Failure to Address Resident's Request for Sleep Aid Medication
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's request for a sleep aid medication. The resident, who had a history of cerebral infarction, epilepsy, delirium, dementia, psychotic disturbance, mood disturbance, and anxiety, was assessed as having little to no cognitive impairment and exhibited no behavioral issues. Despite expressing to staff that he needed medication to help him sleep and reporting poor sleep, there were no physician orders for sleep aid medication in his record. The resident stated he had informed staff of his need, but his request was not addressed. An LPN acknowledged being aware of the resident's request for a sleep aid but admitted that the provider was not notified because she became busy and forgot. The Assistant Director of Nursing confirmed that staff are expected to address such requests at the time they are made and that the nurse should have notified the physician. This failure to act on the resident's expressed preference and request for care was not in accordance with the facility's policy on honoring patient rights and personal choices.