A dilemma

[smartassmommy]

I am on orientation in the ltc where I work until I am certified. The other day a resident did not want his brief changed. My trainer tells me that he can't refuse that (clearly a violation of resident rights as I understand them) while she was changing him I got the lovely reward of a punch in the face. What makes me even sicker is that when I reported the incident to the nurse I got an "oh well" attitude. My question is what should I do?

[Pangea Reunited, ASN, RN]

I assume the resident is confused, as I can't imagine why anyone would choose to be left dirty. I think you should work with him in pairs when he's being combative ...and if there's someone who's more familiar with this gentleman and caring for him, ask them for some good strategies.

[smartassmommy]

He actually has always spoken in a clear concise manner and has full capacity. I think he resents being there which I fully get but the big question is what to do when dealing with what is ultimately a potential rights violation. We do have residents who get their entertainment by causing trouble.

[Pangea Reunited, ASN, RN]

How have the more experienced staff been dealing with him? Does he refuse frequently, or just occasionally? What reason does he give for refusing?

[CryssyD]

Unfortunately, he does have the right to refuse a brief change. Is there some reason for his refusal you can identify? What reason does he give? Is there a nurse or CNA that he likes who can do some intervention here? (Like teaching about need for skin care, odor, basic hygiene.) Is there any chance he can switch to pull-ups, which he can maybe change himself? Maybe he can be allowed to pick times for incontinence checks? Maybe he can be changed by someone he's more comfortable with?

I'm just throwing out ideas, because you need to arrange something that he's OK with. Any procedure done without the (alert) patient's consent is considered battery and he could, if he so chose, nail you to the wall for it. If this problem continues, you might consider getting the family involved--they might be able to talk sense into him.

I've been in this situation myself--a quadriplegic man on a ventilator who already had decubitus ulcers frequently refused to be turned;and all we could do was document it and try to sweet-talk him into letting us turn him. We did end up consulting psych, because we had pointed out that his refusing to be turned was definitely hurting him (impeding the healing of his decubiti, maybe making them worse) and he still refused (self-injurious behavior). It's no fun--you know what care the patient needs, and he won't let you give it to him. It's very frustrating.

As far as the punch in the face, if you have an injury, report it. In future, don't push the issue--it's not worth the hassle, especially for an alert/oriented patient. He has every right to refuse, and you have every right to refuse to put yourself in another confrontational situation where you're forcing something the patient doesn't want. There are better ways to handle the situation than strong-arming it--try to find one. Maybe go to the head nurse or manager?

[smartassmommy]

Had it been up to me, the refusal would have been documented and another attempt made later. It was my trainer who insisted on strong arming him.he won't give a reason for refusal (he seems resentful of being there, perhaps he's hoping that a problem occurs so he can get out of there). I took state test today and got to talk to my classmates. We were talking about the unsafe practices that occur on a daily basis on this unit. My classmate informed me that when she questioned her trainer about another resident who is care planned for a hoyer being transferred as a 2 assist she was told by the trainer "we have our own rules on this unit and anyone who doesn't play by them doesn't last here