Dilemma today regarding an undesirable patient

grandee3 · Nov 2, 2006

Sounds more like drug addiction. Does he harm himself in any way to be admitted to the hospital? Or, does he get admitted because he can get injections? I am sure he's had a psych eval.

I work in at an ALTAC and we have many freq flyers.Some of them are obnixious, they play one nurse against the other. They abuse us verbally. Yet, they keep on getting admitted. LTAC is an option and there are a few hospitals in the area but the company does not want to loose the business so we have to put up with them.

I work in Slidell, La which is right outside New Orleans so we are really getting bombarded with revolving door people. Lots of Psych around here now but no Psych units, no beds.

Do you think we will ever have a leg to stand on with these kind of patients? Administration always believes their side of the story. This is the only thing I dislike about my job. I'm afraid one day a staff member is going to get hurt or something by one of these pt's. I've seen veins popping out of their head when we have to tell them the Dr either changed or D/C'ed their pain med.

medsurgnurse, RN · Nov 2, 2006

I would always enter the room with two staff members. The second staff member can "assist" in the procedure, set the IV pump, set up the supplies etc. Of course, document every behavior that the person does like exposing himself. Having a male staff is better with the type of behavior you are describing but if not available bring in multiple staff. The person is less likely to engage in inappropriate behavior in front of mulitple staff. I've had pts behave badly (not the same as you said) and this has worked. The patient never really caught on. I was "teaching" the other staff or they were "asssisting" me. and pysch consult wouldn't hurt.

TazziRN, RN · Nov 2, 2006

I would always enter the room with two staff members. The second staff member can "assist" in the procedure, set the IV pump, set up the supplies etc. Of course, document every behavior that the person does like exposing himself. Having a male staff is better with the type of behavior you are describing but if not available bring in multiple staff. The person is less likely to engage in inappropriate behavior in front of mulitple staff. I've had pts behave badly (not the same as you said) and this has worked. The patient never really caught on. I was "teaching" the other staff or they were "asssisting" me. and pysch consult wouldn't hurt.

We don't have psych. We are a very rural, isolated hospital. And our ER is two RNs per shift.

TazziRN, RN · Nov 2, 2006

He is on some heavy pain meds at home and only comes in for breakthrough pain, but that's not the issue. He does sometimes cause himself harm to be admitted, like creating abcesses, but again, that's not the issue. The issue is that no one wants to take care of him because of his inappropriate behavior.

rn/writer, RN · Nov 2, 2006

We have a frequent flyer that many of us think has undiagnosed Munchausen's. He came in tonight with pain and had injections ordered. He has, in the past, attempted to kiss me, so I refused to medicate him. My coworker refused because he's also exposed himself to many of our staff. We called the house supe, who called the clinic next door (owned by the hospital) and had a male MA come over and medicate him for us. We are at a total loss about this patient; like any other patient he deserves care but because of his history most of us are not comfortable doing anything to him that requires very close.
Thoughts? Opinions? Don't bash us, please. He causes a lot of stress every time he comes in.

He shouldn't get away with behavior that would be considered assault outside the hospital. My guess is that right now, he does it because he can. That is, thus far there really haven't been any negative consequences for him, and he gets a payoff from the shock and discomfort he generates. Why should he stop when his bad choices don't cost him anything?

I would have the relevant departments confer and come up with a plan for future visits. Present a united front, and tell him upon admission that any out-of-line behavior will be treated as it would be in any other public setting. Tell him very specifically that if he touches staff inappropriately, makes off-color remarks, exposes himself, or engages in any other improper behavior, you will treat him and and turn him over to the police. Then follow through on this.

You can't deny him necessary treatment, but you don't have to tolerate abuse just because you are in a hospital. The thing is you all need to stick together and follow through with pressing charges. Sqeamishness will only communicate to him that he can use his illnesses to harrass others. Not a good message.

If you have trouble sticking to your guns, think about him committing the same acts in a mall or a school or a park. Hospitals should not be safe havens for illegal behavior and you and your coworkers shouldn't have to tolerate his abuse.

BTW, has he had a psych consult? If not, he certainly needs one.

Trauma Columnist · Nov 2, 2006

Hi Tazzi - I would have two staff members enter the room at all times. If he is not undressed, the door would stay open too. Do you have security? If not, what about the police standing by or just "dropping by?"

TazziRN, RN · Nov 2, 2006

I did not think about talking to the bosses about this. I'll do that today.

Side note: in our area there is no answering service, the switchboard and ER are it. Yesterday evening, before I left, I found out that he called the switchboard wanting his PMD paged, to complain about the MA's injection technique. We couldn't help it, someone said "Complain about his technique, or complain that it was a man?"

mamason · Nov 2, 2006

lIf the pt is mentally unstable, then, he/she needs to be treated as such. Security or police, as others have suggested, should nip his/her behavior in the butt. Also, having another staff member witness interaction with this particular pt would be a good thing too, particularly a male staff member. Sounds like this guy gets his kicks off intimidating female staff members. That's extremely inappropriate and it should not be tolerated by anyone. Limits need to be set and what appropriate actions will be taken if pt breaks boundaries need to be discussed with the pt before treatment.Make sure all staff follows through with the consequences. Document. Unfortunatley, this pt's antics are probably taking away much needed time with other pts that truly need your help. How frustrating it must be for you and other staff members.

Antikigirl, ASN, RN · Nov 2, 2006

I would certainly be talking to management and security about this person. And someone missed the ball on checking out the underlying probelms causing the behavior. I would certainly have a discharge planner and MD get together for a little psych stay for evaluation where ever one is. Letting the behavior go is dangerous and not helpful for the patient at all. (what if he is to get carried away and exposes himself to a child? That would be traumatic and life long for that child and him...or what if he hurts himself beyond what he is doing now next time??? Or kisses the wrong person and gets the tar beat out of him?).

Also, while the subject was brought up...did you talk to the MA about his technique with the injection? I find it is helpful if someone talks to others about the reasons they do what they do, and help to educate first..then if it occurs again then write them up. The reason I say this is because as of the last few nights, I have a nurse that comes noc shift (I am swing) and I guess she likes to write folks up for everything! I guess I messed up on a IV pump and didn't hit the secondary piggyback hard enough so the pts normal saline went in a bit too fast. Instead of talking to me (and this isn't her first complaint against me) and saying "hey this is what happened, be careful"...she wrote me up. Okay fine, but I think instead of writing me up and getting me flustered and at this point ticked off...she could have come and spoke to me (even if written up, she can still talk to me, I respond better to conversation than a piece of paper I am stressed about being in my perm record!). I would have gladly started up a convo about how to avoid it in the future and other ways to stop that from happening (she knows I am a proactive person that takes constructive critism very well).

Needless to say...last night I was tired and although I took the critism well...I came home madder than a bee in a shook up hive! All I could think about is "why didn't she come and talk to me?"...which took me time to get over my anger and be proactive (which is actually slow to come this time..but I will get there!). So just a little story to shed light on the subject.

TazziRN, RN · Nov 3, 2006

I talked with my manager today, and she liked the suggestion about coming up with a game plan for all of us to follow. She backed me up about last night, along with my teammate, and she is going to talk with the other managers, social services, risk management, and the PMD to try and get something done. I told her that if it was anything overt, I would have no problem telling him to knock it off, but it's subtle enough that if I were to confront him he could very easily claim to have just been shifting position in bed, etc. It was a relief to hear her say that we have her support, and that she's going to try and help find a workable solution.

timdmb · Nov 3, 2006

press charges?