Catch 22 situation

  1. 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 success, to have her transferred to a more appropriate facility and nobody will take her. At one point she attacked another resident and we had her hospitalized but we were forced to take her back.

    She is completely incontinent of bowel and bladder and impossible to direct/redirect/distract.

    We find ourselves in the position of having to choose between letting her remain in her soaked and soiled Depends indefinitely and risk severe skin breakdown, or change her Depends against her will.

    Our CNAs have large, deep scratches on their arms from her fingernails, which are usually contaminated with feces. Many of them have bruises. One nurse has a black eye and a goose egg on her head. The only way to prevent the resident from injuring herself or others is to have 4-6 staff members assist with changing her.

    Our staff members have been very careful not to injure her in any way and she has remained uninjured. She is never unsupervised.

    I carefully documented that I have discussed the situation with the DON, the administrator, and the agency social worker and that we're working to get her placed in a more appropriate facility but that, in the meantime, we have decided we must use the minimum amount of physical force necessary to change her Depends and avoid skin breakdown.

    Does anybody have any advice how we can handle this to avoid getting in trouble with the state? I am afraid we'll be accused of restraining her.
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  2. 23 Comments

  3. by   CrunchRN
    Wow. What a no win situation. I wish I had good advice, but the only thing I can think of is medications to calm things.
  4. by   litbitblack
    what kind of medication is she on? I would have the MD due a med review as she may be on something that could cause increased behaviors as she continues to decline with her dementia. We have had to send a few of ours to inpt. psych for stabilization when nothing else worked.
  5. by   RRRNNN
    She's on very little for medication. She refuses medications and they have to be hidden in ice cream, which we are being told can be considered abuse. I asked if we could get prn IM ativan to give her prior to providing cares and was told that was chemical sedation. Our physician refuses to prescribe it and our regional director said "no" to it, as well. We are a "no restraint" facility.

    We have tried to get her admitted to a psych unit but they say her dementia diagnosis trumps her schizophrenia diagnosis, so psych does not have to take her.

    She most likely has a UTI, but we can't get a urine sample. She has such severe uterine prolapse that we wouldn't be able to cath her even if she'd be still long enough to do it. Now, of course, we have the new rules about not being able to administer antibiotics to anybody who doesn't have a positive urine culture.....

    All these laws really stink. We're not allowed to use our common sense or our educations. We're not allowed to restrain or force anything but not providing cares is abuse.

    Wish we could send the politicians to run the nursing homes themselves for a while.
    Last edit by RRRNNN on Nov 11
  6. by   litbitblack
    What regular medications does she take?
  7. by   litbitblack
    Dementia is psych as well
  8. by   CoffeeRTC
    Geri psych stay?? Danger to self (hygiene issues that can lead to serious infections) and danger to others with the hitting, bitting, and bruises. Of course you are doing event reports for the staff injuries? Family involvement??
  9. by   Kooky Korky
    Quote from litbitblack
    what kind of medication is she on? I would have the MD due a med review as she may be on something that could cause increased behaviors as she continues to decline with her dementia. We have had to send a few of ours to inpt. psych for stabilization when nothing else worked.
    Have the pharmacist review meds.

    Make staff use protective gowns, gloves, masks, etc. to work with this woman.

    Get her family to take her home. Your staff don't need to be decimated. Legally, you might have an uphill battle to send her home. Or yes, inpatient psych.
  10. by   Kooky Korky
    Quote from RRRNNN
    She's on very little for medication. She refuses medications and they have to be hidden in ice cream, which we are being told can be considered abuse. I asked if we could get prn IM ativan to give her prior to providing cares and was told that was chemical sedation. Our physician refuses to prescribe it and our regional director said "no" to it, as well. We are a "no restraint" facility.

    We have tried to get her admitted to a psych unit but they say her dementia diagnosis trumps her schizophrenia diagnosis, so psych does not have to take her.

    She most likely has a UTI, but we can't get a urine sample. She has such severe uterine prolapse that we wouldn't be able to cath her even if she'd be still long enough to do it. Now, of course, we have the new rules about not being able to administer antibiotics to anybody who doesn't have a positive urine culture.....

    All these laws really stink. We're not allowed to use our common sense or our educations. We're not allowed to restrain or force anything but not providing cares is abuse.

    Wish we could send the politicians to run the nursing homes themselves for a while.
    If you think she has a UTI, get it treated without the C&S. Or find another way to get it. Maybe what she really has is pneumonia and the Rx for that will also cover UTI.

    All the people who are telling you "NO" need to come up with things you can do, ways you can provide care for her. Otherwise, this wild woman has to go home and I doubt family will be jumping with joy to take her.

    A bookkeeper who is savvy with insurance could be a good friend in this mess. I'm not suggesting anything illegal but there has to be something that can be done for and with a patient like this.

    Time for Team and Family Conference.
  11. by   TriciaJ
    I agree with Korky's team and family conference idea. Nice to sit behind a desk and veto everything out of hand. Meanwhile you have a sick and vulnerable patient who is not receiving the care she needs because her brain is too broken for her to act in her own best interests. And caring staff who are trying to do the right thing and being assaulted and injured. This is beyond ridiculous.

    Someone needs to lay it out for the suits and the pumps-and-pearls contingent. There is nothing wrong with a nice bowl of mint chocolate chip with Haldol and Bactrim sprinkles. There is plenty wrong with sitting in soiled clothing, having an untreated infection and lots of nice people going home with injuries.

    I hope that every time she puts so much as a scratch on someone, there is an incident report with copies sent to the regulating agencies as well as the OSHA people. When you hit the bureaucrats with even more bureaucracy, they may eventually take notice. Good luck getting anyone else to take her. She'll be back on your doorstep by nightfall. You need to deal with this in house. With all the ammo you can muster.
  12. by   TriciaJ
    This story is really haunting me. That woman is probably in terrible pain and does not have the cognitive capacity to problem-solve her way out of it. The staff want to help her but the bureaucrats are blocking every avenue. How would they want to be treated if they were in her shoes? Would they want their infection treated in spite of themselves, or would they rather be left alone with their pain and suffering? Time for more empathy, less rule book-waving.

    The rules serve a purpose, until they don't. The letter of the law is now interfering with the intent of the law. OP, please keep us posted. And good luck.
  13. by   Hygiene Queen
    Quote from RRRNNN
    We have tried to get her admitted to a psych unit but they say her dementia diagnosis trumps her schizophrenia diagnosis, so psych does not have to take her.
    That's crap! I worked on a geri-psych unit and we took folks from the nursing home all the time. They were our bread-and-butter, actually.

    Psych won't admit her as a danger to herself or others? Behavioral disturbance? Agitation and aggression? Medication adjustment?

    Come on! You guys need a break and this lady needs to go psych! I'm sorry psych is being so stupid.
  14. by   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.

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