was done to change it.

As far as the care plans....the paperwork LOOKS like all that is happening but I can assure you, it isn't.

[Veronica.c]

clonazepam has a very long half life why not suggest something else? Perhaps lorazepam? also, what else, if anything is he getting during the noc?[/quote']

I didn't know that about clonazepam. Thank you for the info. He gets a few other meds. Geodon 20mg. Metformin 500. Melatonin 5mg OTC. And a few others I can't quite remember at this time. The NP told me that the geodon could be making him sleepy and she would see about changing it.

It's not the geodon. Like I had mentioned before, the one day he didn't get the clonazepam, he was awake and alert the next AM. But no one listens to me.....

[silverbat]

I would wonder, if he is put to bed for goodness sake at 3PM, and left till noon the next day--why is that allowed??!!! I am pretty sure that someone without dementia would get restless and nuts being EXPECTED to remain in bed for that many hours, let alone, someone with dementia!!!!! Maybe if he is engaged in some type of activity he might be entertained, tired and woud sleep better without over-sedation.

AS an MDS coord, I would hope this is addressed in is care plan, and that regular meetings are being held. It is, as a PP poster stated, a federal regulation

[KariZayBSN]

My complaints fall on deaf ears.....my hands are tied. Believe me I want to help so bad. I've been there a year and have yet to cry at work....but I did over this man. A full on melt down and even grabbed my ADON and let her know how upset I was....nothing was done to change it. As far as the care plans....the paperwork LOOKS like all that is happening but I can assure you it isn't.[/quote']

Perhaps it's time to report this to the state obundsman or the state. Another option is to involve the family.

Make your suggestions to the family. Usually the family is listened to.

Regarding the falls: sounds like the patient needs a bed on the floor and a Geri psych eval to ensure proper med dosing. It certainly sounds like he is being chemically restrained and has poor quality of life (hence my state obundsman contact suggestion).

Good luck

[nurseladybug12]

I think that since you work PRN and you do not have to deal with this pt on a daily basis, you should really reserve judgment and not call your coworkers lazy. I would look into whether or not this over-sedation is new or not, since you just noticed it yourself. If so, maybe his kidney function needs to be looked at.

[Mn nurse 22]

We had a pt who was on Ativan qid and PRN and had been for several years, we sent her to the hospital because of change in condition, and altered mental status and they sent her back with a diagnosis of over sedation from Ativan, discontinued it and wrote a fairly hostile note. When I asked another nurse why the pt was on ativan it was because they had tried to kill their roommate. The dose had not changed for quite some time. There were lots of other details that I won't get into but until everyone knows the whole story there might be a reason for the psyc med.

What is the diagnosis for psyc med? Is there any history of violence?

You sound like a good advocate for your patients, but also seem a little closed minded to your opinion only. One day shift of alertness might not be enough to give you a full picture of what is really going on.

[MunoRN, RN]

Clonazepam should certainly be far down the list in terms of how hyperactive dementia is treated, but it's necessarily an improper choice in certain situations. Hyperactive delirium can be torturous for a patient, so simply not treating it so that they are awake more predictably isn't always the better option, balance is the key but that can be hard to find. A patient probably shouldn't be sleeping for 20 hours a day, but they also shouldn't have to be awake and essentially manic for days on end either.

[Blue Roses]

I have a suprisingly similar story. I was taking care of a cancer patient and I don't remember the specifics about her case. But apparently at one point she must have been having trouble sleeping, and the evening nurse glanced at the MAR and noticed an order for Ativan PRN. The evening shift started giving it to her every night, effectively letting her get addicted to it. On the day of her discharge, I was taking care of the patient. When I was giving discharge instructions, the patient wondered why Ativan wasn't prescribed for her to take at home. I was getting ready to page the MD to have this corrected, when I noticed on the MAR the PRN indication.

The evening shift nurses had been giving Ativan to her every night to help her sleep when she was ONLY supposed to have it before a particularly painful dressing change.

I was the one who had to explain the patient and her husband the mistake, apologize, and send them on their way with advice to see their PCP for insomnia medication if needed. Needless to say, I visited our DON's office before I left for the day. I was angry, but I was mostly upset and sad for the patient.

[withasmilelpn]

Because meds like Clonazepam and Ativan do have high risks for over sedation, falls, etc and use is scrutinized heavily by state surveyors, it is to your facilities benefit to cut back on their use at times and monitor their use closely. Documentation needs to be stellar to show that they are in place to benefit the Resident and keep him and others from harm, that other interventions have been tried and they are not being used as a restraint for staff convenience. Periodically pharmacists will request reviews of these meds and suggest cutting such meds back. Physicians have to review those requests and document why they chose to disregard them.

In fact, our facility has a committee that's sole purpose is to review psychotropic med usage and documentation, and these meds also come up for scrutiny in team and when care planning. Residents on psychotropic meds are often followed by psych as well in addition to their general practitioner.

As a PRN nurse, you may not be aware indeed how often this particular subject is addressed for this gentleman as you are not part of his regular caregivers.

Also, one time of alertness in the am when not given his PM dose, while worthy of being noted, is not proof of anything, unfortunately. What I would do is note that, pass it on in report to the next shift and my supervisor and document that as well. Further more I would document thereafter every day I took care of this man when I noted excessive sleepiness and be very precise as to his level of consciousness. When I had several weeks worth of documentation to support me, I'd request a psych eval or follow up. I'd also talk with the other shifts to get their opinion on d/c'ing the medication. My course of action would be to try get the MD/or Psych doc to change the HS dose from scheduled to PRN.

Then, when it is given, staff have to show cause and what non pharmaceutical measures they took in order to justify it. When the surveyors come in and determine the over sedation has not been addressed or documentation does not support giving the med, the facility is likely to be cited and the med will likely be d/c'd.

I also have to suggest that even if you're certain you're right, be humble and ask others what they think. Whenever I want to make a change for a Resident whether it's a med administration time or scheduling pain meds that will affect another shift I try to to get their input. Don't rush to judgement and assume either that they are lazy or incompetent either when they don't agree with you. Be methodical, courteous and try to go through proper channels as much as possible. Document, document, document! If you want to be taken seriously, don't resort to drama or crying - even if you feel like it. Be patient, it takes time sometimes for changes to hapoen. Best of luck to you!

[BrandonLPN, LPN]

The one day he didn't get the Klonopin, he was awake, alert and verbal at 8am med pass. Like he should be everyday.

Why "should" he be up and alert everyday at 8am? He's an old man with alzheimers.

I doubt very much that half a mg of klonopin is knocking him out from bedtime to 12pm the next day. Obviously, he is awake much of the night. Is it really that surprising he sleeps in?

The medication was ordered PRN for agitation. A demented resident trying to get out of bed and falling at 2am counts as agitation. What else was it ordered for?

[wooh, BSN, RN]

Don't rush to judgement and assume either that they are lazy or incompetent either when they don't agree with you.

But that's so much more fun than acknowledging that they may actually be competent and doing the best they can to deal with sundowning with the resources they have.