Am I Wrong?

  1. ........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 question is one of 43 residents in my assisted living facility, and she has a daughter who has literally controlled every aspect of her care for several years now. This apparently includes circumventing our medication administration system to obtain sleep medications for her mother that are left at the bedside, plus the Rozerem we give her every night. The resident herself has VERY poor vision, a fair amount of memory loss, and as far as I'm concerned she is not safe to have these things in her room. We give her her stool softeners and her heart medications because she supposedly is too demented to self-administer........but we're allowing her to have several varieties of sleeping pills??!!

    The daughter---who is not a nurse, but a food-science professor at the university---pops the Sonata and the Ambien for her each night and puts them in a cup for her to take when she wants them, then staff delivers the Rozerem at 8 pm and that also gets left at the bedside. Not only do I fear what could happen if a couple nights' sleepers are 'forgotten' and then taken all at once, that's just WAY too much medication for a frail elderly woman. The Sonata alone would snow me, and I'm half this woman's age and twice her size (and I'll bet my liver and kidneys function a heck of a lot better in the bargain). I can just imagine the daughter going nuclear if Mom falls and breaks her hip, or accidentally OD's.........well, I'm sorry, but I don't want to be held responsible when something bad happens.

    What's even more frustrating is, I had a talk with the daughter today, and she SO does not understand why I have issues with all of this. She thinks that because there is a doctor's order OK'ing the sleepers to be handled in this fashion, I shouldn't object. She doesn't get that the facility is legally responsible for her mother's care, or that as an RN, I MUST refuse to carry out an order that I believe to be inappropriate, or even that her mother is declining both cognitively and physically to the point where it's not safe to "do things the way we've always done them".

    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.

    I don't know, maybe I'm too conservative; I realize I've only been at this facility 8 months, and this daughter's iron-fisted control has apparently not been challenged during the three years the resident has been there. But I'm less worried about alienating her than I am about her mother's safety, and yes, our liability if something happens to her as a result of taking three different types of sleep medications. I know it's not a personal thing, and I don't take it personally, but I admit it does irritate me that the daughter seems to think she knows more than I do about meds, and she will do an end run around me and/or the system to get whatever she thinks her mother should have, whenever she thinks Mom should have it. I wrong in thinking this is too much medication, and how can I make sure we are not held liable if and when things go sideways? I've faxed the NP who ordered the Sonata and Rozerem to find out if she's even aware that the resident is on Ambien; I suspect not, because she's seen the resident only once and I'm sure knows only what the daughter has told her. I've also documented all of this in the chart, and written up the managed risk agreement........beyond that, well, I'm hoping some of you will have some ideas.

    It just goes to show ya, no matter how long you practice or how much you think you know, there's always more to learn! Thank you!
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    About VivaLasViejas, ASN, RN Guide

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    RN and blogger extraordinaire; from OR , US
    Specialty: 20 year(s) of experience in LTC, assisted living, med-surg, psych


  3. by   TheCommuter
    I think that all of those medications are immensely excessive! I am a 25 year old female and all of those pills would send me dropping to the floor if I were to take them. I cannot visualize a 90 year old woman taking all of these meds and experiencing a beneficial outcome.
  4. by   southern_rn_brat
    omg! Does the doc even realize his patient has more than one sleeping med ordered? No way jose should she take all that no matter what is ordered! you done good girl.

    Talk about a chemical restraint
  5. by   LoraLou
    It depends on what this woman has done throughout her life and what sort of medications she is used to taking. Not that I don't agree with you that is a lot of medication, but if she is someone who has taken a lot of various medications throughout her lifetime she could have built up quite an immunity to them and must take a lot. Have you ever checked on her after she has taken them all?
  6. by   rn/writer
    Not only is that boatload of medication for a frail 90-year-old, I'm disturbed about them being left at bedside. Goes against everything I've been taught. I understand this is assisted living, but there are just too many things that can go wrong when you don't see her take them. She could say she dropped them. Did she take them and forget? Do you tear apart the room looking for them? What if you don't find them? And that's just one bad scenario.

    Were all three meds ordered by the same doc? Can you ask the a pharmacist what the half-life of each would be in an elderly person of such-and-such a weight? Ask him also what the combined effect might be. Don't know if these meds tend to potentiate each other's effects, but that could well be a concern. Are her liver and kidney function okay? Is she rousable after taking all three? What are her vitals like? Does she seem snowed the next day?

    You mentioned that she has a fair amount of memory loss. That can be a side effect of oversedation. As can lethargy.

    Does the patient want all of these meds and does the daughter allow her any say in the matter?

    Not an easy situation to deal with. She's lucky to have a conscientious nurse.
  7. by   GatorRN
    WOW!! Those 3 sleep aids together would snow me for days!! I can only imagine what they must do to a 90 yr old LOL. As RN/Writer suggested, could those pills be responsible for her memory loss? Depending on when she takes them throughout the night, especially being left at her bedside and not really knowing when, they could very well influence her memory loss during the day.

    I'd be curious to find out if this NP knows that she's taking all 3. If she/he is aware of it and continues to prescribe it that way, I think I just might ask for something in writing from the NP stating they have no problem with it, noting your concern, to keep in her records...CYA. Perhaps the NP could talk with the pts daughter about the effects of taking so much sleep aid on a 90 yo LOL. The daughter may listen to the NP moreso than a nurse. Some ppl are just wierd like that.
  8. by   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
  9. by   BSNtobe2009
    Hey, I'm not a nurse but have just a general observation of what I have read. Is the woman able to get up and move or even eat?

    I just know that the very few times I have take a sleep aid, it has severely supressed my appetite, and leaves me very weak, and I can only imagine what it would do to a 90 year old woman. If she isn't getting proper nutrition because she is overly medicated, I know she is 90 years old, but could this be contributing to her health issues as well?
  10. by   traumaRUs
    Marla - you are very correct - way too much sleeping medication! Like another poster asked: how many doctors does she have ordering meds? At the age of 90 y/o, renal and hepatic impairment are a given, so clearance of these medications is delayed.

    I would certainly want to contact the corporate lawyer to see if you want to continue to have this pt in your facility due to the increased risk of falls.
  11. by   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.

  12. by   santhony44
    I think you're right to be concerned. I'd be leery of giving one of these to the patient you describe, much less all three.

    Keep pressing to get the documentation from the NP and/or MD that they know what she takes; it also wouldn't hurt to have someone actually lay eyes and hands on her.

    Document everything you do, and keep copies. Document whatever you can about the resident's memory, behavior, etc. along with her physical condition. Keep your own private documentation about your concerns and what you are doing about them. Keep copies of everything! I'd also sit down and write out your conversations with the daughter, as close to verbatim as possible, and keep it as objective as possible.

    And if your facility has someone in charge of risk management, that person needs to be involved as well.
  13. by   txspadequeenRN
    First thing ,if you are in a ALF dont you have to be capable of taking your own medications. If her dememtia is severe enough to hinder her ability to take her meds she has no buisness in a ALF. Maybe placement in a another facility with a higher level of care may be more appropriate. Next. I would imagine that the Doc that put her on all this meant for the previous sleeper to be D/C'd... not taken all at once. This increases her risk for all kinds of things and I would be scared to death she would fall and break a hip. I would contact her doctor and let him know what she is taking. Ask for 2 of those meds to be D/C'd then get them from her room and give them back to the Daughter. I dont work in ALF, so I dont know the in's and out's. But I do know you and your patient are in a bad way at the hands of someone that clearly just has no clue!!! I would hate for this lady to become injured and then the daugher turn to her lawyer and say "well that nurse never told me she should not be on 3 sleeping pills at the same time"..... The daughter only runs the show until it becomes unsafe then you the RN must step in to protect your patient. I would be very worried and would put a stop to this pronto.
    Last edit by txspadequeenRN on Oct 12, '06
  14. by   CarVsTree
    Any chance daughter is diverting? Smells like diversion to me.