Re: LTC medication changes, any ideas how to handle this?

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Re: LTC medication changes, any ideas how to handle this?

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Anyone on here have experience dealing with LTC staff and their LO's medications. When my mother was in MC at AL she saw her own Dr of many years and we had her medication fairly well regulated. Now that she is in LTC she is dealing only with their doctors and they have made several changes to her medication without talking to me. At her last care conference I brought up that I see from her med list they gave me in advance that there were several changes to her medications. I brought it up to the charge nurse that I had noticed a very large change in her behavior and symptoms and wondered if this was why. At first they said they hadn't noticed, but I told them it was since moving to LTC and I had been thinking it was due to the move but it is getting worse not improving. For one she is extremely angry and seems to be hullucinating or imagining all sorts of strange things. She insists that a man came in her room and forced her to disrobe and go to bed. In her mind she thinks he could have raped and assaulted her. Since no men work on the unit she may have mixed up a woman as a man and in her confusion they may have made her go to bed when she didn't want to. There are other things she complains about as well. When I told the nurse this and ask about possibly restarting her discontinued medications. I was told that they were aware that I am a retired RN and ask from what dept. I had retired from. I told them OB but didn't feel that they needed my full work history. The charge nurse scoffed and said well you don't know geriatrics medicine and we do. I tried to ignore the comment and went on to ask about at least restarting her pain medications since all they are giving her is 2 tylenol a day. She ask what do I want her to have so I said what her medical issues are and ask to restart her Mobic daily and Tramodal at bedtime along with 2 arthritis strength tylenol twice a day. She said NO! She would check about possibly restarting Mobic. Now a week and a half later nothing different. When I ask she said she put a note in her chart and the NP hadn't ordered anything different. Everytime I see my mother she cries to me that she is in so much pain yet the nurse said they are unaware that she is in pain. Mom isn't telling them but she is acting out and I believe it is the pain that is causing the agitation. I have ask to meet with the NP to discuss this and was told she is here Monday through Friday during the day come see her if you want but they don't believe there is any need since they have made a note. I worked 40 years in nursing and know for a fact if a nurse brings it to a doctors attention that a patient or family has an issue they will address it. I am trying to stay on this woman's good side and work with them. Any ideas for a way to handle this differently? Oh I did retire from OB but I also worked on Med/Surg, OR, Recovery, ER and Evening Charge Nurse in ICU. My sister was a nurse manager of a nursing home unit for a number of years and now is an ICU nurse. I didn't tell her this because I didn't want to get in a pissing match about who had the best resume.

Alzheimer's & Dementia Long Term Care Medical Care Medications

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I suggest you immediately remove your mother from the care of the "subcontracted" medical service that serves her AL. My Mother was also placed under the care of "their" doctor when we moved her into AL. She was moving from her home state to a new AL facility near my sister. We had to do this to get her admitted to the AL and make sure she had continuity in her medications. No one attempted to change her medications, but she never even saw their doctor and yet services were prescribed for her without our permission (psychological counseling) that only confused and upset her and which were then billed to Medicare at dramatic prices. Once we discovered this, we removed Mother from the doctor's "care" and are now taking her to private doctors outside the facility. It is more trouble for us, but better for our mother. These medical services attached to AL's are, in my opinion, simply money mills whose billings may actually defraud Medicare. I would also check into whether her state has a long term care ombudsman office and relay your concerns to them. If you have your mother's POA for medical decisions, you should have all the power you need to take her to an outside doctor.

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This is not an assisted living facility. While in AL she could see her own Dr. Now she is in LTC and must use their medical services, no option. NYS and Medicare will not cover outside of facility’s doctor other than specialists. Also her care is managed by a MLTC because is on Medicaid. I have found the Healthcare providers to be pretty good to work with. So far my only issue has been the nurse manager and I have gone over her. In this area we a short on ombudsmen. I have even been contacted about training and doing this service since I already volunteer at office for aging. Maybe in the future but not right now.

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Take her list of medications to your pharmacist or doctor & discuss it with him or her. Do not tolerate being treated disrespectfully. You do not have to give them your work history

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Pissing contest indeed!! Like you have to bring in your resume. I never say what I did for a living because I worked in (that despised field of ..... health insurance.) So often conversations end up in a non productive situation of guilt shifting. I first document my concern with a photo. Next. I verbally discuss the problem with the supervisor as well as show them the photo on my phone. That shows the exact situation as well as puts them on to the fact that I am willing and able to press forward. If it continues, I take another photo, write up my complaint ( they have a form for this) take a photo of the completed form and give it (and show the second photo) to supervisor. At this point I make an appointment with the Facility director and director of nursing to discuss how we can work towards a solution that will work for all of us.
Document the specific problem, your conversations with the staff and during your care conference ask who you should be talking to about the communication difficulties you have experienced.

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You need to skip right on over those folks you already tried to communicate with. You've already seen the results - nothing. Go directly to the doctor and talk about her meds because he's the only one that can make changes anyway (or his PA if he doesn't actually show up on site). Also have them check her for bladder infection. All too common in the facilities and will create big-time behavior, hallucination issues very quickly

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Don't discuss this with the nursing staff insist on an appointment with their Dr and go through it all with him/her. I don't care how long she has been geriatric nursing this does not make her a drug specialist and I am sure you have come across a far wider range of prescribing needs than someone who has spent far too long emptying bedpans and clearing up incontinence. Great to try and work with them, but work with the organ grinder not the monkey.

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If you are the POA you can tell the nurses that you want to be notified prior to any medication changes. You also have a right to meet with the facility doctor to discuss your concerns. If you can't meet with them due to your schedule you can certainly request that the doctor calls you after each visit!

Pain can definitely cause agitation in individuals especially those with dementia who can't communicate that they hurt. This would be the first thing I would get corrected!

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I am DPOA and MedicalPOA. I have said to please run all changes through me. My meeting with the NP was very positive.

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All these abbreviations leave me confused. What is an LTC? LO? MC?
Definitions or whole words would be helpful for participation in discussion.

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Long term care,loved one,memory care

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I took care of my SO for 2 1/2 years in SCF. I didn’t like their Drs so I told them he will continue to see his own Dr. I hired a Medivan to take him to the Dr every 3 months or when needed. Thus his own Dr prescribed his meds and they had to follow his orders. Nurses have to follow Drs orders. They can request new orders but Dr has to give them. Try talking to nurses on different shifts and they may get more done for you.

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Talk to dr not the nurses - you are better educated about meds than most people - stick to you guns & ask, ask & ask some more - do a bit of reading on the meds she used to take & the meds she is taking now so you can talk with assurance about her meds

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I had a difference of opinion concerning the addition of a new drug (Zoloft) given to my mother in LTC. Interestingly, the nurse called me about starting mom on it; it appeared that they were asking me if it were okay, but perhaps really just informing me. I replied that it was a med she had never taken before and that she has had many negative reactions to meds in the past. My response was I was okay with it as long as she was taken off of it if there were negative reactions. Well.......there were. About four to five weeks in, she started having seizures and nausea and ended up in hospital. They treated her for symptoms and low sodium and sent her back. One week later, same thing, except add tongue thrusting; she ended up in the hospital again. The doctor in hospital decided that the Zoloft was to blame and cut her dose in half with the recommendation to stop all together. (You can't stop cold turkey.) Even paring back had its difficulties. You would have to see it to believe it; my mother appeared to move in slow motion for days. When after two weeks, the LTC doctor informed me that he had no intention to stop mom's Zoloft, I hit the roof. Clearly, I stated, mom couldn't tolerate the med. It was given her to specifically help her gain weight (off-label) and with the nausea and seizures, that wasn't happening. Clearly, it was causing neurological impairment. It was a poison to her. His response? Are you a doctor? No, never said I was. Second, he "regretted" to inform me that although I was mom's Healthcare Proxy and DPA, I did not have the right to make decisions for her. The ugly truth. I was trying to preserve mom's ability to decide for herself, but clearly she couldn't. I knew her best. The things the doctor said to me that day were unprofessional on his part, although true. I should have filed a complaint. Instead, mom ended up in hospital for the third time in four weeks for the same problem. I relayed all to the doctor there, who removed the Zoloft altogether from mom's meds schedule. Guess what? The seizures, nausea, and tongue thrusting stopped. From that point, the in-house doctor got over his ego thing and we worked better together. Just know, that I never acted like I new better than the professionals, however, I knew my mother better than they did. I knew that if given a choice, she always opted for less medication, not more, because she had a history of reacting badly to medications. As a woman in her thirties, she suffered medication-induced lupus, in fact. Therefore, I did fight fiercely on her behalf as her advocate/daughter. So, if you can't get anywhere, you do have options. There may an opportunity upon hospitalization to work it out with a different doctor. Also, sometimes a facility will have a second in-house doctor or a list of doctors who have privileges at the facility. Find out and switch out. The last consideration is to move your mom to a new facility. Hopefully, it won't come to that.

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My mother also had a severely bad reaction to Zoloft (which I agreed might be good for her depression). The "very low sodium' side effect is quite rare, but that's what happened to her. 3 weeks in the hospital. Maybe it's not quite so rare among elders. Everyone reading this should be aware that the relatively innocuous Zoloft (sertraline) may cause severe problems for you elder person!

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The nurse can only give meds that are ordered. LTC has a different caregiver mix than in hospitals. I am an RN too - med/surg, ob/gyn, and critical care. Most LTC have CNAs giving the care and LPNs giving the meds. There may be only a few RNs in the place to address care plans and management and probably don't know the clients well. That being said, thank God you are advocating for your mom. Ask for the contact information for her doctor. Ask for a meeting with her doctor to address the issues you listed. He/She should be able to prescribe the medications your mom needs. Also ask to speak to management of the LTC. Explain the behavior of the staff during your care plan visit. All staff should treat you with respect, even if they disagree with you on treatment.

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I am so sorry you are experiencing this. It is not at all right. My mother has been in 2 different facilities and I never had such issues in general or when certain conditions arose that required additional medications. I also was able to speak with the staff doctor or his assistant. I would address this ASAP with how many people hired there and indicate your extreme displeasure. As you can see here from responses this is not at all justifiable.

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This is shocking. Ask for a meeting with the doctor immediately. At least where we take mom, the NPs are not authorized to prescribe controlled substances like tramadol so we have to deal directly with the doctor. I am concerned that the nurse you describe seems more concerned with being right than your mom. Hope it goes well and quickly if she is in pain.

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All I can say is What the Hell!? You are her MPOA and by rights everything should go through you! What part of that do t you get? You are your mother's medical decision maker. We had an issue at one point where they discontinued a medication of my dad's. My sister who is also an RN and I are my dad's medical POA. We told them they are to go through one of us for every medication decision. We have had no problems since. We speak directly to the doctor or go through the Nurse coordinator or DON. But never are they allowed to start or DC a medication without our say. We’ve even asked for changes such as adding Tylenol every 6 hours and there was never a problem with that. I think you may need to report this type of behavior. What about a MPOA do they not understand?

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I respect your experience as a nurse. Your experience as your mom’s daughter and caregiver should be enough for them to respect you and see you as a partner in your mom’s care. If only it were that simple. I would talk to the doctor‘s’ and try to develop a relationship so that future requests hopefully meet with less resistance. I get your frustration. My dad is 98. I wish I had your medical background, but like you will go toe to toe for Dad when something isn’t right. Good luck!

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Just an offhanded comment here. I think all family members need a set of scrubs to wear to family visits at nursing homes. Give them the illusion we are all knowledgeable.

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That is awesome!

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The LTC is under your Congressman and state senate. Call your Congressman first then send a letter with all your issues and before you do that ask that the LTC Doctor meet with you. Your Congressman may even pay them an unexpected visit!

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Even without your excellent nursing history you as your mother's next of kin and I assume POA, have a right to make medication decisions on behalf of your mother. These nurses you are dealing with should be reported to the relevant authorities. Of course this home wants you to use their doctor and pharmacy, it's more income for them, but you have a right to continue using those of your choice.

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I have to say I have had the same experience with all you have said . The only thing different is I am not a nurse.

I find you have to be on it all the time, unfortunately. My mom had a UTI and a blood clot in her leg. It took a month to get things going so they would deal with it.
This was at the level of the Dr. Also,as you said you don't want a pissing contest - we are there for our moms, if not us who? So it got to the point where I got very angry when I went in and her leg and foot is swollen so she cannot get her shoe on. That is when I about lost it. I went to the PA and was very matter of fact and state now she cannot get her shoe on her leg is so swollen and I did walk off and she followed and to a look and says there is really not much we can do! I really lost it at that point. After that they did do xrays at the home and then scheduled her for a sonagram whch showed a clot in her leg. (she was in there for a second stroke and the last one was major) So mom cannot talk and won't say she is in pain. So I took the xrays from when she went to an orthopedic Dr who says she had bone on bone at the hip region. She had a blood clot in her heart so never could have a hip replacement. She is 93.
Everything you described is what my mom is going thru. I go every day and I think the nursing home expects me so they are doing better- but , what about the ones who have no one?? So sad.
I am gald I am not imagining this stuff as it gets overwhelming and you do dread saying something.
We are their voice! Remember that

Good Luck!

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As a Nurse u know there is a chain of command. If you get nowhere by the time you have spoken to the DON then call the doctor who has been prescribing the meds. Make sure he knows you are a nurse. Loved it when my daughter wore her scrubs when visiting my parents in rehabs/LTC. It meant she knew what was going on and what her grands needed. She was always very nice but staff as quick to make corrections.

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I visited the NP today. That was interesting since the Unit nurse manager had told me that I just needed to come during the time she was there and no appointment needed. I got there and was told that I needed an appointment to see her and that she was busy. Said I should of discussed with NM first. I said I want to talk to DON since it was the NM that said to just come in. They promptly called NP and she came right down within a few minutes to talk with me. Was very upset that my concerns had not been brought to her attention sooner and promised to take care of it. I think we got the medication situation sorted and she is changing my mother to a Dr that we have worked with previously. I plan on in the future to have a talk with the NM and bring up that we have got off on the wrong foot and try to resolve any problems. We’ll see how that goes. I don’t want to be known as a trouble maker but Mom’s best interests come first.

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I think the problem is that your mom denies pain when asked. My mom did the same thing.

The nurses would say "are you in pain?" and she'd say "no, I'm fine". Then she would call one of us and be weeping in agony.

After going back and forth, I got the nurse on the phone right after mom "denied" pain. I asked mom to tell me how she felt and she expressed that she was in pain.

This opened up a conversation about how "no" was my mom's default setting and she would likely deny anything in order to be "polite" and "a good patient".

We finally got mom on a regular regimen of pain meds rather than PRN.

Also know that LTC facilities are under tremendous pressure to reduce ALL medications for thie elderly patients.

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Exactly! I think my Mom does that same thing. Since it is a new place I don't think they know her as well as I do so need to listen to me. I plan to go see the NP tomorrow. So I hope that goes well and we can figure out what is best for my mother and not just what meets the states criteria to reduce meds.

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If she was falling so frequently perhaps that is their reason for withdrawal of some medications? But I would hope you as family would be informed. I see your hesitance in wanting to give it a bit more time, for sure. Keep us informed as you go along. I trust you will instinctively know which is the best way to "go"; or certainly are the best judge. Nothing, as we all know, is a sure thing. Good luck!

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I believe her frequent falls are do to increasing weakness and an unawareness of her changing abilities. She thinks she can still just stand up and walk where she wants to in her head but she lack of strength and imbalance issues won't allow it. My issue with the old nursing home is that they were aware of this and she would have staff right in the area where she was sitting and they would allow her to get up on her own to go to the bathroom where she would fall. Possibly the adjustment to her dementia meds and pain meds were an effort to help with the balance issue but there needs to be a "happy" medium.

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Something is very wrong here, in my own opinion. I am a retired RN. If family EVER came to me as you did it wouldn't matter if you were a nurse or a hotel maid. You KNOW your Mom and you know the changes you are seeing, and you are very descriptive about them.
I think you need to meet with the doctor in charge here if there is no satisfaction from the NP. I don't like the sound of the way your concerns are being handled, and I HATE the sounds of the changes for your Mom. We are all aware that some changes, with change of facility are inevitable, but this is a LOT of change when she was apparently well maintained.
Is it the tramadol? Are they worried about addiction in a person this age for whom it is working. Something just seems so off about this. I am aware that you are the one giving us YOUR side of this story, but you are not only being ignored (and they didn't know how she was before so how would they recognize "change" without you?), but you are being BELITTLED. Indeed, made fun of because you are an RN. Huh? Really? How crass. Would they take your story seriously if you jerked sodas? Because they SHOULD! You are the one who knows your Mom and her history. (UTI ruled out?)
As I said, were I the director that particular nurse speaking with you would be bouncing down the road to Unemployment Compensation right now. Every patient is a mystery and it is the patient and the family who provides the clues and the ultimate solving of the puzzle.
When my bro was in rehab we had medication problems (anxiety made his BP pop, they put him on meds without parameters and he was falling around for PT). They took SO SERIOUSLY all we said. They began to measure before pills, orthostatic measurements, everything. And the medication was held at first, then D/C. Same thing with antianxiety meds which had the opposite affect (as occ. they can) on him. They LISTENED! That is their JOB.
Something is WRONG at this place. IMHO. As an RN or as ANYTHING ELSE. Keep a diary. Think Ombudsman.

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I have ruled out the UTI. I guess why I am so hesitant to let them know my concerns is that this is a new LTC facility after I moved her from one that was just horrendous. The last place was dirty, she fell constantly because no one was paying attention and they messed with her meds without even telling me anything. I kept voicing my concerns but finally just decided to move her, this new place is closer her care so far, except for this, has been much better and the place is clean and bright. She has only been in this place about 3 1/2 weeks. Still I agree that the Charge nurse needs to give more credence to what I'm telling them regardless of my background.

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Re: LTC medication changes, any ideas how to handle this?

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