I need help managing a very difficult resident!

[Lovely_RN, MSN]

Sorry in advance for the super lengthy post but I really need some good counsel. I have been working so hard recently that it's only now that I have had 2 days in a row off that I have had time to ponder and become alarmed about my situation at my new job.

I am a new LPN of less than 2 months and I currently work in a LTC. I work the 3-11pm shift and I am the charge nurse for 40 residents and 3 CNAs. It's a pretty tough shift with a huge med pass, treatments, GT feeds etc.

I have one resident who is a huge problem and I don't know what to do about her. Also my nurse manager (who is on day shift) is not helpful in the least when it comes to dealing with this lady.

This resident is a transfer from another nursing home where she had a slip and fall accident. She is legally blind (i'm not sure how much she sees) and immobile because she is recovering from surgical wounds that aren't healing properly because of her DM.

This resident has told me flat out that she is engaged in a lawsuit with her previous NH and she says things that make me fear for my license.

She is extremely demanding, tells lies, and is impossible to satisfy. No matter how much we cater to her she manages to find fault with everything that we do and gives the impression that she is being neglected and abused.

She is not senile (she is actually only middle aged) nor does she suffer from any sort of mental illness (recent psych consult has been done).

When she is out of bed she complains that she wants to go to bed. When she is in bed she wants to get out and it's always immediately like right now. When I try to set limits and say that aides are with another resident but I can have them fulfill your request within x,y, z time frame she gets angry and then complains to the next shift that we had her OOB for hours and hours and says that we ignored her.

She hates all of the food so I always had to call the kitchen for substitute meals for her on every shift I worked. So I finally got wise to her and had the dietitian consult with her to select a few things that she likes to eat. So now her new thing is that the food is not fit for a "dog" to eat and that she wants something different. She says I can't wait for my son to get here because I never get enough to eat around here. I asked her to clarify her statement because there is a difference between not getting enough to eat and not liking what you are offered. One gives the impression that we are trying to starve you and the other is that you just don't like the food.

She acknowledged to me that she just doesn't like the food but she says many sly comments like this all the time.

The worse is that she will say that we do not administer her pain meds and nebulizer treatments. She has said this to me about other shifts and I have been asked by other nurse's on different shifts.

I caught her red-handed lying about not getting medication.

I worked a double shift 3-11pm and 11-7am a few nights ago.

I gave her her 10pm nebulizer on scheudle as well as her hs ambien and tylenol 650mg at 9:50pm. At exactly 11:05pm I hear her start to moan and groan and call "nurse, nurse, nurse". I go into her room and all I said was "Yes, i'm here" so I guess she didn't recognize my voice.

She says "I didn't get my 10pm treatment or any medication and I can't breath".

My jaw dropped!

I told her that I am the evening nurse and that I gave her her meds and treatment a little over an hour ago. She was shocked she asked me what time it was and I told her and then she asked where the night nurse was and I told her that I was staying all night.

I took her vitals and listened to her lungs and she had no signs of respiratory distress. So I told her that if she really felt that she needed another treatment at that moment I would have to call the doctor and have respiratory come up because I can't administer nebulizers prn.

She then sighed and said well ok then I guess I will just lay here and die then.

I have tried to listen to her when she wants to talk but I can't stay for more than 5-10 minutes because my time is very limited. Also a lot of what she tells me turns out to be lies.

Everything that I do for this resident has backfired on me.

She was depressed because her children never call or come to visit her so I got the social worker to contact her children and basically made them call her. She was on the phone for 2.5 hours the evening that her son finally did call and what does she do? The next day she complained to the nurse manager that we didn't put her to bed until 10:30pm at night and that she was in pain from sitting in her wheelchair for so long. This is a lie because she was on the phone until 8:30pm and then as soon as she was done the aides put her to bed. Trust me, no CNA is waiting to clean and put a resident to bed at 10:30pm because they are worn out by that time and are just doing final bedchecks to make sure that all the residents are dry.

I got her a new bed because the old one with the handcrank wasn't good enough for her. She wanted one with electronic controls so she wouldn't have to always bug us to come in and raise and lower her bed. Well I get it done and what happens? She says the side rails on the new bed are too short and now the pillow that she uses to prop her side up will fall on the floor. So now she is on the call bell every two seconds for us to pick up her pillow and blanket that keep "mysteriously" falling on the floor.

When I go into her room I explain to her that I am doing _________ and that I cannot come back to her room for _________ amount of time. I ask her to tell me everything she needs but it is inevitable that as soon as my foot crosses the threshold of her door that she will be on that call bell again to tell me one last thing she has forgotten.

The worst was on Friday. She requested to be taken OOB at 2pm by the previous shift. When I came in at 3pm she wanted to put back into bed. I explained to her all of the tasks that have to be done during change of shift and advised her that it would not be until after dinner time that we could put her back to bed.

I am not kidding you guys it was impossible to get her back to bed anytime sooner. The DNS called a meeting for the CNAs at 3:30pm and then one for the nurses at 4:00pm. Between 3-4p I had to count my narcs, get report, do my fingersticks, hang 3 feedings and oh did I mention a resident hurt themself in the elevator so I had to do some impromptu wound care, call the supervisor and then the doc, start an incident report etc. Could her timing be any worse? The CNAs are just as busy running around doing rounds and then 2 of them have to take residents down to the dining hall while one stays on the floor to serve.

Meanwhile I have this lady in her WC complaining very loudly for all to hear that we wouldn't like to be treated this way and says that she is being neglected.

My nurse manager is sitting at the nurse's station trying to finish her work so that she can go home. She is in a bad mood (all of the time) so all she does is bark out that I need to do this and that. Mind you she is always still around long after her shift, taking up space at the nurse's station and in general being a witch. She also likes to leave her orders for me to pick up (like I don't have enough freaking things to do as it is) and complains constantly about how incompetent everyone around her is.

She speaks to me in an accusatory tone of voice at all times. I feel like I constantly have to be on the defense with this woman. One time I came into work and without so much as a good afternoon she jumps all over me about how I didn't do any treatments and pass this or that med because of omissions in the MAR and TAR. I had to (respectfully) interject on her tirade and point out to her that the previous night was my day off. This facility couldn't get an evening nurse for a long time on my floor and now I know why. I find myself writing down my days off in a little notebook so that I can defend myself when I am accused of not doing this and that. I know that I am a new nurse and that I will forget to do things or not do them properly at all times but this woman acts as if I am a lazy, sneaky, good for nothing.

Also this NM held a meeting for us 3-11pm people because of this resident's complaints and claimed that the resident said we are the worst shift. Which I find hard to believe because the same resident has told me that night shift and day shift are the worse on separate occasions. How can this experienced nurse not know that this resident is manipulating us? She basically screamed at me and was flipping through the chart telling me that I need to document what this lady is doing and I am telling her that if she would read the notes that she would see that I have been doing just that! There is rarely a shift that goes by that I don't write a behavior note about this resident but the NM isn't reading this woman's notes and when I pointed this out to her she looked at notes saw how many I do write and then she shut up and changed the subject w/o acknowledging that she is falsely accusing me of not doing my job.

I document, document, and document some more about this lady but is that going to be enough to save me if and when the poop hits the fan? I'm not feeling to good about this woman I can almost swear that she is looking for another lawsuit and I don't feel that my co-worker's have my back in anyway.

There is actually more that this resident has said and done but this would truly be a book length post.

I'm just so inexperienced and I feel like maybe I am the frog in the pot on slow boil. If I get out of this place can I just expect more of the same? Or am I working in a toxic environment? This place should have a revolving door because they lose nurses just that quickly and the only ones who seem to stay are the older nurse's who are close to retirement. All of the nurse's my age or younger are recent hires of less than 6 months. Is that a sign that I need to get the hell out of dodge?

[GeneralDogsbody]

Oh you poor thing!!I feel for you.Demanding ,manipulative patients are a nighmare!!Do what you are doing,document,document,document.Also ,when possible have a witness in the room with you.Is there any use speaking to the relatives about her behavior.Maybe they can help( or not!!) Remember this is only one patient,she will not be there forever.Do you enjoy working there other than her?

I expect your NM is probably as worried,re complaints etc.

[Bugaloo]

sounds like a tough situation. there are always going to be patients like this, but, in a ltc setting, where she could be there a while, it can get old, quick.

when you have a demanding, never satisfied patient that lies about the things she has "not had done for her" and then tells you that she is suing the last place she stayed....the best thing to do is document your orifice off until you can find another job.

the manager is not going to help you out on this one. she is not doing her job. besides that, she is trying to pile more on you when it sounds as if you have enough to do.

my advice to you: look for another job. it sounds as if you have done everything correctly. you have tended to her needs time and time again. you have tried to set boundaries and be firm. you have went over and beyond what is expected of you. you are not appreciated for what you do. if i was a manager, i would hire you in a heartbeat.:redbeathe you seem to have a good head on your shoulders and truly look out for your patients.

i applaud your efforts, but i would leave this job...the sooner, the better. good luck!

[delta32]

are you sure your not in NY? it sounds like my unit that i just left 3 weeks ago. I was the nurse manager on that floor for the rehab unit. it sounds like your on a rehab unit as well. this is what i would suggest:

-keep a list of times and demands that the resident makes and document them in your chart and keep a record for your self as well.

- re consult psych- even if they don't diagnose her as having a mential illness thay can gove recomendations. it deffinatley sounds like she has borderline personality disorder. part of the disorder is manipulative personality and they like to devid and conquire. The unit needs to present as a united front with this patient and call her on her behavior. she trives on turning you guys against each other.

the last recomendation is to stop playing her games. If she wants to complain in her wheel chair let her. nothing says you have to listen to her abuse. if she wants to yell neglect to another staff member you too MUST confront her on her behavior. please talk to your DON if you need too so that the team is not the same page. No matter what you do she is not going to be happy so don't stress it. if she wants to be nasty turn and walk away. you do not have to take abuse.

Jamie

[rn-jane]

I am so sorry for you. If your manager refuses to listen to you, get out! There are better jobs out there girl that would welcome you. We all have difficult patients, but if your head nurse is not caring about what is going on in your facility then find another. Where is this woman's family? If you can get your boss to listen to you then I think a interdisplinary meeting is in order to colloborate about this resident.

[delta32]

I wanted to add to my previous post. If you have to force a family to call her then they most likey are sick of her behavior as well. There usually is a reason why families don't visit or call

Jamie

[facetiousgoddess]

Falon,

imho This resident can not be managed. You are observing a behavioral pattern that has taken a lifetime to develope. Her behaviors work for her. She receives some form of internal gratification. It reminds me of the old joke: "How many psychiatrists does it take to change a lightbulb? Only one but the light bulb really has to want to change."

You have done everything by the book. Psych consult, limit setting, documentation, dietary consults etc. All these folks fluttering around, so concerned with your manipulative resident at the hub.

I agree with Delta32, have psych diagnose and recommend...but I'll bet my next paycheck when you attempt to initiate those recommendations, and you know she will ask what the med is for...she refuses and starts down a whole new road of "Oh so now you think I'm crazy...."

I've had a few like this, fortunately they were short term sub acute. At one point I felt my license was jeopardized and went to our UM and refused to accept the resident on my assignment, after making the resident aware that because of her behaviors, I would no longer be her nurse as nurses also have rights and I would no longer allow her to violate mine. Fortunately, I was in a supportive environment.

The question at this point, short of a miracle and your resident doing a behavioral 360....is what does Falon want? Is this a facility where you wish to continue to practice? Obviously there a no guarantees in changing workplaces. Each comes with its own frustrations.

I work per diem at several facilities in several different capacities at several different pay rates because I've limited tolerance for facility politics. Cowardly perhaps. But after 2 years of and a brick dust tattoo this is how I stay in love with our profession.

Tres

Hope I wasn't preachy!!!

[Lovely_RN, MSN]

Thanks for the good advice from everyone.

I will suggest the interdisciplinary meeting with the NM and see where that goes. If I can't communicate more efficiently with the NM then I am going to request a transfer to another floor or find another job because I can't continue to work with someone who isn't interested in working as a team.

I can't go over her head to the supervisor or the DNS without severe consequences. She is already making my job difficult and uncomfortable but I know that there will be hell to pay if she feels that I am undermining her.

[Lovely_RN, MSN]

You know what? The more I think about it the more my mind is made up that it is time to leave this place. Since I have a job and I am not under threat of being fired I am just going to take my time and try to find something half way decent.

If the nurse manager and this difficult woman were the only problems I encountered in my six weeks then I would tough it out but there have been more problems. I don't want to be a job jumper but I don't think that this is the place for a new grad.

[bethin]

As someone previously stated, leave asap. Any manager that barks at you, accuses you of things you did not do and does not back you up, offer suggestions, etc is just bad news.

Get out fast.

And I have to wonder why you have to call her family and her family doesn't call her?? I don't suppose it has anything to do with her manipulative behavior?

Who is her POA? Why not call them personally and see if this is normal behavior for her or not. Then leave because I doubt if Mother Theresa herself came down and spoke to her that this woman would not change.

Reminds me of a pt I had a few months ago - he let it be known to me that he sues everyone so he can have money to vacation in Europe. He's sued Walmart (frivolous lawsuit, he tripped over a brightly YELLOW painted curb). Sounds like she could be his sister.

[canoehead, BSN, RN]

The patient is the first of many you encounter that will not change, and refuses to be happy. No biggie. In time you will be able to process her behaviors, and realize she is there not to make you work harder, but for your entertainment. (Just a coping mechanism for the really demanding patients)

The manager is the bad news in this scenario. If she is accusing you falsely, and not acknowledging her mistakes there will come a time when you get accused of something and you won't be able to prove your innocence. The job is a time bomb. Keep a low profile, and don't poke the dragon, and look for another position. Supportive bosses and coworkers can make a job worthwhile. You could have a whole floor of patients like the one you describe, and if your coworkers have your back it is easy as a wink. Good luck.

Bethin- We had a dark line painted on the floor of our ER to indicate where patients needed to stand for visual acuity testing. I kept stumbling over it into the desk, and threatened to sue maintenance :) so eventually they scraped it up.

[bethin]

Bethin- We had a dark line painted on the floor of our ER to indicate where patients needed to stand for visual acuity testing. I kept stumbling over it into the desk, and threatened to sue maintenance :) so eventually they scraped it up.

That sounds reasonable - you warned them of the problem. But suing because you trip over a pebble in a parking lot of Kohl's?? That's taking it too far and big companies hate lawsuits so they settle.

Good answer to the OP's question. I just think the whole team needs to get on board with this pt and it's not happening. Management, charge nurse, dr, etc needs to be on the same page and firmly tell the pt that her behavior is unacceptable and if she don't like it, there are other LTCF out there,