Need advice: Frequent falls of non compliant homebound pt with dementia

[autumnlea]

I'm RN supervisor for home health agency.

We have an at home 87 yr old frail, non compliant female pt with frequent falls and dementia.

Family wants to know from us how they and/or we, can keep her from falling out of wheelchair 4-6 x daily without using restraints (which we never use.)

I have spoken with the daughter several times re. state law prohibiting use of restraints.

She has a room to room monitor so she can hear her Mother.

Our 2 CNA's live on with the patient in her home. CNA's each have 12 hr shift.

Client will try to stand up or ambulate without giving any indication of her desires to get up and she has frequent daily falls up tp 6 x a day resulting in bruises and discomfort.

Any suggestions as to how without restraints this situation can be better managed?

Thanks for ANY suggestions or examples of what you have seen or done in similar situation.

[heron, ASN, RN]

Viva and kbrn nailed it, so I won't repeat their points. I do want to reinforce the point about injury. I've been a nurse long enough to see a patient in a facility I worked in hang himself on a posey. (This was just after they changed the application to put the ties in front rather than in back. Whoever applied the posey put it on the old way, with ties in back.)

A second death occured many years later, in a different facility, when a patient on my unit hung herself between the siderails on her bed.

Restraints actually require more monitoring than leaving a patient free to move.

As for alarms, I've never expected them to prevent falls per se. What they're good for is letting caregivers know that the patient is on the move ... if the caregiver actually responds to the alarm, she/he will be able to either prevent the fall or be immediately on hand to render assistance if the patient manages to go down.

But then, there's the problem of alarm fatigue - a big one in ltc. It might not be so much of an issue in a home care setting.

[canigraduate]

Babies have no control over their limbs. Adults do. Babies can't think enough to figure out how to get out of the car seat. Adults can. Dementia patients are confused, not necessarily stupid. Also, you love your babies (hopefully, there are some nasty people out there) and are watching them like hawks. People who tie old folks down want to be able to leave them alone and have them be in the same place when they come back.

Two totally different situations.

I don't know if you've seen the pictures, but people who are restrained can seriously injure themselves trying to get free. They can dislocate joints, get fractures, and in some very sad cases have actually strangled themselves. It's NOT a good idea to restrain adults unless they are in imminent danger and you are watching them 1:1.

[ktwlpn, LPN]

Studies have shown that restraints are not only dangerous but actually increase agitation.I hope I don't see this gal in my LTC anytime soon,we are restraint free.

I suggest getting her to the doc and get some labs and a UA and some outpatient PT.The cna's need to trained that when she attempts to stand they should assist her to do so safely and walk with her (with whatever equipment she needs-a walker,merrywalker,etc)Take her outside through the neighborhood a few times a day (in a w/ch if needed) OTC pain reliever once or twice a day if not contraindicated.Lay her down for a nap once or twice a day.Make sure the lights are on,the TV is not blaring,play restful music.

Educate this family-if they want 1 to 1 care to try and eliminate falls then they need other staff to do the chores and someone needs to relieve the cna's for breaks during their shifts. I worked as a home health aide a few times years ago-these families had me doing laundry,shampooing the dog,cleaning the kitchen and starting dinner. I have still seen patients fall with 1 to 1 care, I had a man once stand up and dive over me-he hadn't stood and walked for months.Anything can happen.

[NayRN]

I've got some of the same issues as the others have: benzos are chemical restraints and drugging a person "for their own good," especially in their own home/outside of acute care (she's not in ICU trying to rip out her ET tube) has some ethical implications. What is her activity schedule like? She's in her own home with caregivers and family? Is she taken to outside activities and for walks around the neighborhood (in her wheelchair). She's obviously strong enough to get out of the chair, but fails to maintain an upright position-have we checked orthostatics? If she's one on one with a CNA all of the time, what is the CNA's job description? Is she there to care for the patient's medical needs or is she there as a housekeeper? Is she supposed to be cooking and doing laundry? Maybe this job description should be re-evaluated. What part does the family have in her care? Can't they take care of the laundry and food prep so that the CNA can focus on the patient's care?

[autumnlea]

Client lives alone in her home. CNA is a live in. with alternate CNA live in on weekends.

To help avoid the many daily falls ( bruised places on bridge of nose, forearms)

CNA puts client's walker up against the chair client is sitting in when client attempts to get out of the chair. Client often calls for her Mother when wondering around the house.

Thank you one and ALL for your wise and much needed advice. I agree that some restraints could be worse but I also agree that this is an unsafe ( for client), labor intensive/exhaustive ( for care givers) situation. Thank you again.

[MrChicagoRN, RN]

Client lives alone in her home. CNA is a live in. with alternate CNA live in on weekends.

To help avoid the many daily falls ( bruised places on bridge of nose, forearms)

CNA puts client's walker up against the chair client is sitting in when client attempts to get out of the chair. Client often calls for her Mother when wondering around the house.

Thank you one and ALL for your wise and much needed advice. I agree that some restraints could be worse but I also agree that this is an unsafe ( for client), labor intensive/exhaustive ( for care givers) situation. Thank you again.

Maybe I missed it, but is anyone actually WALKING this lady?

As someone else mentioned, these clients like to walk. I've found that instead of struggling to keep them in a chair, if you simply get them up and walk them regularly, and talk to them, the restlessness may decrease significantly.

How much are the CNA engaging with the patient on a regular basis? Does the CNA wander (escort) the house with her, talking to her about her mom and her family? What diversionary activities are being offered?

Has she received an PT safety eval, or an OT functional assessment?

[mcdebb]

I was thinking the same thing as SaoirseRN.... is a seat belt (as used for safety) allowed without it being a restraints. My husband is a school bus drive for Special Children in Philadelphia, PA and there is a differance between the two (for school buses anyway)!

Some need restraints and some only require seat-belts. Good Luck!!!!

[autumnlea]

She is frail and weak. She used to like to walk outside in front of her house. Now unable to.

She tires easily. Caregiver does walk with her all the time. They sit on front porch together for lunch.

Family doesnt come around much. She watches TV, sleeps, eats and sits on porch. Ive suggested to CNA to read to her or to sing with her ( or to her.)

Sometimes caregiver is to much in her face/ stands so close that it's imposing, such as: when attempting to stand up after sitting in front of TV for a length of time, cg leans forward and discourages her from getting up. I've told her to give client a little space, literally but stand and walk with her when she does move about the house. Cg appears to be very attentive when Im there. Client is well groomed and well dressed. Home is kept clean and clutter free.

[ktwlpn, LPN]

Client lives alone in her home. CNA is a live in. with alternate CNA live in on weekends.

To help avoid the many daily falls ( bruised places on bridge of nose, forearms)

CNA puts client's walker up against the chair client is sitting in when client attempts to get out of the chair. Client often calls for her Mother when wondering around the house.

Thank you one and ALL for your wise and much needed advice. I agree that some restraints could be worse but I also agree that this is an unsafe ( for client), labor intensive/exhaustive ( for care givers) situation. Thank you again.

This lady is in an unsafe situation-I would call the office of aging.PLease tell me what state you are in-not the tri-state area,I hope?