Where Do Residents Rights End? Long, Sorry.

Long Term Care Columnist / Guide · Feb 24, 2005

Residents and administrators such as the ones you're dealing with are the reason I got out of assisted living. They are a liability to your license, and yours will be the first head on the chopping block when the CMS surveyors come in to inspect your facility and find this totally inappropriate resident living in his own filth.

Believe me, you can't win in this situation, because you're caught in the middle between the resident (and/or his family) who wants to "age in place", the other staff who can't or won't handle him, and the corporate bigwigs who only care about the money his extra care needs will bring in. I've seen this happen time and time again........the family doesn't want to move the resident to a higher level of care, the administration refuses to fight them on it even though they've been told the resident is no longer appropriate for ALF, and the staff is left to continue dealing with an impossible situation, while the nurse---who probably isn't even in the facility more than 20 hours a week---is stuck with the liability.

If you are going to remain employed there, I recommend that you document EVERYTHING that goes on and what you tried to do about it in the resident's chart, plus keep a notebook of your own with the dates, times, and content of discussions with family, residents, staff, and administration. I'd also get your local Senior Services division involved.....sometimes they can get someone moved out when all else fails. (One caveat: your employer will probably find some bogus reason to cut back your hours or eliminate your position, so be prepared to shine up your resume!)

Sorry I don't have any real words of wisdom for you........but you have my sympathies. I've been there, done that, got the crappy baseball cap to show for it. :stone

NurseFirst · Feb 24, 2005

If you couldn't use the waterless cleaner, and tell him you are giving him a massage?

NurseFirst

I've got issues at work. I work in an Assisted Living facility, in a secure Alzheimers/Demetia unit. One particular resident refuses to bathe. He's not oriented to time, or place. He stinks, none of the other residents want anything to do with him. He hoards his Poise pads, can't find them, so he stuffs toilet paper(and i mean half a roll to a full roll) into his underwear. Is this not great breeding grounds for a UTI? This man has had UTI's every month for the last three months straight, and off and on for the past year. I've tried everything I know to get him in the shower. His family members have tried talking him into it over the phone, as they live out of state. I've tried bribing him with his favorite snacks, catching him while he's already in the bathroom. I even went as far as reasoning with him, but he's already beyond the reasoning stage of Alzheimer's. So, the other night, it was his shower night. It had been one week and three days since he had had a shower. He stunk of urine and filth. His hair was so full of grease that it was matted to his head. His teeth had some severe plaque build up. He has almost a full beard from not shaving. His pants were on backwards and had not been changed since he had had his last shower. So, I tried everything I knew to get him in the shower. He still refused. So I made him get in. I forced him. He screamed and yelled and bellowed the whole time. Even took the shower head off and beat the aide with it. This guy has nothing to give as far as Ativan, Haldol, etc. I've been a nurse for a whopping two years now. I felt absolutely horrible by doing this to this man. I called my administrator, she said, it was OK, but since we are assisted living she was going to call the corporation and see what else could be done. I told her the other shifts are afraid of him, so they won't touch him. They won't clean his room because it stinks and he gets mad. They basically neglect him. He hoards things, his room needs to be checked everyday. I'm the only one that goes into his room and removes TRASHBAGS FULL of shredded newspapers, napkins, and toilet paper.
Well, I go into work today and find the nastiest note haning for all to see about how first shift does not neglect anyone. It also stated that they do give him showers and they do clean his room everyday, etc etc. So why am I being corrected? Did I do the wrong thing? Should I have just let him go for another week until he decided it was time to get into the shower?

barefootlady, ADN, RN · Feb 24, 2005

I agree this patient no longer fits into the assisted living environment. I agree that the administration knows he is beyond the capabilities of the staff/unit to deal with. Now, that said, was any of these baths, clothing changes, daily pericare and other aspects of care charted? If there is no charting then it was not done. If there is false charting, then start your own system and keep it faithfully, chart his appearance, chart his conduct, chart the condition of room. After 2 weeks and things are still the same, go to the DON or Administrator and tell them you have concerns and feel like you are being singled out because you feel this patient is not getting adequate care and you are the only one recording it. Might work, might get you fired but it is the right thing to do. The waterless bath is a good idea along with waterless shampoo for so long a period of time, but it is even recommended by these products that a bath/shower be given to promote skin care and prevent problems.

CoffeeRTC, BSN, RN · Feb 24, 2005

Alright, we talked about rights and legalities alittle,but what are some interventions to clean this man...I'd love to hear from some with experiences in getting agitated residents to bathe/ clean. What works? Like I said before, we did a "swimming" session and even had an aid go "stand in the rain" (shower) with a resident, but give some more examples...

NurseyBaby'05, BSN, RN · Feb 24, 2005

What about a psych consult? One of the 302 criteria is failure to complete ADL's. This is a form of self-harm. Long-term psych placement would not be good for this part. resident, but with a short stay, at least he could be evaluated for pharmacological and behavioral interventions and it they have a positive effect on his behavior. Our psych facility in Pittsburgh has a special unit for geriatric psych patients. If a psych facility establishes a pattern with him not being able to care for himself, then it may force the issue with his fam and be the back-up your facility needs to get him into LTC.

Cheez-It! · Feb 24, 2005

It's funny that someone said something about my hours getting cut. I went to a normal full time position of 32 hours down to 30 and once again i'm down to 28 hours a wk. Wonder what I did? :chuckle

I document faithfully everything I do. I call every family member I can when any situation arise, even something stupid as PT not coming in for a resident. This resident's daughter is fully aware of the situation. She has tried to talk him into getting into the shower. She also knows that he's no longer appropriate for AL. She has also mentined taking him home to her state for more appropriate care. She knows it's time.

It truly amazes me how horrible the AL facilities are. I personally believe they should be done away with. I took this job in the hopes that I could do "real" care. I hoped that I could sit with my residents and enjoy a cup of coffee with them, do a crossword puzzle, converse about the "old days," paint their nails or whatever they wanted to do. when I first started working there two years ago, I got to do this. It wasn't out of the ordinary for the aides to have nothing to do, so they spent time with the residents. I got to spend real, quality time, with these people.

And now ... the corporation has decided to "flag" our facility. Meaning we're not bringing in the moolah. Their respons was to cut hours, mine and the aides, cut the food budget down, and overtime is allowed what so ever. If you have it, there better be a d*mn good reason, such as someone's dead or the building's on fire. I've had four residents die within hospice care, I've had residents with restraints, residents that can't stand without 2x assist, more fx'd hips and falls in this facility than any other two facilities combined ... Where does it end? They just don't care. They just seem to make exceptions for the ones they know that have the money and are willing to pay. Screw patient care and safety. I'm supposed to be super nurse, able to catch a falling resident in a single leap and bound, when the truth is, they shouldn't even be there. The real truth is, on some days, I don't even have time to look at some residents. I have to shove pills down their throats and run to the next. :angryfire

I just recently had a resident fall and break her hip. She could hardly stand with x1 assist before the fx, and now they're talking about her plan of care when she comes back. (she's hopspice too) There's no way this woman will be able to qualify for assisted living, but because the family has money falling out of their ears, and because the family insists she doesn't go to LTC, she'll come back! Not to mention, their last name is known extremely well in this small town. And we, the poor staff, are going to have to deal with her. I've actually pulled this woman around behind my med cart (W/C) so I would know where she was and to make sure she wasn't trying to stand on her own. I've also put her in the nurses station with me, for hours at a time. Are they nuts or just plain dumb?

AL was a good idea at the time, but the laws are so vague. I've actually started having panic attacks, and had to be treated for anxiety. This whole "situation" has totally turned me against nursing. I finally had enough and decided to go to back to school to get a bachelors in Technical Management, specifically for Computer Information Systems. I hope I can take my medical knowledge and combine it with my new computer knowledge and begin a new career. I just hope to get my degree, start anew, and then contact everyone I can and have this facility audited as much as I can. I'm going to do something about it, as much as I can without being fired. It's bull. Everyone says the residents in LTC have little care, try an AL facility.

PamUK · Feb 24, 2005

I would like to repsond to the original posting

I'm not sure of the laws in the States, but doubt they are much different to the UK. If someone is not competent to consent to any kind of care and does not cooperate with you, you can only do what is necessary, in their "best interests". Clearly, toilet rolls stuffed down his pants that cause UTI's, must be removed. If he refuses to bath, he is not going to becaome seriously ill becasue of it... its unpleasant for those around him. All you can do is employ all your poweres of persuasion and or try other alternatives as others have suggested. I'm not sure there is anything else you can do. You are not going to get 10 nurses (as someone else suggested - not maliciously I might add) and force him into the shower are you? Let him remain unclean... the other residents might object so much that they start to leave, then the administration will have to do something!

Do you think that, even though he has alzhemiers (spelling dodgy) he still has the ability to know what's going on and play "games" with you all? Once you back off nagging him, it stops becoming a "game" and he will eventually comply of his own accord. It may not be to your standards, but who's judging? Its a thought anyway.

As far as the room not being cleaned regulary, that is unacceptable. Whoever is responsible for cleaning his room each day needs their orifices kicking.

Hope you are documenting everything. What you do (or dont do) or say to him, what his response was including body language. Document any conversations you have with his family, the administration and what the response is

Could you make contact with a long term facility and see what they would do in this situation?

dbsn00 · Feb 24, 2005

It's funny that someone said something about my hours getting cut. I went to a normal full time position of 32 hours down to 30 and once again i'm down to 28 hours a wk. Wonder what I did? :chuckle
I document faithfully everything I do. I call every family member I can when any situation arise, even something stupid as PT not coming in for a resident. This resident's daughter is fully aware of the situation. She has tried to talk him into getting into the shower. She also knows that he's no longer appropriate for AL. She has also mentined taking him home to her state for more appropriate care. She knows it's time.
It truly amazes me how horrible the AL facilities are. I personally believe they should be done away with. I took this job in the hopes that I could do "real" care. I hoped that I could sit with my residents and enjoy a cup of coffee with them, do a crossword puzzle, converse about the "old days," paint their nails or whatever they wanted to do. when I first started working there two years ago, I got to do this. It wasn't out of the ordinary for the aides to have nothing to do, so they spent time with the residents. I got to spend real, quality time, with these people.
And now ... the corporation has decided to "flag" our facility. Meaning we're not bringing in the moolah. Their respons was to cut hours, mine and the aides, cut the food budget down, and overtime is allowed what so ever. If you have it, there better be a d*mn good reason, such as someone's dead or the building's on fire. I've had four residents die within hospice care, I've had residents with restraints, residents that can't stand without 2x assist, more fx'd hips and falls in this facility than any other two facilities combined ... Where does it end? They just don't care. They just seem to make exceptions for the ones they know that have the money and are willing to pay. Screw patient care and safety. I'm supposed to be super nurse, able to catch a falling resident in a single leap and bound, when the truth is, they shouldn't even be there. The real truth is, on some days, I don't even have time to look at some residents. I have to shove pills down their throats and run to the next. :angryfire
I just recently had a resident fall and break her hip. She could hardly stand with x1 assist before the fx, and now they're talking about her plan of care when she comes back. (she's hopspice too) There's no way this woman will be able to qualify for assisted living, but because the family has money falling out of their ears, and because the family insists she doesn't go to LTC, she'll come back! Not to mention, their last name is known extremely well in this small town. And we, the poor staff, are going to have to deal with her. I've actually pulled this woman around behind my med cart (W/C) so I would know where she was and to make sure she wasn't trying to stand on her own. I've also put her in the nurses station with me, for hours at a time. Are they nuts or just plain dumb?
AL was a good idea at the time, but the laws are so vague. I've actually started having panic attacks, and had to be treated for anxiety. This whole "situation" has totally turned me against nursing. I finally had enough and decided to go to back to school to get a bachelors in Technical Management, specifically for Computer Information Systems. I hope I can take my medical knowledge and combine it with my new computer knowledge and begin a new career. I just hope to get my degree, start anew, and then contact everyone I can and have this facility audited as much as I can. I'm going to do something about it, as much as I can without being fired. It's bull. Everyone says the residents in LTC have little care, try an AL facility.

:uhoh21: sounds like you should start looking for another job...your facility is taking people who don't meet AL criteria & with the $$$ rolling in it's probably gonna get worse :eek: If you're having panic attacks it's time to go! But PLEASE reconsider not continuing with nursing because you sound like you've got what it takes but are at the wrong place of employment. I work in LTC & it can be SO depressing at times :crying2: - no matter how much you do for someone sometimes it just not enough...but when you do reach someone & truly comfort them it's great!! Also, perhaps geriatrics is not for you. There are so many specialties out there, why not try something new? It would be a shame to lose another good nurse to burnout

Cheez-It! · Feb 25, 2005

Do you think that, even though he has alzhemiers (spelling dodgy) he still has the ability to know what's going on and play "games" with you all? Once you back off nagging him, it stops becoming a "game" and he will eventually comply of his own accord. It may not be to your standards, but who's judging? Its a thought anyway.

He DOES play games. He will tell you he's not "going to do it, just becuase I want him too." If you leave him to do it on his own, it doesn't get done.

If he refuses to bath, he is not going to becaome seriously ill becasue of it... its unpleasant for those around him. All you can do is employ all your poweres of persuasion and or try other alternatives as others have suggested. I'm not sure there is anything else you can do. You are not going to get 10 nurses (as someone else suggested - not maliciously I might add) and force him into the shower are you? Let him remain unclean... the other residents might object so much that they start to leave, then the administration will have to do something!

As far as the other residents, the already run when they see him coming. At meals he sits alone. Everyone refuses to sit with him. He has no "friends" in the facility like most residents do. I'm at a loss. I have no idea what to do with him. I have spoke to the administration and all they say is, "Teamwork." It takes teamwork." What does that have to do with anything? They're missing the whole point. What it comes down to is he's neglected. If my shift can't get him done D/T behavior, the next shift will try. As soon as he raises his voice, they leave, write in the book refuse, and that's it. He's an issue, liabilitly, and I just plain do not want him in the facility anymore.

As far as becoming seriously ill, I doubt that also. But what about skin health, and his UTI's? I just recieved yet another order last night to do another UA. This makes the third UTI in the past 3 months. The man won't get up out of bed but for, on an average, I would venture to say five to six hours a day. The rest of the time he lays in bed. I see ulcers in someone's future .......

UM Review RN, ASN, RN · Feb 25, 2005

Definitely sounds like a psych issue. Can you get him a psych consult?

LauraF, RN, ASN, CNA, LPN, RN · Feb 25, 2005

Maybe someone is thinking that he is acting out like this because of a UTI. Has he ever had a follow up UA to confirm clearing of the bacteria? Just a thought. Otherwise I agree with Nurse Ratched that he has gone beyond the scope of Assisted Living. Is there a social worker at your facility? She surely would notice and be able to deal with this. What about the residents that complain about him, maybe give them admin's phone number. If they threaten to leave loss of more money. Good luck. It is very tough.

DidiRN · Feb 26, 2005

Not bathing a patient properly would be considered neglect in this country and would have very serious repercussions. Not only lawsuits but the facility could get in a heap of trouble too.

This thread really concerns me...I have a mother with dementia who has deteriorated to a degree that she is just about ready to be placed, and a few months back or so I had posted a question about how does a dementia assisted living work. I have not worked in one, but had wondered how on earth could someone be safely watched in this condition in an assisted living environment. I could see if they were in the very early stages of it, but I kind of wondered how bad do they have to get before they are moved to a LTC. I just recently talked with a DON from an LTC who had told me she did not believe that dementia/alzheimer patients were appropriate for assisted living, period. I really can't give an opinion since I don't work in LTC or AL, but it definitely concerned me, at least for my own mother's sake.

I would like to repsond to the original posting
I'm not sure of the laws in the States, but doubt they are much different to the UK. If someone is not competent to consent to any kind of care and does not cooperate with you, you can only do what is necessary, in their "best interests". Clearly, toilet rolls stuffed down his pants that cause UTI's, must be removed. If he refuses to bath, he is not going to becaome seriously ill becasue of it... its unpleasant for those around him. All you can do is employ all your poweres of persuasion and or try other alternatives as others have suggested. I'm not sure there is anything else you can do. You are not going to get 10 nurses (as someone else suggested - not maliciously I might add) and force him into the shower are you? Let him remain unclean... the other residents might object so much that they start to leave, then the administration will have to do something!