Abuse?

[weirdRN, RN]

Inmate X has charges of XYZ. At another jail, this inmate was allowed a kind of informal undeclared PC status because there were multiple assaults and threats to the inmate's life. When he went to a different facility, they sent him to a GP unit and began treating him as such. He was assaulted the first day he was on the compound, and so was sent to a seg unit. Since then, this Inmate states unable to care for self. Urinates on himself and refuses to do any self care. Refuses to feed himself or do more than defecate in the toilet. Security ignores him, except to hose him down every now and then, and he does not complain to the nurse during any tier rounds. Inmate eventually Brought to medical because of the stench and psych referral. Admitted into infirmary. For three weeks inmate is not bathed or helped feed himself because the Medical Director says there is nothing wrong with him. No condom catheter care is performed. Then nurse T comes along, she is only there every couple of weeks and so has not had to deal with this inmate yet. She refuses to be denied. She forces CNA M to help clean Inmate X ( That is another story). The two of them lift X into a shower chair, where RN T procedes to begin removing X's diaper and cath. The cath will not unroll properly because of the hair that is caught in the cath roll, so she pulls it from X's member. CNA M is not doing much beyond saying ewww yuck at this point. RN T pushes X into the shower and turns on the water. She douses X with antibacterial soap, and scrubs him roughly all over. Then she rinses him and pours straight hibicleanse over the areas that are still not coming clean, and washes him again. She then rinses him and he is still not clean of the dried urine, feces and food matierial that is stuck in his beard and hair and to his skin, so she takes another wash cloth and washed him yet again with regular soap. RN T argues with the inmate through out the showering that he can do things for himself if only he will try. RN T appeared to me to be trying to provoke X into doing something for himself. She pushed him upright by the back of his neck using just her one hand. She must not have been holding on because he went too far forward and bumped his head on the shower wall. She apologized, but he said he wasn't hurt. She pulled up his arms and found a HUGE yeast infection. He yelled about having his arms brought above his head. Said no one had done any kind of range of motion with him. Ever. RN T finishes shower and goes to clean his perianal area. she suggests that the area may need trimmed or shaved because of the condom cath not being on properly and not being taken care of properly. When she goes to wash his member, she finds an area on the underside of his member that is about the size of a quarter that is into the meat of the inmate's member. It appears to have a lot of skin cells built up around it. RN T says she would like to see the inmate have an indwelling catheter and calls the MD who says, no, this inmate is able to care for himself and it would be for convinence only. The next day the inmate was discharged to the Special Observation housing unit in preparation for movement back to the seg unit. In the SOH unit, the officers are once again hosing the inmate down and mostly ignoring the inmate.

So, this situation presents lots of ethical delimmas. I could sure use some input. Anyone have any thoughts on this one?

[tirzo13]

If inmate is PC, and they send him to GP, thats a case against the state right there.

I would also wonder about the nurse forcing the inmate to shower, thats borderline assault and false imprisonment, the nurse is not custody, there would have to be some kind of order that he can't refuse bathing, the cops could get away with hosing him, as they are cops, they have a bit more protection than nurses.

Its really tough, as nursing care was required, yeast infection, cath. care, assessment, etc. but if the MD says there is nothing wrong with him, its tough.

On the flipside, his lawyer could have said he got the yeast infection because no one was doing anything for him in the first place, so the nurse was right in that respect.

I would have documented that patient refuses all care and assessments, and notified the MD that patient has not bathed in weeks. I would not have proceeded past an assessment and cath. care.

He needs a serious psych eval, and standing orders for bathing and assessments.

[weirdRN, RN]

As I said it is a very complex situation. The inmate wanted assistance bathing and so on, but it was, to him, better than nothing. The inmate did not complain. The CMA did. So, does this RN warrant a reprimand or firing? or both? Does this situation open the company up to mal-practice suit? A

Now the story about CMA M. CMA M stated she had come into work that day to watch the "game" with her friends. She stated that because she was so busy, she never got to see them. RN T interupted that plan, by requiring CMA M to assist in the infirmary. CMA M is apparently having sex with an officer. She has been observed constantly flirting with custody staff and several have complained. That afternoon, even after she was allowed to leave the infirmary floor, she wasn't able to get her groove on because she got so soiled while assisting with inmate X. She was pissed, so she wrote this information report regarding the bathing of Inmate X. Incidentally, during the bathing of Inmate X, the CMA did not once intervene or step into to do more than transfer the inmate.

[RN1989]

Although the roughness and manner of the care that this nurse gave is not what I consider appropriate, I can understand her attempts to get the pt to care for himself. I am not sure that I would call it abuse, but a poor choice in the manner that she conducted it and she needs to be counseled on providing kinder treatment to the inmates.

I do believe that this inmate was neglected by both the doctor and the other staff. He obviously was not cared for as the nurse found him to be unclean with sores on his member due to lack of peri-care. Thus you could actually say that there is a case for negligent care. Whether you think the pt IS capable of doing things things does not negate the fact that he ISN'T cleaning himself, feeding himself, etc. and thus MUST have these things provided for him. The doctor was sooooo wrong to order the staff to basically leave the pt alone (doesn't matter that he is an inmate, he is still a pt). This inmate could very well have a case against this doc and the staff.

He needs to be sent for a psych consult ASAP. No person who is fully functioning would allow themselves to starve and have their body so filthy and start rotting from a penile sore! Yes, inmates will pull staff like this for a time, but no one will let it get to the extreme of the pain of a penile ulcer. For some reason this man has reverted to some type of psych state and needs care that general prison is not able to provide. The longer this goes on, the more of a case this man and his family have against the prison as this is neglect and inhumane treatment. Please work to get this man the help he needs.

Thank you for your caring about this man's treatment.

[traumaRUs, MSN, APRN]

Gosh - it sounds to me like this guy needs a physical (neuro) work-up first. Is someone sure he didn't have a stroke which resulted in his lack of self-care???

[weirdRN, RN]

The RN gave the bath before the care conference on Monday Morning. The Doc did not order nor did he approve for any testing above what happens at the prison. The general consensus is that he is either A. Malingering for secondary gain, AEB his decline and decompensation brought on by the assault and subsequent segregation (MD's opinion) or B. there is an underlying illness that adequate testing has not brought out (Psych's opinion) .

The inmate was/is a psych patient. I suggested that the inmate was reverting to a state near what one of his victims would have at some point experienced, and suggested that if we did things for him and encouraged him that he would perk up and get back with the program. The RN agreed and we both were in on it that we would play good cop/bad cop, to try to get him to do things for himself. It has obviously not worked and now my friend is in poo because CMA M intensely dislikes her, and has kicked up such a fuss that my friend believes she will get fired. I posted another thread titled Due Process, because, an NM said my friend has not had due process in this situation.

I had a long discussion with a person who would know, and that person basically said the inmate is deathly afraid that another inmate is going to hurt him, and so wants to be in a place where he is not in contact with inmates. I do not think it will matter where this inmate goes, he will always be a burden to the staff around him. He was given 95 years plus life when he was 22 for the things he did. I think he is hoping that someone will off him just by the way he acts so superior to everyone around him.

[tirzo13]

I just don't think you can force a shower on someone, unless the Inmate has been determined by PSYCH MD that he is unable to care for himself.

So, though the IM may have not complained, the CMA M (does this mean medical assistant?) does have a reason to "ratt" out the RN, as thats still assault and false imprisonment.

I'm sure there is policy somewhere in your facility that you can't force showers on some one without an order.

I would think its enough to fire someone, though i'd myself would have a conference with the nurse, documenting the meeting, and put her on probation.

But again, the patient/inmates family has a case for neglect as he has sores and yeast infection.

But still without the psych eval stating he can't care for himself, and standing orders for automatic showers, the RN kind of took it all upon herself.

Policy is Policy, rules are rules.

I don't know that the prison really has to abide by due process. If she violated a policy, i'm sure in her contract that in itself is grounds for termination.

She can call her union, but really the unions to me seem rather weak against the prisons.

Staff get walked off all the time, i never see any due process.

[RN1989]

This is a very complex situation. This man likely has a case for neglect but an attorny will likely not take it - due to the man's hx. He just isn't a reliable plaintiff or witness.

Even if the man was not a prisoner, he could have a shower "forced" on him in the interest of health and safety, even without a psych consult. Healthcare workers "force" things like this all the time - when people come in the hospital or are in LTC facilities, we help them bathe. Even when some LOL is screaming her head off that she doesn't want her diaper changed, we still do it because we understand that the woman has poor judgement and is unable to make appropriate decisions and leaving her in a wet or dirty diaper would be harmful to her. Then you have issues of apparent consent. Even if consent is not expressly given, the persons actions may indicate the apparent consent, because their behavior indicated that they were going along with what was happening. Either way, if the man was deemed to be mentally ill, a "forced" shower would have been appropriate. If the man was AOx3, a "forced" shower could have been appropropriate either by his behavior that allowed the shower or by the fact that he could be endangering others. I don't agree however in the C.O.s hosing the guy down. The motive is ok but the method is not.

This man is in tight quarters with many other people. It would be a health and safety issue to allow him to remain filthy with sores,etc. Not just for himself but for the other people. MRSA and other infections can spread rampantly throughout close quarters such as prison. A person who is covered in urine, feces, and has open wounds that can be harboring infection is a safety concern of not only other inmates but of the C.O.s and staff in that facility.

There is a fine line between violating someone's civil rights and protecting others in this type of case. It would probably be much different if the man was in his own home vs being incarcerated. But many free world rules do not apply when someone is in prison.

In a perfect world, there would be a P&P book for everything. But hospitals are bad about not having good P&Ps and a prison is probably worse. The prison should probably write a policy regarding this for future use, since it has come up once.

All employers should have P&P written regarding staff discipline and termination. Tirzo13 is correct that lots of employees do not get due process in these matters - that doesn't make it right. Just because an employee does not sue an employer for workplace violations does not mean that the employer should get away with terminating someone without cause, even though many employers reserve that right, especially in right to work states. My guess would be that the RN will get fired because to an outside observer, it looks like she is the bad guy here. And this would help to satisfy any family, advocate/ombudsmen that wanted to complain about the man's treatment. Termination is always the easy way out for an employer because an employer can be held liable for their employees actions. I still am more concerned about the fact that this man obviously has mental health issues and now physical issues that the doctor is not addressing them. I understand that there are many inmates who abuse the system but I really don't think this is the case here. I am also concerned that the staff are following doctors orders to NOT give basic hygiene to the man. If someone went to the trouble to put on a condom cath, then obviously there are issues of medical need here and the staff have a duty to the pt to provide care, regardless of the Med. Dir. orders. In this case, the Med. Dir. is wrong and a nurse that does not provide needed care is WRONG! In the free world, this doc would be looking at negligence charges, as well as any staff who followed his orders. Just because a doc writes an order, that does not mean that a nurse is covered when the nurse knows that the order is wrong. In addition, I am wondering why security and procedure is so lax that the CMA came to work on her day off so that she could play with her buddies at work. This is totally inappropriate and if I were the manager, we would be starting with verbal counseling, working up the ladder to termination. This is inappropriate in any work situation but even more so in a secure prison setting.

If they are looking to fire the RN, there probably isn't much she can do unless she is willing to put up a heck of a fight. And unless this is a private prison vs a state run, most states have limits about lawsuits against the government. Sounds like there are a lot of issues at this place, as there are in most prisons unfortunately, but they will use her as the scape goat because what she did seems more out in the open than the real issues of poor medical care.

[karbyr]

I agree with you nurse 1989, this nurse did the right thing, although her methods may have been a little "off". I am wondering who stated her treatment was rough? The CMA who was angry about having her overpaid "play time" interrupted? The prison environment is just plain different and you run into situations that are at best appalling. One of the worst situations is the ho-hum attitude of other nurses who want to use the policies and regulations to AVOID doing their job, which includes patient advocacy. Even if it is stated that this nurse violated policy by not having an order to shower this patient, I believe she would have a great defense in "qualified immunity" showing that she really believed she was doing the right thing.

[ZippyGBR, BSN, RN]

is there a documented assessment of the inmate / patient's (mental )capacity .

iuf the inmate / prisoner is found of proper assessment to have capacity to refuse then any unwanted physical contact is battery and any 'threat' to interven is assault.

if there isn't the doctor is in deep do -do (for not making sure this was done)as are the nursing staff - for letting the doc get away with this

[EC l.p.n]

that is really sad that a nurse could do that stuff. i have worked with people that either have done bad stuff or had a diease and never was like that. the person who had aids was the one i liked the best and held his hand. why are them people even in nursing? if they dont care they need to get out of nursing.

[iwanna]

I don't work in corrections, but I do have interview next week. So, I have been surfing this board to find out all I can about this area. So, I have a few questions here: What is the policy for inmates who refused to bathe? I know that I workd in psych facility, and we did bathe patients screaming and yelling. Of course, these were pts. with dementia.

But, I would think for health issues, these inmates need to bathe AT LEAST once a week. Well, I hope at least the one's that are in close quarters with other inmates.

This issue seems like a real dilemma. Legal mess?

What is the routine for this? I would think as a nurse you can just follow P&P,notify dr. and document, document, document that people were notified. Perhaps, some employees just have attitude they don't care about these inmates. An attitude that they don't deserve good care. However, that is not up to us to judge. Everyone is entitled to the adequate health care, no matter what they have done. It is not up to us to judge. Our job is to provide care, no matter what. And, to be careful to handle matters in a way that we do not cross the line. Sounds tough to me.

I am glad that I read this post. It is opening my eyes of what to expect.(if I would get the job)