Dangerous patients - page 5

Just looking for some help to find written law for a situation. I work in LTC. We have a new resident who on their first day on the hall attacked one of our nurses by strangling them and telling them they were going to kill... Read More

  1. 3
    Quote from Tiffanybaybay
    Should you come to the ED because you need a pregnancy test? NO. Should you come to the ED to have you toe nails cut? NO. Should you come to the ED because you think you might have the flu and spiked a low grade fever an hour ago? NO.
    How are demented and/or delirious people strangling others comparable to patients with long toenails, possible buns in the oven, or mild fevers? Should the LTC staff just let this resident rampage until the MD shows up the next morning, or until the resident can see the MD at the next available appointment time? If only delirium were curable with clippers or dip stick, or as benign as long toenails...

    If there's a chance that someone's indigestion might be a heart attack, the patient ought to be worked up to rule that out. Likewise, if there's a chance that a LTC resident's violent behavior might be the first sign of UTI or some other medical problem, that too needs to be worked up to rule it out. It's not dumping, it's addressing the needs of patients who might be in acute medical danger. An untreated MI is dangerous for the person having the MI. An untreated infection with delirium is dangerous for the patient as well as those around him/her.

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  2. 0
    In my early days of my healthcare experience, most pts with a psychiatric crisis were transported to the ED, including combative elderly pts. We had a protocol in place to get in contact with the local psych hospitals and they were transferred to the psych hospitals. We would stabilize them in the ED, and if there were a bed available, they are a direct admit. If there was not a bed available, they were transferred to a Crisis response unit. I don't know where the OP or posters live, but do any of the posters have local psych hospitals that take involuntary or dangerous pts??? And if so, is the process for them to transfer them to a psych facility???

    Where is the process, and if not, who's taking the steps to have this conversation??? This whole ordeal of potentially violent and violent pts getting sent back and forth sounds totally unsafe, for both facilities...the pts should be going to a Crisis center or a psych hospital for a treatment plan, IMHO.
  3. 4
    TiffanyBayBay says: "It does sound like a dump. I don't want to be rude, and I don't know you or this specific case but many times we get pt's from LTC and when they get to us they are sweet as pie. They meet after waiting hours to see a psych dr, NOT AN ED MD! and they again are sweet as pie sometimes leading us to think that these LTC facilities are just trying to abuse pt (as they often are found to do) and this particular pt wouldn't let them get away with it. So then back they go."
    That is one of the most insulting things I have ever read on allnurses. We don't try to abuse patients. If we could deal with them in our facilities, we would. Y'all can strap anyone down with leather restraints and shoot them full of Haldol, but, apparently, you don't consider THAT to be abusive. Come walk a mile in my shoes before you make comments like this. Oh, wait....you wouldn't be able to do what I do since I actually have regulations to follow about residents' rights.
    lucinda1518, casi, LTCNS, and 1 other like this.
  4. 0
    Quote from Tiffanybaybay
    It does sound like a dump. I don't want to be rude, and I don't know you or this specific case but many times we get pt's from LTC and when they get to us they are sweet as pie. They meet after waiting hours to see a psych dr, NOT AN ED MD! and they again are sweet as pie sometimes leading us to think that these LTC facilities are just trying to abuse pt (as they often are found to do) and this particular pt wouldn't let them get away with it. So then back they go.

    Now sometimes they are legit crazies. But if they get sent to a LTC because they are demented, then you send them to us because they are sundowning... IDK it just doesn't make sense, they were demented in the first place.

    Also many people forget that it is an ED. We have the resources to deal with EVERYTHING! We're an ed. But should you use an ED for everything just because we have the resources? NO. Should you come to the ED because you need a pregnancy test? NO. Should you come to the ED to have you toe nails cut? NO. Should you come to the ED because you think you might have the flu and spiked a low grade fever an hour ago? NO. But we have the reasources to handle these things. Hence you can see why the resources arguement is a lame arguement to use in this case. If you used that reasoning for every medical issue you would always go to an ED, why use a doctors office for anything?!

    And speaking from experience, please refrain from being upset when you or someone you love has to wait while having an MI because 3 LTC's in the area have demented pt's that suddenly are acting demented, and they all sent them to us because we have the resources. This is the case, there is usually more than 1 LTC in the hospital area... and the ed must deal with their sundowning pt's and the area's trauma's, burns, rapes, and medical issues. Sounds like overwhelming one little department. So now you or someone you love with a true medical emergency must wait while half the ed wrestles with some unknown male we just recieved riled up from a LTC... where's that w10? LOL. Let's not even get started on what a waste of tax dollars that is.

    My suggestion is that if a facility accepts care for someone who is demented they should develop protocols to deal with demented people. That's like accepting care for a person with AFIB, but then when their HR increases, stating, WE DON"T HAVE THE RESOUCES TO DEAL WITH THIS!!! Lol. silly.

    I don't mean to jump down your throat or be rude. But I hate LTC dumps too. And to me this would classify as a classic dump.
    Seriously? I'm not even a nurse yet and even I know the difference between someone suffering from psychosis and someone who needs to find out of they're pregnant. If a pt is confused and combative isn't it better for the patient to direct them somewhere they can actually get the help they need?? Be it sedation or a psych consult or whatever. No the MD who is working ER isn't psych but can't he refer these people to psych so that they can get the medical attention they need, being that LTC isn't equipped. To me it sounds like getting sent out is the best thing for the patient and if you think that a demented person becoming friendly due to a change of scenery that perhaps makes them think they're 30 again means they're abused I don't know what to tell you!!

    "No day but today"
  5. 2
    If one of my residents is having a psychotic episode where he's a danger to the staff and the other residents, you can bet your bippy I'm going to send him to the local ED. An acute psychotic episode is a medical emergency we are not equipped to deal with.

    Someone upthread said ED staff having to wrestle a crazy pt down prevents them from dealing with a true medical emergency. C'mon.

    First of all, the ED has way way way way way more staff than LTC. For my 49 residents on night shift it's me and two aides and an on call doc sleeping at home who may or may not answer my page. For 49 occupied beds in a ED you've got ten nurses, half a dozen techs, a secretary, a RT and a couple doctors on site. And I'm probably being conservative.

    It's not physically possible for us to control a psychotic resident. There would *literally* be no other staff to care for the 48 other residents. And, remember, you guys only need to dogpile on him long enough to apply the restraints and administer the IM geodon. Again, not even an option that's on the table for us.
    chevyv and LTCNS like this.
  6. 1
    In the last post, you stated things as "appears to be".. That's much more professional than assuming we are dumping. I have worked both in ER and LTC. Our LTC regulation book is enormous, and LTC is now the most regulated business IN THE WORLD. We cannot TDO a patient via police unless they are physically threatening. So, when they have an acute outbreak, they go to the hospital. Now, if my patient fractures a bone and my facility is not designed for it, where do they go? ER. If they have a psychotic episode, where do they go? ER. Not because we are dumping, but because it is the only way to ensure the safety of our other residents which is a REGULATION of LTC (at least here in VA). When we determine that we need to send a patient to the ER, we don't just say "Oh well, we can't handle it. Send them to the nurses at the ER." No. We say that we are sending them to the ER so that a PHYSICIAN (which is not on LTC STAFF) can evaluate the patient and either A) Admit them, B) send them to a more appropriate ER with psych (most in VA have this) or C) send them back after sedating and relaxing them. I'm so sorry you feel it's dumping, but it is our only option in most cases. I'm not saying no one ever dumps patients, but that's not the goal. The goal is to keep our patients, but do so safely. Here's another scenario. When I was in the ER I used to get mad when they sent a patient to us that was "altered mental status" but no real reason. I used to whine and moan because the LTC was dumping them. Now when I went to LTC where I am a DON now, I see why- The facility nurses are geared towards geriatrics and the skill set matches that. LTC nurses may not be as capable as an ER nurse in THESE situations only because of the type of work that is being done. I learned that we all had our place, and by accusing them of dumping only made it worse. My issue here is NOT the problem of dumping, but the problem of being so accusatory and flat out mean about it when it does not appear you have made any effort to attempt to understand what the other facility is going through... It's always unprofessional to assume another nurse in your own profession is doing something to "dump" a patient or any OTHER derogatory accusations... That is why I said unprofessional - we need to go to the other facility, find out if they really are dumping, or as a hospital TEACH the facility (many do here in VA) how to use SBAR properly to assure safe patient information communication with the physicians before going to the ER. Also, in the end, remember that when we send a patient to the ER even if it's psych, IT IS BECAUSE WE RECEIVED A PHYSICIAN'S ORDER TO DO SO...... Yes, that's right. Silly, right? Nurses need a physician's order to send a patient to the ER, but a lay person can just go on their own. I don't like it, but it IS a regulation. Remember that the next time you get a patient, remember the nurse got an order to do so. Most of our physicians in LTC are associated with hospitals, so they give us an order to send the patient to the hospital that they are associated with so they can get better continuity of care. Please, please learn more, assess and evaluate before saying things like this. It puts the fire through me because all it does is separate everyone....
    LTCNS likes this.
  7. 0
    Quote from NurseGuyBri
    In the last post, you stated things as "appears to be".. That's much more professional than assuming we are dumping. I have worked both in ER and LTC. Our LTC regulation book is enormous, and LTC is now the most regulated business IN THE WORLD. We cannot TDO a patient via police unless they are physically threatening. So, when they have an acute outbreak, they go to the hospital. Now, if my patient fractures a bone and my facility is not designed for it, where do they go? ER. If they have a psychotic episode, where do they go? ER. Not because we are dumping, but because it is the only way to ensure the safety of our other residents which is a REGULATION of LTC (at least here in VA). When we determine that we need to send a patient to the ER, we don't just say "Oh well, we can't handle it. Send them to the nurses at the ER." No. We say that we are sending them to the ER so that a PHYSICIAN (which is not on LTC STAFF) can evaluate the patient and either A) Admit them, B) send them to a more appropriate ER with psych (most in VA have this) or C) send them back after sedating and relaxing them. I'm so sorry you feel it's dumping, but it is our only option in most cases. I'm not saying no one ever dumps patients, but that's not the goal. The goal is to keep our patients, but do so safely. Here's another scenario. When I was in the ER I used to get mad when they sent a patient to us that was "altered mental status" but no real reason. I used to whine and moan because the LTC was dumping them. Now when I went to LTC where I am a DON now, I see why- The facility nurses are geared towards geriatrics and the skill set matches that. LTC nurses may not be as capable as an ER nurse in THESE situations only because of the type of work that is being done. I learned that we all had our place, and by accusing them of dumping only made it worse. My issue here is NOT the problem of dumping, but the problem of being so accusatory and flat out mean about it when it does not appear you have made any effort to attempt to understand what the other facility is going through... It's always unprofessional to assume another nurse in your own profession is doing something to "dump" a patient or any OTHER derogatory accusations... That is why I said unprofessional - we need to go to the other facility, find out if they really are dumping, or as a hospital TEACH the facility (many do here in VA) how to use SBAR properly to assure safe patient information communication with the physicians before going to the ER. Also, in the end, remember that when we send a patient to the ER even if it's psych, IT IS BECAUSE WE RECEIVED A PHYSICIAN'S ORDER TO DO SO...... Yes, that's right. Silly, right? Nurses need a physician's order to send a patient to the ER, but a lay person can just go on their own. I don't like it, but it IS a regulation. Remember that the next time you get a patient, remember the nurse got an order to do so. Most of our physicians in LTC are associated with hospitals, so they give us an order to send the patient to the hospital that they are associated with so they can get better continuity of care. Please, please learn more, assess and evaluate before saying things like this. It puts the fire through me because all it does is separate everyone....
    ^Wow...Well said NurseGuyBri!!! Well said.
  8. 1
    A 80 year old man walks into a Target and puts an employee in a choke hold. Police bring him to the ER because its obvious to them there is something medical (dementia) going on. Is that an ER dump? Do you just release them back into public even though they are an obvious risk to others?

    As a LTC nurse I would have shipped that patient to the ER as well. I would have also been ****** that they shipped the resident right back. I would have then been questioning the competence of the ER staff when I found out their original plan was to put the resident in a cab and send them back.

    I'm a nurse who is VERY careful about what I send into the ER. If I can treat someone who is sick in their home, I'm sure as hell going to do it. Also if I am sending them out I'm going to make sure they are sick. Honestly the paperwork to send someone out and then get them back again in the same shift is a freaking pain in the butt.

    Here's why I would have sent out the above resident.
    1. Restraints are a big no no in LTC. This includes chemical restraints. Even if you are able to obtain and order for a dose of anti-psychotic medication for someone who is having acute behaviors giving the medication PO is out of the question. The person won't take it. Asking the resident to drop pants so you can give them an IM injection also isn't going to work. I can't force anything on anyone who refuses something.

    2. LTC in a home setting full of vulnerable adults including the patient above. I am putting all of the residents at risk, including the psychotic patient. I can not do that.

    3. These behaviors are an exacerbation of dementia. This isn't run of the mill sun downing. How is this different than sending someone with an acute exacerbation of COPD into the ER? In LTC we can normally handle COPD, but sometimes it turns into something acute that needs more than LTC.

    I'm sorry if I'm not making a lot of sense. Still awake after a night shift and I haven't been getting a lot of sleep due to a newborn.
    IowaKaren likes this.


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