Targeted by psychotic, manipulative patient

[HM7380]

I work in a LTC/Rehab facility. There is a patient there who does NOT belong (she is 65 and has absolutely nothing physically wrong with her). However, she is homeless, and because of the money grubbing higher ups, they won't discharge her. She is psychologically disturbed (though not diagnosed as such), and has targeted myself and one of my CNAs. She was able to have the CNA suspended pending an investigation due to a complete BS allegation of abuse, and she said shes coming for my job next. (She also stated to me that she knew what to say and what to do, to have me fired and my license taken.) On Sunday, she spit in my face, and trapped me in a bathroom and tried to punch me... Shes one of my patients, so I can't keep COMPLETELY away from her, though I do have another nurse take her her medication, etc. The patient hovers at her door and waits until I come down the hall, then jumps out in front of me and begins verbally abusing me, screaming, and threatening me. I really am at a loss as to what to do. I've made reports. I've filed grievences. I've had all the staff who witness her terrifying behavior write statements...

My question is... is there anything else I can do? I'm sure if it wasn't me she was targeting, it would be someone else, but to let this nutcase spit in my face and take a swing at my head is absurd. How would you handle it? It's getting to the point where I'm afraid to go to work. She really DOES know how to work the system and get the staff in trouble. She comes up with stories to try and pit the staff against each other, and because until shes targeted YOU, she seems like a somewhat off, but mostly together 65 year old woman.

This is the second time shes been at my facility... The first time they kicked her out for assaulting another resident. However, I'm sure they won't do anything if she assaults a nurse (I've been assaulted by another patient, and they told me that if I couldn't handle being attacked, to hit the door.)

Any suggestions as to what I can do?????? I've got to find a way to get this lady out of my facility before she attacks me or another resident again!!!!

[NurseLatteDNP, MSN, DNP, RN]

I would file charges and also start looking for another job.

[Batman25]

If she assaults you again go right to the phone and call the police. If your employer is telling you assault is part of the job you need to look for a new one. They are nuts.

In the interim, DO NOT go into this patient's room alone. Take a witness each and every time. All of you should be doing that. If it can arranged you don't care for them all the better. I'd be pushing for that with management. Keep a log for yourself and make sure Risk Management gets a copy of every grievance you file. Definitely make the doctor aware a psych evaluation gets done ASAP.

[carolmaccas66, BSN, RN]

I totally agree with Bella's "Document, Document, Document" but would like to add, keep a copy for your records.

I will tell you this however, if you were my employee and you came to me with this, THE VERY FIRST TIME I would have confronted her with the consequences (in front of the Executive Director) which would start with the police being called and her being discharged. Do what you can to me but DO NOT mess with my people.

Excellent and very well said. No-one would assult staff under my care as Charge Nurse either, and she should be d/c even though she is homeless. It's got to the point where 'it's OK to assult the nurse cos I'm mentally ill/homeless/confused (insert excuse here)'. We need to drum it through the publics heads NO IT IS NOT OK UNDER ANY CIRCUMSTANCES!

In Aust public hospitals now we have big signs saying ZERO ABUSE TOLERATED (in any shape or form). POLICE WILL BE CALLED AND YOU WILL BE PROSECUTED, then kicked out.

I love that sign cos I can always refer to it, and tell the pscyhotic patients who's Mummy says 'he doesn't know he's hitting people over the head or whacking their shins' - too bad, we don't care, it is still zero abuse regardless of what YOU think your child's diagnosis is. And I usually add by the way, until you have been partially strangled and punched fully in the side of the head like I have, you REALLY HAVE NO IDEA what you are talking about. It's VERY SCARY, to say the least.

[RxOnly]

I live in MA, and I don't know if it's just MA or the whole country- but here it is absolutely ILLEGAL to spit on someone. I can't believe what your employer told you... that is just insane. Taking physical and/or mental abuse should never be part of your job description.

I agree with everyone else in regards to documentation (which you seem to be doing a good job at, especially having witnesses write reports). Keep copies for yourself- make sure those incident reports you send to management don't go "missing" ...Don't be afraid to call the cops if she gets so out of control she can't be de-escalated. In the meantime, I'd definitely start the job hunt... I know it's easier said than done these days, but you need to work in a place where management actually cares about you.

So sorry to hear this and best of luck to you! Keep us updated!

p.s. Maybe a little anonymous tip to your state BON may spark an investigation?? Just a thought.

[JenniferSews]

If she assaults you again go right to the phone and call the police. If your employer is telling you assault is part of the job you need to look for a new one. They are nuts.

In the interim, DO NOT go into this patient's room alone. Take a witness each and every time. All of you should be doing that. If it can arranged you don't care for them all the better. I'd be pushing for that with management. Keep a log for yourself and make sure Risk Management gets a copy of every grievance you file. Definitely make the doctor aware a psych evaluation gets done ASAP.

I agree. One witness not enough? Demand that the charge/manager/ADON/DON/Administrator be there to watch every interaction. Then I really would call the police. We have done it before at my facility. The patient may present as AO3 and completely innocent, but the police aren't stupid. If the person has a prior history they can see it and treat the incident appropriately. If you don't establish a pattern then this person will likely continue the same behavior in your facility and then the next.

[Guest717236]

In the absence of a psychiatric diagnosis, you sure can not treat

a character disorder with medications or behavior modification.

Next step, call the police. You may want to let them know that

there is a client who escalates and next time they do you will call them.

Giving them a heads up , will help them to expect the call.

Her insight is nill, as she does not appreciate the fact she has a

safe place to live.

That said, she should be charged for assault and be held accountable

and dismissed from your LTC.

[Mike A. Fungin RN]

File assault charges against her for spitting in your face and let the court sort it out. Period.

[sarmedic70]

Yes, most definitely document everything in addition to having your staff document......this is a hard situation to say the least in that you are at a disadvantage with regardless to skills set in dealing with a possible psychiatric dx. I am utterly apalled as to the alleged lack of response from those above you with regards to dealing with assaultive patients. If the training and skills set are not provided to the staff then it is shame on them and THEY should be hitting the door. It is hard to say what is truly going on with this patient as to why she is being this way. There are a number of possibilities and she should be seen by a psychiatrist to rule out any possible psychiatric disorders. In the meantime, the suggestions given to you of going to your RM, if you have one, or to your BON, is an immediate thing you can do.. Also, you have every right to have charges filed on this patient. We do it at our state psych facility if need be. In your case, the patient could be pinked slipped and removed from your facility. I have seen it done.in fact, before I became a psych RN, we had a LTC pt come through our ED to be transferred to another facility....a psych facility......I had to remain with this pt all night as his 1:1. So it can be done. Best of luck to you. Keep us posted as to the outcome, developments.

[srerrn2]

Lots of good advice here. If assaulted, by all means call the police and press charges. Assault also includes spitting. One word of caution. While it is VERY important to document the heck out of these situations, do NOT copy the actual charts and remove them from the facility. There can be legal and HIPPA issues with this. Rather, keep a notebook for personal use and document these incidents in this manner.

Many people have suggested you leave this facility. Personally, I would not want to work for this type of company where management does not back up its staff. That being said, I understand jobs can be difficult to find right now and/or you really enjoy your other residents and co-workers and don't want to leave. You should not be forced out because of one resident who sounds like a pretty classic case of Borderline Personality Disorder. Good Luck!!!

[CapeCodMermaid, RN]

First off....the managers aren't getting rich on people like this. The money grubbing (paraphrasing) don't make money on a homeless Medicaid resident. The BON will not intervene against a resident...and why do you all think to call and make a tip anonymously...jeez...The police won't always intervene...they'll tell you it's not their problem. While spitting on someone is thoroughly disgusting and shouldn't be allowed, I'm not sure it's against the law in Massachusetts. Hate speech, is, however, taken very seriously in this state.

I don't allow my staff to be hit by anyone. If the residents are assaulting the staff it's usually a trip to a psych facility or an increase in their medication. We've developed good relationships with the psych hospitals and 99.9% of the time take the patient back when they are 'fixed'.

You can always contact your local ombudsman and let him/her know what's going on. I talk to the ombudsman frequently and always let him know about the troublesome residents.

[Pappilli0n]

I don't know about you, but I always felt the "getting to work" part of my day was the toughest. BUT, knowing

you have this particular patient to look forward to must be really difficult.....to the point of tears, I would guess.

My first "legal" advice (and it's nothing new to all of us) is to DOC-U-MENT every incident and negative encounter

with this patient. he higher ups will say, "no one can be THAT bad ALL the time, so inlcude some positive times as well in order to draw up some STATistical "proofs" of her behavior. The ratio should be an overwhelming 10 to

one!

Second, refuse to take that particular patient. Third, be prepared to be called up by your Manager about why you did not want to be the nurse for that particular patient. Emphasize the importance of maintaining a safe AND

healthy environment for the patient (always 1st) and you along with the entire staff. Physical encounters should

not be tolerated and should give you "cause" if your request goes unheeded.

And lastly, but totally not the least of importance......try positive approaches to the patient. IF she sees you as

an easy target, you're doomed. IF she sees you as a happy and involved care taker, she will have no place to

embed her negativity. This will help your sanity, if not hers. GOOD LUCK.

Just thought of another route.....The Case Manager for your patient as

well as Quality Control. Money is the name of their game. This patient

is costing the hospital money and could eventually cause a law suit for

physical violence to staff or environmnet!!

[Scarlette Wings]

your employers have a responsibility to provide a safe non-hostile work environment and it is a legal issue. i would either press charges against the patient with the police department, record her if possible, or be ready to call eeoc and osha and everyone else if need be if the chain of command does not work for you. document every episode, witnesses, and each time you report it up the chain of command. good luck.