Catch 22 situation - page 2

I'm risk manager at LTC facility in KS. We have a resident with advanced dementia and schizophrenia. She has a BIMS of 3 and is strong, violent, and resisting cares. We have attempted, without... Read More

  1. by   hppygr8ful
    Quote from litbitblack
    Dementia is psych as well
    Actually it's not - Dementia is considered a medical diagnosis and can not be used as criteria for admission to a psychiatric facility. Does this patient have family or a conservator. If she has a diagnosis of schizophrenia does she see a psychiatrist at least quarterly if not you may be neglecting her needs and can be cited. Maybe a long acting injection like Haldol dec that can be given once a month would be worth trying - it's general not used for elderly patients so some caution is necessary.

    My mother was extremely violent and is currently on 25mg of Seroquel twice a day (little baby dose) and she is much calmer. Is you facility doing behavior counts to justify medication? The family or conservator needs to be given 90 days to help find a solution or be given notice that she has to be moved. It may be more appropriate for her to be in a specialized dementia care facility.

    Hppy
  2. by   MunoRN
    Quote from hppygr8ful
    Actually it's not - Dementia is considered a medical diagnosis and can not be used as criteria for admission to a psychiatric facility. Does this patient have family or a conservator. If she has a diagnosis of schizophrenia does she see a psychiatrist at least quarterly if not you may be neglecting her needs and can be cited. Maybe a long acting injection like Haldol dec that can be given once a month would be worth trying - it's general not used for elderly patients so some caution is necessary.

    My mother was extremely violent and is currently on 25mg of Seroquel twice a day (little baby dose) and she is much calmer. Is you facility doing behavior counts to justify medication? The family or conservator needs to be given 90 days to help find a solution or be given notice that she has to be moved. It may be more appropriate for her to be in a specialized dementia care facility.

    Hppy
    Technically Alzheimer's Dementia is considered a psychiatric disorder and is listed by the APA as a DSM diagnosis. As a neurocognitive disorder it's classified as a separate subgroup of mental illness than schizophrenia, but still falls under the general umbrella of mental health disorders.
  3. by   NurseCard
    This poor woman clearly is not capable of making decisions, and therefore
    if the family is okay with it, I don't see the problem in crushing meds and
    mixing them in ice cream and giving them to her. Like others have said,
    this poor woman is likely suffering.
  4. by   hppygr8ful
    Quote from MunoRN
    Technically Alzheimer's Dementia is considered a psychiatric disorder and is listed by the APA as a DSM diagnosis. As a neurocognitive disorder it's classified as a separate subgroup of mental illness than schizophrenia, but still falls under the general umbrella of mental health disorders.
    I have been working psych for 17 years and we and constantly turning away dementia patients because they don't meet criteria for involuntary psych hospitalization. In the most general sense of the law with regard to involuntary the patient must be considered a clear and present danger to themselves or others or be gravely disabled by reason of mental illness. Since most of these patients are in custodial settings they don't qualify as gravely disabled. In my own mother's case she has a diagnosis of dementia of unspecified type. She is also most likely bi-polar. She actually tried to kill another resident at her memory care facility and was arrested and taken to an ER where she was diagnosed with a UTI. The memory care facility filed a 30 day notice the same day that they would not be taking her back. Because I know several psychiatrists in the area I was able to get her admitted into a gero-psych facility as a voluntary patient under the signature of her POA my sister. She spent 88 days in gero-psych while we found a more appropriate living arrangement for her. During that time she had several medications tried and her behavior was stabilized. It has been a long hard road and much learning has taken place about what Medicare does and does not cover and the laws surrounding long term care. If a psychiatric medication is required to treat a psychiatric diagnosis - then chemical restraint laws don't apply as long as there is good documentation by a prescribing psychiatrist.

    There are ways to force this woman's family to act - but as the average nursing home patient brings in somewhere between 5K to 8K month to an LTC the bean counters don't push it.

    Hppy
  5. by   Glycerine82
    Can you send her to the ED as a danger to herself/others? In my state this is what we do and these folks end up going inpatient psych to get their meds straightened out.

    What we do to these people is simply horrendous, this poor woman has no way to advocate for herself and the system is FAILING her, miserably.

    I hope you find a solution, please keep us posted.
  6. by   Davey Do
    Quote from TriciaJ
    There is nothing wrong with a nice bowl of mint chocolate chip with Haldol and Bactrim sprinkles.
    Tastes god and is good for you!

    Seriously, RRRNNN, I appreciate your situation and endeavor to provide appropriate services for this Patient in need.

    On Gero Psych, we often admit and treat Patients with their Axis I diagnosis or for dementia under Psychosis NOS.

    You've got some really good feedback and info from the other posters. I wish you the best of luck.
  7. by   applewhitern
    I am confused about this. If the patient cannot take care of herself, or make decisions, why doesn't she have a court-ordered sponsor to make decisions for her? We have a psych unit as well, but our hospital would not put up with this. She would either get cleaned up and treated, with or without a court order, or be discharged home. (I realize this is not at a hospital, but can't fathom not being allowed to clean or treat a patient, just because the patient is demented.)
  8. by   RRRNNN
    Wow I'm surprised to see how much support and advice have been offered. Thank you very much.

    The situation is complicated by the fact that her only family member is her son who was only very recently released from prison. We have not built repoire with him and don't know that we will be able to.

    I have to confess that my knowledge of psych meds is limited. I don't remember what meds she's on but I will look when I get to work today and I'll call our facility psychiatrist myself and see what we might be able to do. I'm sure there is a reason she's not on more scheduled medications. With the recent crack down on prn antipsychotics, us not being a geri-psych unit and having little experience with such things, in addition to the state having us under a microscope, this situation has my stomach tied up in knots.

    We have sent her out to the ER for being a danger to herself and others and they send her back to us.
    Last edit by RRRNNN on Nov 13
  9. by   djh123
    We had someone who was almost that unruly, dangerous, etc. Had Parkinson's but wasn't overly medicated. Was sent to some psych facility, but we got him back eventually. But then, despite the strong general push to NOT heavily sedate anyone, that's what they did - he was heavily medicated and no longer violent.
  10. by   cyc0sys
    Quote from MunoRN
    That's an impressive combination of bad decisions you facility is making. To start with, treating the symptoms of a condition or illness is not a "chemical restraint", and actually failing to treat these symptoms can constitute neglect and potentially criminal abuse.

    The patient poses a threat to staff, which is one thing if the facility is making reasonable attempts to mitigate this threat, but choosing to nothing not only opens them up to civil suits, but it exposes them to criminal charges.

    The patient does not appear to have decision making capacity, which requires the facility to legally establish this as well as have a decision make appointed, when this is a court appointed advocate they generally will decline any sort of life sustaining treatment in a patient such as this, including even antibiotics since from your description the patient is likely fairly miserable on an ongoing basis.
    /\/\/\/\/\/\Yes. This all of this. /\/\/\/\/\

    As a Risk Manager your primary responsible for the safety of the patients and staff. I wouldn't play games if management refuses to act. When the music stops, and it will, you won't have a chair or job.

    I'd set down and have a talk with the DON. Have her issue/sign a policy to instruct the CNAs and Floor Nurses to send this patient out via EMS at the onset of a violent episode, after all other means have been exhausted. Document the behavior, SBAR, incident report, and notify family. Then you'll have your bases cover if SHTF.

    At some point, admin will either dropped the Pt, place in Memory/ Psyche Care, or get the behaviors under control medically.

    Love this>>>>"That's an impressive combination of bad decisions you facility is making."
  11. by   RRRNNN
    Thank you so much for your support. I was feeling insane because I was the only one in management who saw the seriousness of the situation. I was starting to wonder if I was over-reacting.

    I had to state things very, very strongly to the higher ups this morning before I was finally able to get them to listen. After digging further I found out that the resident has been sleeping through her morning meds often so the nurses have just not been giving them on those days instead of getting an order to give them late. Just holding psych meds - and then complaining that the psych resident is acting up. Our DON knew this and had not told me or done anything about it!

    Also, after further digging, found out that her dementia diagnosis wasn't even properly worked up and that it might not be accurate. Our facility psychiatrist is coming to look at her and if she doesn't have dementia, but rather is functioning very poorly due to poorly-controlled psych issues, we're going to be able to have that diagnosis removed from her record and get her placed into a more appropriate facility, better able to meet her needs.

    In the meantime we have clarified and at least the managers are finally all in agreement that prn ativan and antipsychotics are NOT chemical restraints. Convincing the charge nurses of this is another issue. The CNAs are going to approach her for cares and if she declines they will have the nurse administer prn meds and try again later.

    Hallelujay - but why on earth did this have to be so difficult? I wound up in a shouting match over it and was just about to hand in my badge and walk out.

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