Aggressive Resident and Alcohol

[guest336699]

I had an aggressive resident that was hitting and swearing at staff. Due to this I told the resident to stop doing these things to the staff or I wouldn't give him his PRN 3oz of alcohol for the evening, he refused to stop and I told him he would have to ask the next shift nurse if she would give him some. Well, the resident went to social services and now I'm in trouble and they say they are going to report me to state. Was I in the wrong? And what should I do you protect myself legally?

[JKL33]

You will need to retain a lawyer familiar with representing nurses.

A couple of things come to mind but they are suppositions derived from other nursing knowledge, not knowledge r/t this particular situation:

- I assume the patient had an order for his 3 oz alcohol daily PRN. I don't think I would have threatened to withhold this any more than I would anything else (other care, other PRNs, etc.). Threatening to withhold something that someone is reasonably entitled to is not the same thing as appropriate boundaries.

- Instead, you would facilitate therapeutic care in the moment and then initiate care planning that addresses the behavioral situation for the future.

- These are adults presumably living in a situation that is now considered their home. This may have seemed like a reasonable negotiation in the moment, but it realistically prevented him from having his own allowed things in his own home, and in the end this is a punitive action not a therapeutic action.

- The facility should have a plan that keeps the patient, employees and other patients safe, and also individualized plans as far as safety relates to specific patients.

I hope you will get it sorted out without too much difficulty!

[kp2016]

When it comes to protecting yourself legally after an issue has already occured getting a lawyer is really the only answer.

BTW withholding alcohol from an alcoholic patient is very likely to escalate inappropriate behavior and not a tactic I would personally use. 3oz is a (relatively for an alcoholic) small amount. A better tactic would have been to tell them that you are getting them their alcohol (give them something they want) and then request that they talk to you about what's bothering them after they have had their drink.

[rac1, ASN, BSN, RN]

Quote

I assume the patient had an order for his 3 oz alcohol daily PRN. I don't think I would have threatened to withhold this any more than I would anything else (other care, other PRNs, etc.). Threatening to withhold something that someone is reasonably entitled to is not the same thing as appropriate boundaries.

I agree with this, however not entirely. I think that I, personally, could have justified withholding the alcohol based on the residents' aggression - believing that the PRN alcohol could incite more aggressive behavior since alcohol has the potential to reduce inhibition. There is plenty of research for alcohol relating to aggressive behavior. So I don't think it is wrong to tell a resident that he would not be able to have his alcohol - especially since it is PRN. And I certainly have held scheduled meds when they are contraindicated too, for that matter. So a real contraindication for a medication, whether PRN or scheduled can be a completely appropriate action.

However, I think it DOES matter how you approach the resident and what you say. If the patient is told the above (that he is being too aggressive and that his behavior is inappropriate and that the nurse is not comfortable giving alcohol because it can potentiate further aggressive behavior, and put the RN/other residents at risk...etc....) - I think it is perfectly plausible and appropriately. However, I have been around plenty of nurses and heard their power hungry minds try to force patient behavior with veiled and outright threats - when they could easily justify their thought process in a professional manner. THAT is certainly not appropriate. However, I think some people do not have that sort of logic or reasoning to be able to be professional in that way - they let anger and fear get in the way of the nursing process.

[canoehead, BSN, RN]

I think there should be a care plan in how to respond to aggressive behavior. If withholding ETOH is part of the plan, fine. But if there is a care plan in place, it should be followed rather than coming up with new consequences.

[kbrn2002, ADN, RN]

Withholding an ordered prn or even threatening to refuse to give an ordered PRN as punishment for bad behavior is wrong and a violation of residents rights. If your employer has already informed you they intend to report this to the BON you should retain an attorney. If it's the resident that stated they are going to report you to state you should still retain an attorney and update your employer before they are blindsided by a state investigation. No matter who intends to report you or by now has reported you regardless of the outcome you should probably be looking for a different job as your days with this employer are most likely numbered.

If this resident has a history of aggressive behavior how is he care planned to have that addressed? Follow the care plan and if those interventions are ineffective then follow up with the provider if further medical interventions including withholding an ordered med are needed. Document the behavior and every unsuccessful intervention attempted before escalating to the provider. To cover your own behind I'd even call the DON when interventions prove ineffective before escalating it to the provider. If the aggression is something new the DON definitely needs to be informed immediately as resident aggression isn't to be taken lightly and interventions need to put in place.

Hindsight is 20/20 so while it's not much help for your current situation about the only way to get around the potential consequences of withholding an ordered med would have been to call the provider and request an order to hold the prn alcohol. As another poster mentioned there are valid medical reasons for withholding alcohol from an aggressive resident but to do that without violating that residents right to the receive the ordered prn alcohol if it was requested you'd need a doctor's order.

[ArmyRntoMD, BSN, RN]

Lol 3 oz of ETOH will cause inhibition? It would barely cause inhibition in a non alcoholic patient, in the alcoholic patient it’s withholding a med he needs to function normally. Why would you hold this?