Dementia care - altercations

  1. OK ~ I had been in acute and critical care for 20 years. But since 2004 I have been in assisted living. Currently I am in a 'memory care' facility. All residents have significant dementia along with their other medical concerns. You may probably know that staffing is scant and without certificate or license. The RN is the only licensed person there and in a facility of my size (30 residents) - part time (20 hours/wk).
    My biggest concern at present are a half dozen {mostly male} that get into physical altercations. :angryfire I can care plan all I want and direct staff to attempt to intervene and re-direct early on before intrusive or obnoxious behavior escalates to physical altercation, but these people have no 'sensor' anymore to inappropriate social behavior. And many things are just 'knee jerk' reaction. One was a military MP followed by a carreer as a police officer - plus a boxer while in the military. He is 'set to go' to defend and protect and can deliver a swift double punch to the face when he perceives another affronted or to defend himself. Another can turn on a dime from pleasant and joking to yelling, name calling, throwing and pushing. Another intrudes on others so badly in all aspects throughout the day that he invokes the rath of others. He is resistant to any care and when attempts are made to re-direct or care for he becomes combative. I have worried greatly for the safety of my staff. Although his punches do not deliver much pack, his grip could be lethal (especially after trying to loose him from the juglars of one of the aids!). They all live in their own reality and we go with that and try to calm. One gentleman speaks to no one or nothing in particular, but his comments can incite reaction from others. If there is a verbal or physical reaction by another this little 'Italian hot rod' can spark fire rapidly. If one or two get started it can incite a 'revolution' !

    Oh, I could just go on...... But I really need to know what to do to reduce these physical altercations. Recently I am getting one or two a day and I need to be able to care plan a reasonable solution. I really need to try to avert any injury to residents or staff ! Yes ~ being a small facility and long term, we know our residents well and intimately. We do try to keep those that offend each other separated, but remember - most are independently mobile. We try to listen and be aware of inciting verbage or behaviors to intervene before it escalates to physical confrontation.
    I am at a loss and I don't want anyone hurt.

    Any ideas ? PLEASE !!!!!
  2. Visit joies1 profile page

    About joies1

    Joined: Feb '06; Posts: 16; Likes: 21
    dementia care
    Specialty: 25 year(s) of experience in acute, critical, home, assisted, MRDD


  3. by   SuesquatchRN
    Frankly, they need more supervision than an ALF can provide. Far more.
  4. by   CoffeeRTC
    I think that setting is inappropriate for those type of behaviors. Even in a regualar LTC SNF setting those are hard to deal with...I'm thinking he needs alz spedific care?

    I think is will be hard to deal with even with all the care planning due to the staffing situation.
  5. by   litbitblack
    THe care planning should involve everything that has been done to reduce the risk of harm to these pts and staff workers. If nothing is working then a team meeting with the family to move these residents to cert dementia care. I work in a cert dementia care ltc and we have one nurse and two techs to 15 residents and they are in the behavioral suite. We use a lot of redirection and alot of activities. If they are involved in activities the incidence of occurances is reduced. Good luck. If your facility can not provide safe places for all your residents and staff due to whatever reason then the pts causing the problems really need to be somewhere else suited for dem/alz pts
  6. by   sam1998
    I agree, I worked with dementia residents in a LTC setting for years, and at the facility there is a 12-room, all-male unit devoted to residents with such behaviors, as well as sexually inapproprate behaviors toward females. That way, they are separated from more vulnerable residents and are monitored more closely. Sure, altercations occurred, but nothing drastic in the years I worked there. Honestly, I took being hit or kicked at times as part of the job. Sometimes there's nothing you can do to prevent certain things from occurring, you just have to do the best you can and keep documentation. Write incident reports and help ensure behaviors are documented so physicians are aware and can make changes in medications if necessary. Alzheimer's-affected adults with unpredictable, potentially dangerous behaviors should ideally be in a specialized facility... although sadly, some of them don't end up in the nicest places due to financial restrictions. The place I worked accepts many residents that other facilities said they would not, due to behaviors. It has an activity staff who helps provide diversion for residents. However, it's a private facility that is quite expensive and doesn't accept Medicare, restricting many people. As the aging population grows in this country, some changes are going to have to be made so increasing number of people with Alzheimer's and other forms of dementia can afford to get the safe, quality care they deserve.
  7. by   joies1
    Thanks to all that wrote with your responses. I appologize for being so tardy with my return. Just dealing with holidays, work and illness has kept me away.
    I couldn't agree more about staffing. I feel we are terribly understaffed for the needs and behaviors of our residents, but there will be no changing that ! . . . And we are a dementia facility. In Oregon dementia facilities are under the 'assisted living' regs. Senior psyche/dementia specialty units can be counted on one hand - taking time and much hoop jumping to get someone in IF there is available temporary space.
    I am interested in 'sam1998' response about having a separate area for the 'trouble making gentlemen'. It has been my impression that the interaction and interface between my gents just exacerbates their behaviors. I think all would behave much better if they were alone and not in an interactive community. I would like to think differently than that !
    At least, since intial post, the county psyche specialist is finally understanding (after 2-3 months!) that our concerns for one of the men needs to be addressed sooner, rather than later. Whooppee !!!!

    Again ~ thanks ! And any input welcome.
  8. by   achot chavi
    Don't you have a psychiatrist or psychologist to help you?
    I would consult with someone who is trained to deal with these extreme behavior issues.
    I think in time you get to instinctively know how to deal with this, Can you talk to your predecessor.
    Obviously - document , document, document.
    Are you alone when you deal with these men?
    I don't think we have to allow ourselves to be physically abused.
    BTW- I once tried Negative Reinforcement and it helped a lot. But your situation sounds worse.
    You need staff meetings with someone who can teach them how to control the situation. I would have 2 staff members provide care to prevent anyone getting hurt.
    If one of your staff gets seriously hurt- they can sue the facility.
  9. by   joies1
    Surely you jest ! ~ A psychiatrist at hand ! No, I know you are not. But surely must be accustomed to a different environment. As mentioned before, our first resource is the county psyche specialist. She covers 2 counties and is hard pressed for time. It is a slow process, taking weeks and months to alter this and up that or . . . . whatever. Of course I can always contact the PCP (which I do because I have to request a psyche eval). Unfortunately, many PCPs do not know their way around senior dementia/psyche meds. One of the greatest assets is the pharmacist who comes every quarter and advises needs or modifications to us or MD directly. As many of my residents are no longer articulate, short term memory is virtually nil, and none based in the reality that is evident to others - a typical 'sit down and talk' eval is almost laughable. We do have a wonderful facility about 100 miles away that is well equipped and able to {MD specialists, RN specialists, etc} take the truly problematic temporarily and endeavor to create the best solution for that individual. All ducks must be in a row. All sanctions in place. And, of course, there must be room in the inn.
    Sorry, cannot contact prior predecessor. We are under new ownership and management for not quite a year. Prior ran the facility to bankruptcy and sorely did not pass state survey. At least we passed survey well a couple months ago and, most often, stay - begrudenly - within budget.
    I do not want this to sound like a gripe session. I can gripe and complain to myself all I want. This needs to be solution oriented to respect the residents we care for, provide the best care we can, while safeguarding other residents and staff. I appreciate the 2 staff members to provide our more difficult situations or residents. And this is done. We do have to be realistic, though. There is never more than 1 med aide and 2 resident aides on any shift. Of course admin, office manager, activity director and myself can hands on input time, care and intervention but that amounts to 1/3 of a 24 hr day, 5 days a week. And, as you well know, each of us have our own special obligations to accomplish. A day is never done that is finished !

    I couldn't agree more with staff meetings that are solution oriented and truly care education full. I think we could make great strides for the majority of our residents's care and well being while developing greater understanding and workability between the shifts and departments. It would allow us to problem solve as a working group. Though we do have our staff meetings they are pretty much by rote - often too boring for even myself to keep attention. I value the input and interaction of my 'hands on' staff. They are the 'meat and potatoes' of our work.
    Hey ! I guess that will be a New Year's resolution ! To Initiate a truly meaningful forum for our staff, at staff meetings. The required 'by rote' requirements can be handled differently and serve the same purpose.

    I thank you so much for your thoughtful response and, certainly, the 'heads up'.

    Ya know ~ at this point ~ I am thinking that a thread - or sticky? - needs to be initiated for all the assisted living (including dementia care) facilities. We seem to be such an off-shoot of primary, acute, or, even LTC, that little is addressed or understood. And yet - especially if you are a 'baby boomer' like me - could be near around the corner - and certainly an eventuality for an ever enlarging population.
  10. by   achot chavi
    Thanks for making me appreciate what we've got here in terms of psych support.
    BTW care must be consistent- that means that if you decide on a plan of care to control a certain behavior- it must be across the board- all staff members doing the same intervention.
    Good Luck with all your New Years resolutions
  11. by   Aspen1
    You could be in danger of receiving and immediate jeopardy tag over this. You know the residents are volatile, altercations have already happened. Have any of these events been reported to the State?

    It seems to me that alternative placement must be found for at least your worst offenders. Is there a nearby geri-psych unit? We often us geri-psych to get their meds adjusted. But if their behaviors do not improve, alternative placement must be found. The safety of your unit depends on it.
  12. by   joies1
    Thank you so much for your concern and direct response. Like the old movie said "Let it be said. Let it be done !" All those concerns have passed. Yes, one was sent to another facility - the most volatile. Another has passed away. Another that got swept up in the confrontations moved to a foster care home and returned to his sweet, gentle self. And the last has had no incidents or altercations ~ now quiet and cooperative.
    Though challenges remain every day, I am so thankful that that particular time and combination of residents has been resolved.
    Believe me - if it ever happens again I will be more forceful to gain resolution.

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