Chemical Restraints

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    I work in the Special Care Unit of a long-term care facility that has a policy of resident's rights to be free from all restraints, including chemical restraints. Our 'Unit' as they call it, has 12 residents and 2 aides on staff until 8:30 pm, by that time most of the residents have been bedded down for the night so only one aide is needed. One of our little ladies (Ms. S) is a woman suffering from dementia which makes her a danger to herself and others because she is not able to comprehend simple directions such as 'please sit down here until I can come back and help you.' She speaks in a constant stream of random words strung together incoherently. If left unattended she will make threatening gestures to and get into altarcations with the other residents. She's unsteady on her feet and needs to be supervised continuously. Her oxygen saturations are in the 40% range unless she is on 5 liters of O2, yet she constantly takes the cannula off. She refuses to stay in one spot unless they tranquilize the consciousness right out of her. Today was a case in point. From the time she was awake this morning she was disruptive of everything that was going on. Every time she got up from her seat I had to drop everything I was doing and run to her side so she wouldn't get up and walk around unsupervised (this happened innumerable times today). I was of little help to the other aide for the entire shift because I was doing nothing but 1:1 with this helpless little lady who also cannot feed herself or do any self-care.

    The last 2 days were exactly the same as today, the only difference was that at some point when the exasperation level got too high we'd call the nurse for a prn dose of Ativan or whatever so she could be subdued enough for us to be able to attend to the other residents who needed toileting or bathing, etc. Once the medication hits, she falls dead asleep -- allowing us to get things done and take care of other residents who are also fall risks. The most stressful thing on my shift is when the other aide is with a resident, I'm doing 1:1 with Ms. S and cannot leave her side -- suddenly I hear an alarm down the hall from another resident who is trying to self-transfer for the 40th time today and I can do nothing but wait for the other aide to take care of the chronic alarm setter-offer. Ms. S cannot be distracted with music, movies, activites, crafts, or any simple diversions because she just cannot focus.....you name it, we've tried it. The only thing she responds to is heavy doses of CNS depressants and anti-psychotic drugs. I ask you.....is this not using a chemical restraint? Not that I mind.....without it we would have to staff one person to do nothing but stay with her 24/7. I guess what I don't understand is, what's the difference between sedating a psychotic person and using a chemical restraint?
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    From what you've wrote it does seem like you're facility is giving is high enough to sedate her to the point of being unable to move, which would technically be chemically restraining her. Also you've indicated that you're giving the medications for the sake of the staff and not to be therapeutic for the patient.

    This seems to me to fall under the jurisdiction of JHACO because this involves a patient's safety and quality of care. Here's their website for filing a complaint: E-dition
    The very worst thing that will happen is that they'll look into it and decide nothing needs to change, so you don't stand to lose anything by reporting them.

    Here is a website with hotlines for each state to report elder abuse: NCEA Find State Resources Don't be afraid to blow the whistle, the best that will happen is that the patient will be moved to a more appropriate setting and the very worse that will happen is that they'll investigate and determine that nothing was wrong.

    You could also tell your story to the center for medicare advocacy: Center for Medicare Advocacy

    Here's a link to an article talking about just this issue: GRAY MATTERS: Nursing Homes and Drugs - Wellsphere
    If you have a friend or a loved one in a nursing home, you should be aware of one of the more insidious practices facing many residents. They can save the nursing home money but they rob patients of what remains of their spirit, dignity and independence. It’s not easy for residents, especially newcomers, to come to terms with being in a nursing home, especially if they are relatively healthy, ambulatory and generally of sound mind. But if they’re restless, troubled and a bit depressed (and who wouldn’t be), too many nursing homes will take measures that can be debilitating.
    Instead of helping unsteady residents go to the restroom when they need to, attendants often will fit them with diapers as a matter of routine because there’s not enough staff to tend to every resident’s needs when they need to go to the toilet quickly. And staff members don’t want to be blamed for a fall.
    Worse, if an elderly patient who is rebelling against being in the home and its restrictions or rules, or is unruly, the staff may get a doctor to prescribe a sedative. Only the worst of homes will use physical restraints which are forbidden by law, but more often – too often – nursing homes are resorting to anti-psychotic drugs for residents who are not psychotic but suffering from dementia, anxiety or a show of anger and impatience with being confined.
    In January 2007, according to the Center for Medicare Advocacy , a nursing home ombudsman reported to the California Health Department that a resident at a skilled nursing facility had been held down and forcibly injected with an anti-psychotic drug. The patient was not psychotic, but suffering from dementia and Alzheimer’s disease. An investigation, said the Center,
    “determined that 22 patients, including some who were suffering from Alzheimer’s...were being given high doses of psychotropic medication not for therapeutic reasons but to simply control them for the convenience of the staff.”
    This investigation, which may include criminal prosecutions, is still underway, but the problem persists elsewhere.
    The Boston Globe reported on March 8 that 2,500 nursing home residents in Massachusetts were given “powerful anti-psychotic drugs last year that were not intended or recommended for their medical condition.” The drugs were intended and licensed by the Food and Drug Administration for people with severe and diagnosed mental illnesses such as schizophrenia or bipolar disorder.
    But the FDA has sought to discourage the use of these drugs for dementia, a gradual loss of memory or anxiety, by issuing what is known as “black box” warnings on the inappropriate uses for the drugs. But warnings are often ignored by doctors who serve nursing homes and are not usually available, or by short-handed nurses and poorly paid or trained attendants who tend to too many demanding patients.
    Toby Edelman, a senior attorney for the Center told me, “Anti-psychotic drugs are used because there’s not enough staff and facilities. They know they shouldn’t use physical restraints. Using drugs inappropriately as chemical restraints is less visible, but has the same effect.”
    “The misuse of anti-psychotic medications in the treatment or control of nursing home residents is pervasive,” said the Center. “In the fourth quarter of 2009, the federal government reports that 26 percent of the nation’s 1.4 million nursing home residents –354,900 people – received anti-psychotic drugs...frequently for reasons not approved by the FDA.“
    In February, 2007, Dr. David Graham, an FDA official, told a congressional committee that as many as “15,000 elderly people in nursing homes (are) dying each year from the off-label (not FDA approved) use of anti-psychotic medications for an indication that FDA knows the drug doesn’t work.”
    The drugs include Seroquel, Risperdal and Zyprexa, which replaced an older drug, Haldol. The use of these chemical restraints is not all the fault of besieged nurses and aides. Last November, Omnicare, the nation;’s largest nursing home pharmacy agreed to pay $98 million and its supplier-drug manufacture paid $14 million because of a kickback scheme involving Johnson & Johnson’s drug Risperdal. The scheme allowed Johnson & Johnson to push the sale and use of the drug.
    On March 10, Bloomberg News reported that despite the FDA warnings on the possible misuse of Risperdal, the largest selling drug of its kind, Johnson & Johnson made plans to reach $302 million in geriatric sales of the drug for this year claiming it was safe and effective. According to Bloomberg, unsealed documents in a lawsuit by Louisiana against the company disclosed “a J&J business plan...called for increasing the drug’s market share for elderly dementia sales, an unapproved use.”
    In January 2009, Eli Lilly agreed to pay fines of $1.4 billion for illegally pushing the sales and off-brand use of its anti-psychotic drug, Zyprexa. According to the U.S. Justice Department, the company promoted the use of Zyprexa by claiming it would help facilities sedate resident who would otherwise require more care.
    Nursing homes are handsomely paid by Medicaid, long term care insurance or by the resident. Numerous studies have found that residents get better care in not-for profit homes.
    With these drugs at hand, physicians are often unaware of the possible side effects on people who are not psychotic. But then, the Center notes, physicians who are supposed to supervise patients often prescribe without seeing them.
    Psychiatrists are rarely available except for the most troubled residents. Edelman said that nursing home and the long term care pharmacies rely on “chart orders” left by doctors when they are unavailable.
    “Physicians are present in nursing homes only intermittently,” Edelman said, They do not have offices, they work out of their cars.”
    The Center and other patient advocates seek federal legislation to enforce existing law requiring that a physician be on call and available when a patient requires prescription drugs.
    Nursing homes and pharmacies argue that if federal law is not amended to allow “chart orders,” residents will not get pain medications they need. But anti-psychotic drugs are not mere pain killers. They can turn an anxious or slightly depressed or forgetful patient into a zombie.
    And the easy access to painkillers can tempt staff members into overusing or even stealing them for their own use. That’s why the Drug Enforcement Agency has been involved in the effort to reduce the availability and use of these drugs on unsuspecting patients.
    Said Edelman, the Center’s concern “speaks to the dangers of indiscriminate use of pain medications and the lack of physicians to detect and respond to life-threatening problems involving their use.”
    Got a friend or loved one in a nursing home? If he or she is asleep most of the time or non-responsive, demand to know the drug that’s been used and question why. If there is no satisfactory answer, complain to the home’s ombudsman or contact the Center for Medicare Advocacy .
    Or write to saulfriedman@comcast.net
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    Oh my god. Thank you for this information. I don't think they would have been very forthcoming with this if I'd asked the DON for a sit-down talk with her about it. The truth is that this is a long-established and very well respected LTC facility and I believe that for the most part every one of the residents is well taken care of. Even Ms. S is actually treated very gently and kindly, and it seems that they try and try and try other measures to get her to calm down and be engaged in music or a cute video movie or whatever before they bring out the big guns. The trouble is, because of how difficult it is to just contain her it's taking more and more of the aides' time to just deal with her, meanwhile the other residents are sitting around bored and not being engaged in activities, which we are required to provide for them because the other aide on staff is busy just toileting and taking care of the resident's physical needs. It appears to me that they just need to staff an aide who does nothing but take care of this one resident for 2-3 hours per shift so that the other aides can really attend to the other residents. That way we can have a quiet enjoyable atmosphere and not the usual chaos, we can do more involving activities, and the other 'alarming' little lady who also won't stay in one spot for very long can get taken care of better.

    For the past few days there's been a representative from the corporate headquarters inspecting the facility and gathering notes, perhaps she can advocate for a better situation for Ms. S. She has a special heart for the people in our Unit. When she showed up a few days ago it was during one of the most chaotic shifts I've ever experienced. Because of Ms. S, we only had 5 of the 12 residents up for breakfast, and a couple of them had to wait until after lunch before we could even get them out of bed. I only hope that they don't try to keep it from this representative how much we really need a change in the way we deal with Ms. S because her need for total and continual care is starting to effect the quality of care for the other residents as well as the safety of the little lady who keeps setting off her RN sensors. Ms. S never has family or friends visit and I don't know if there's even anyone advocating for the way she's being taken care of. Perhaps she's just been abandoned there because of how difficult she is to deal with, I don't know for sure. All I know is I've not once seen a family member come visit her.

    Probably the reason for the corporate representative visit here is because the State is preparing to inspect and apparently this LTC does a whoooooooole lot of 'cleaning up' and ship-shaping everything to appear that we're doing a top-notch job of taking care of everyone. I'm told that they even put extra staff on every shift so there's less chaos. This will be my first go-around with a State inspection so it's going to be quite a learning experience I bet.

    Thank you for taking the time to post this great information. I have some thinking to do. :uhoh21:
    rdsxfnrn likes this.
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    Those situations are so hard. In truth, residents like that need 1 on 1 supervision during the waking hours, but because of the cost of paying an extra employee for that time, most places just don't do it.

    We have had a few residents (mine is not a geriatric facility, rather it's developmentally disabled kids and young adults) that, after several issues, were required by the state to have 1 on 1 care. Not only were these residents requiring most of their aides' time, but they were also becoming combative with other residents and staff. Our facility eventually found a more fitting facility for those residents because of the cost of paying an extra aide 24/7.

    I hope your facility finds a solution, too. It's just not fair to the other residents to go without care because facilities are keeping residents who require more acute care in units that don't have the staffing for it.

    One big thing: I urge you, if the state surveyor talks to you and asks you any questions, to convey your concerns about this resident. You don't have to worry about your facility getting angry with you for it, because it is kept anonymous, but it will let the state surveyor know that they need to keep an eye on that situation.
    Sally Lou likes this.
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    When I've had a resident like that I put them in a wheelchair with a chair alarm and let them follow me around all night. I park them outside the door when doing care on someone else so I'm right there if they stand up.
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    I'm too lazy to go back and read your posts again, but is this a restraint-free facility? (speaking more about physical, rather than chemical ones)

    A Lap Buddy may be appropriate for her. It's a cushion that connects to the WC over their lap to prevent them from standing up. They work great, if your facility is one that uses them. Low-to-the-ground WCs work well, too, because it is more difficult for residents to stand up from lower positions.

    Document, document, document. If you aren't allowed to add to residents' progress notes at your facility, report it to any and every nurse that will listen to you, as many times as it takes. If they can get enough examples of this obtrusive behavior, the physician may be able to order a psych consult or play around with her medications so that she will be more calm but not asleep all the time.
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    Quote from CoffeemateCNA
    I'm too lazy to go back and read your posts again, but is this a restraint-free facility? (speaking more about physical, rather than chemical ones)

    A Lap Buddy may be appropriate for her. It's a cushion that connects to the WC over their lap to prevent them from standing up. They work great, if your facility is one that uses them. Low-to-the-ground WCs work well, too, because it is more difficult for residents to stand up from lower positions.
    Never mind this. I did go back and read and it is a restraint-free facility. Just document, document, document as mentioned.
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    Quote from fuzzywuzzy
    When I've had a resident like that I put them in a wheelchair with a chair alarm and let them follow me around all night. I park them outside the door when doing care on someone else so I'm right there if they stand up.
    That would be fine except we're not allowed to put an alarm on her unless it's in her care plan. They'd come down on me like a ton of bricks if I put an alarm on her just for my own convenience. She does have an alarm on her bed at night but otherwise we're not allowed. She's ambulatory and doesn't need a wheelchair or even a walker, and if you tried to put her in one you'd have the same problem.....turn your back for a moment and she'd be up and out of it. If I'm toileting a resident who needs extensive assistance, I simply cannot leave them in the bathroom while I go out the door to take care of Ms. S if her alarm went off. I could end up with 2 people under my care falling and there'd be hell to pay -- including me getting fired. There is no easy solution to this problem. Oh wait.....I mean there's no --cost effective-- solution to this problem. What this little lady needs is 1:1 supervision when she's awake and because her care already costs a fortune they're not about to staff another aide just for her. We're stuck with this impossible situation.
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    Quote from CoffeemateCNA
    I'm too lazy to go back and read your posts again, but is this a restraint-free facility? (speaking more about physical, rather than chemical ones)

    A Lap Buddy may be appropriate for her. It's a cushion that connects to the WC over their lap to prevent them from standing up. They work great, if your facility is one that uses them. Low-to-the-ground WCs work well, too, because it is more difficult for residents to stand up from lower positions.

    Document, document, document. If you aren't allowed to add to residents' progress notes at your facility, report it to any and every nurse that will listen to you, as many times as it takes. If they can get enough examples of this obtrusive behavior, the physician may be able to order a psych consult or play around with her medications so that she will be more calm but not asleep all the time.
    Yes, this facility is restraint-free, even to the point of considering not allowing 'tabs' alarms....those are the alarms that attach to a person's clothing or sleepwear that make a really wicked sound when the pin is pulled out because they tried to stand up or get out of their bed or wheelchair. So far they have not removed the tabs alarms from the residents because they know we'd have a higher incidence of falls. Ms. S also does not need a wheelchair, and we can't even try to use one unless the nurse does an assessment that proves she can't walk at all -- that is not about to happen. I've asked if it's possible to put her in a really low chair or even a nice casual bean bag chair because she's not able to get up from a low position. I was flatly told No -- that would restrict her movement and is considered a restraint...so NO. All my documentation is limited to tapping entries in a hand-held computer, I never get to write anything unless it's something that needs to be red-alerted. Red-alerts are for the residents' safety and well-being, not for us to effect changes that would make our working conditions better.

    The only thing us Unit aides can do is to hit that panic button a few times every shift when things get really out of hand. The nurses will get so sick and tired of having to intervene every hour on the hour, perhaps they'll try to do something to change this situation. That's something we haven't tried yet.....so that's what my next plan of action is. Sometimes I feel like I'm banging my head against a wall.:smackingf
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    Oh...and one more thing....I don't know what is going on with her medications, but they keep switching her around -- dropping this one and adding that one. Apparently some of the psycho-tropic meds she's been on have had some bad side effects so they've stopped using some of the ones she was previously on that kept her more calm and relaxed. Some of the ones that used to work on her don't work as well. Occasionally a prn med will wear off within a couple of hours and then it's back to the same behavior that throws everything into chaos again. All I can really do is tolerate this crap and just do the best I can.


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