What Would You Do?

[megananne7]

You're doing your med pass in a nursing home/assisted living. You have a new resident with dementia who has been in the facility for about a week or two and has had some behavioral problems.

The family has debated about moving the patient to another facility but the patient has seen a psychiatrist which prescribed risperdal and has been doing well on it.

Patient's family member/POA comes in about 7:00pm and refuses you to give the risperdal to the family member r/t suspicions the patient is having side effects & information he has read about the medication. You have no way to get a hold of this psychiatrist as you don't have a pager number for him and the office is closed.

What do you do?

[nightmare, RN]

Document fully why you have not given meds detailing POA's concerns and try and get them an appointment to see psychiatrist ASAP.Do you have a more senior member of staff on duty who could talk to POA about their concerns?

[leslie :-D]

it's not an emergent situation.

cite the reason for refusal in back of the mar.

leave the nm/adon a note with poa's concerns.

leslie

[fultzymom]

Document the POAs refusal of the medication. Listen et document the reason's/concerns that the POA has, et educate them on the medication. Then notify MD (via fax--not an emergency) and leave a note for follow up for the next shift et your supervisor/DON. Also, a request could be made for the POA to meet with the PCP.

[megananne7]

What I did was hold the med/documented as refused for 2 doses (the one at 8pm and the one at 8am) until the doctor could be contacted, per family/POA request. All was well.

Well, when the DON finds out she says it's a med error & I get written up for it. She said it would never stand up in court and says family/POA can't refuse meds for patient's, that it's up to the MD.

If they can't refuse meds, than they can't refuse treatments which makes absolutely no sense and you might as well not have a POA to begin with if they can't make medical decisions for the dementia patient who doesn't know what the heck is going on in the first place.

[Daytonite, BSN, RN]

i would not give the medication and document very thoroughly why and include the poas point of view on this. i would then get a physician's order to back this up to protect myself.

as far as notifying the psychiatrist, usually there should be instructions for emergency contact or an answering service taking messages for the doctor so a message can be left. a fax could be sent. at the very least the day shift needs to follow up asap the next morning and contact him. not being able to reach the psychiatrist, i would have notified the patient's attending physician who admitted the resident and is their physician of record immediately since he is in charge of the patient's overall care. he needs to be notified of the family's wishes, the holding of this medication, and that the psychiatrist was not able to be reached and you need to obtain an order to hold the medication or give it if he instructs you to do so. the don or nursing manager also needs to be notified for follow up the next day. that should cya pretty well. of course, document every thing to protect yourself.

most nursing homes have pretty strict rules (as per state law) that any physician who takes on the responsibility of being an attending physician must make himself available 24 hours a day. this includes having an answering service that can reach him or arranging for another physician to be on call for him during off hours. it may not apply to consultants (such as this psychiatrist), but sure does apply to the attending physician of record for this patient. even when we had consulting physicians (such as psychiatrists) ordering medications for nursing home residents, we still verified the orders with the attending physician of record since that doctor was the "big cheese" of the patient's case.

if none of this is done, the family can complain to the state department of health and the nurses, facility and doctor can end up in deep doo-doo over this for not following proper procedures of notification.

our obligation is to follow the doctor's orders. when what the family wants and what the doctor has ordered are in conflict you always go to a doctor for resolution of the conflict. to go out on our own is an error in judgment. i wouldn't have dinged you for a med error, necessarily, but for failure to exhaust all your resources to notify a doctor. if i had been unable to reach a doctor, any doctor, my next call would have been to the don, or whoever was on call for the don, to get direction on how to proceed next. they might not be happy about getting a call over this, but giving staff direction when these kinds of dilemmas come up is part of their job. it also might have saved you from getting charged with a med error.

[jjjoy, LPN]

If the family member had POA and demanded that the med be held, I don't see how it could be construed as medication error if the nurse clearly documented why it was held and promptly addressed the issue in the morning.

Wouldn't it also have been likely had the nurse contacted the DON or MD at home at night, she would've been dinged for "overreacting" and not just documenting it and waiting until the morning? It couldn't be considered a med error in that case but could still count against her in her eval.

[IMustBeCrazy]

I work inpatient psych, so some of the rules I must follow are likely more strict re: med consent. In my state, inpatient psych pts MUST give verbal informed consent (with another RN witness to cosign) or give written informed consent for psychotropic medications. Activated Power of attorney-Health Care agents CANNOT give either consent or refusal of consent for psychotropic meds, only court appointed guardians can.

Was this POA-HC ever actually activated by the physician?? Additionally, activated POA-HC agent in my state cannot consent for pt to be admitted to an inpatient psych unit, that remains in realm of the guardian only or pt if they are able to give informed consent and have no guardian.

Where I am, it is somewhat different when the pt is OFF the psych unit, generally less stringent as far as the consent statute goes, but again it depends largely upon the type of facility the pt is in at the time.

I bring this up only to highlight that you will want to be crystal clear on whether you can even give psychotropic medication in your facility based on only an activated POA-HC consent. The pt may require a court-appointed guardian's consent in order to receive their psychotropics.

I also agree re: notifying DON if physician was not available to communicate family refusal of medications (assuming it was legitimate for them to do so), and document, document, document.