Behaviors and Call Lights! Help!

[carolbear]

I just started a new position as a Staff Development Nurse. Talking and working closely with the CNA's and Nurses, I have found a common thread to poor morale. It's the one patient on the unit who is not demented but has behavioral problems. We all know the one.....the one who puts on the call light 15 minutes after the CNA or Nurse has met all the resident's needs.....and continues this behavior, often with the resident yelling at the poor CNA who has eight other resident's she must attend to. This is also a survey nightmare. You have your DON's and Administrators telling you that you have to answer the call lights within three minutes. What a horrible nightmare. To top it off the resident has been assessed to death! Nothing physical, nothing environmental AND the resident refuses mental health!! It is just the way they have been all their life. How does one deal with this type of resident and their demanding family members? Can't force psych on the resident who refuses, nor can you make them see mental health? Does anyone out there have sucessful experience with this kind of patient?

[CapeCodMermaid, RN]

As a current DON I have to disagree with a few of the things you've said. In Massachusetts the bed hold for a MassHealth patient is 10 days.

If their 10 day bed hold is up, we are not in any way obligated to take them back. We send them out because we cannot deal with their behaviors (or acute illness, whichever the case may be)and do NOT have to take them back if we can no longer meet their needs.

I try to screen every resident who is admitted to my facility. However, if I say no for whatever reason, it then goes to either the ED who is NOT a nurse and only cares about the payor source or it goes up the chain to one of the corporate people who may or may not be a nurse and has really no idea of what kind of residents MY staff is capable of caring for. We would get cited NOT for refusing a particular resident but for accepting someone into the facility we could not care for.

[Patti 2nd gen RN]

as an ex-don and an ex-surveyor your dministrators practice is unacceptable .

what needs to be done is that staff (especially the idt members) need to address the residents behavior. if you transfer the resident and don't take them back because they exceeded their 7 day bedhold and if the resident wants to come back and you still have empty beds, you can get cited.

the problem is administrators and don's do not screen the resident prior to admission. they need to make sure they have enough trained staff to take care of the that particular resident.

according to the federal and state regulations, if you accept and admit a resident to your facility, you better be able to take care of them.

absolutely--they shouldn't have been admitted in the first place--but it's not the don's and the administrators who whave to deal with these patients on a daily basis and be abused and emotionally worn down--it's the people in the trenches-- "you better be able to take care of them" the nurses have no influence with the admissions issues--we have argued and tried to stop certain admissions and the bottom line is that the beds must be filled---the people who okay admissions are not the people taking care of them-our company has people in several hospitals who are screeners---the last unacceptable patient was actually declined by a screener, then the hospital called, and got over by lying to the don about the patients status--which happens frequently--especially with weekend admissions--when there is no screener and the person accepting the admssion is not a nurse---or the hospital people describe daytime behavior and not nighttime behaviors ---or when we get admssions after 9pm, with only on-call docs on the phone, and several times not told the appropriate equipments--beds, resp. stuff etc---or the family doesn't come in that late, and we don't have important info we need to take care of the patients that night----but we can't put a limit on what time people get admitted--it's not a hospital--we have to live with different rules about restraints, and have a whole lot less resources to work with--so the preparation time does matter---i would love to get only the patients that are within our scope of safe practice--the question remains though, what can the people in the trenches do quickly to deal with those patients that are not within our scope--(that are not 911 candidates)behaviorally or medically--no one seems to have a safe legal fast answer--all the answers put our licenses at risk one way or another....i am glad for any support i can get.....even if it doesn't follow every rule....neither does life...often it feels like mash--triage which rule you can follow for the greater good--any concrete suggestions about giving the people who take care of the patients the authority on admissions would be helpful--but somehow, i can't see it....

[nursedawn67, LPN]

has this resident been assessed for everything? pain (some people just won't own up to hurting), depression, doesn't like to be alone, is used to sleeping in a bed (I have seen people that at home slept in a recliner and when in bed rings all nite/day long, put in a geri chair/recliner...out like a light), UTI, cough/cold/puemonia? Not that this is always the case but....worth checking. Others maybe can be care planned to frequently turn on call light for no real needs, that way if state sees it on they see oh she/he is care planned for it...maybe that would help

[deb101]

I work in KY and we have had behavior as described-we try all the usual-could they have an illness,social contract-and when that fails we issue a 30 day notice for discharge and assist them in finding another place, often a behavioral unit. Residents/family are told on admission the reasons we discharge and although some throw a fit we don't keep abusive residents and do everything needed to keep the other residents in a safe enviroment. Of course, we always include the state ombudsman in this process.

[not now, RN]

Oh I wish you all knew my call light friend.

Tiny, thin, with one good eye, massive stroke, only a few staff members could understand what she was saying, if she was mad at you she'd whisper to make you lean in and she'd pop you with her fist! I was her CNA once for four hours and I changed her brief around 15 times. That's all she ever used the call light for. You'd walk in and she'd want to be changed. She would hold the call button down until you changed her. If you told her she wasn't wet (often she wasn't) she'd yell until you changed her. She'd yell if she didn't think you were coming fast enough.

She was on behavior monitoring until she died. She would tell family that we abused her, left her dirty/wet and ignored her. Family constantly threatened to sue. We had to set up a sheet where the CNA charted her status every 15 minutes (wet, dry, sleeping) and she still called constantly!

[withasmilelpn]

as an ex-don and an ex-surveyor your dministrators practice is unacceptable .

what needs to be done is that staff (especially the idt members) need to address the residents behavior. if you transfer the resident and don't take them back because they exceeded their 7 day bedhold and if the resident wants to come back and you still have empty beds, you can get cited.

the problem is administrators and don's do not screen the resident prior to admission. they need to make sure they have enough trained staff to take care of the that particular resident.

according to the federal and state regulations, if you accept and admit a resident to your facility, you better be able to take care of them.

the person who screens them is not a nurse and does not work with or know the staff. our company's policy states exactly what type of patients we will accept, but their policy has no bearing on what are staff are inserviced on. the other day they admitted a man with a pca pump on evening shift with absolutely no one that knew how to set it up and monitor it. he arrived at 3pm and offgoing rn tried to tell administration that fact plus the fact that lpns can't do pca pumps. they were annoyed with her and disagreed as well. the pump arrived at 5pm. luckily a nurse coming in at 7p for the vent unit (they don't do the 8 hour shifts like the rest of the facility) did know what to do. she also pointed out that we didn't have the correct paperwork usually used for the narcotic count .

a week later, i brought in the state practice act with the section that deals with the scope of practice for lpns. it turns out that the annoying rn was correct. lpns can not administer or monitor pca pumps in my state.

we admitted a deconditioned patient who also needed rehab for alcoholism. she recieved ot, pt but no real counseling. we just are't set up that way. she's been d/cd home- what do you think her chances of recovery are?

we have a ton of psych pts now- there are no behavioral contracts to deal with them.... the list goes on and on.

i really appreciate having an ex-surveyors point of view, though. i often wonder just how much they are aware of and how much expeience working in the field they have.

[nrsbetrn]

I would like a copy of this template if you don't mind. Sounds like a good idea. FAX [phone]

[SuesquatchRN, BSN, RN]

I had one resident who would call her husband and have him call us at the nurse's station! Always during lunch, when there was no one AT the desk.

[NurseCubanitaRN2b, BSN, RN]

We have a few patients like that....What's worse is that nurses know that you're with another person who puts on the call light as soon as you leave the room....and you must return just for them to take 5 minutes to spit out why they called you again....these nurses are paging you to go to room such and such etc etc......some nurses are good and they actually help relieve the call light situation....I've had nurses who offer the bedpan....and when another nurse tells them "Why are you doing that for, that's why we have CNA's" and the nurses says "I was a CNA once and I know what it's like....I have free time, so why not help them out".....The state is in our facility right now and it's so much fun watching the DON & DSD go around answering call lights, which they normally don't do....and always overstaff....I just wish it were like that permantly....

[NurseCubanitaRN2b, BSN, RN]

A good friend of mine works at a snf where there is a patient who USES A WHISTLE if you don't answer his call light within a minute....his wife gave him the whistle and he uses it. From what I heard he even uses it at night when the others are asleep. I think that's going a little bit too far, and I feel sorry for that facility and I'm glad I don't work there.

[banditrn]

Oh I wish you all knew my call light friend.

Tiny, thin, with one good eye, massive stroke, only a few staff members could understand what she was saying, if she was mad at you she'd whisper to make you lean in and she'd pop you with her fist! I was her CNA once for four hours and I changed her brief around 15 times. That's all she ever used the call light for. You'd walk in and she'd want to be changed. She would hold the call button down until you changed her. If you told her she wasn't wet (often she wasn't) she'd yell until you changed her. She'd yell if she didn't think you were coming fast enough.

She was on behavior monitoring until she died. She would tell family that we abused her, left her dirty/wet and ignored her. Family constantly threatened to sue. We had to set up a sheet where the CNA charted her status every 15 minutes (wet, dry, sleeping) and she still called constantly!

It's ridiculous to think that with the patient load in most LTC, that you could be in her room even every 15 minutes! That family needed a 'care conference'! For people like that that require extra time, that means someone else isn't going to get as much as they need.

And the guy with the whistle? I'd have a chat with him! I've done it a few times - always respectfully, mind you, but just to let them know that they aren't the only resident there. Might also point out to him how annoying it would be to him if he were sleeping, and everyone else started blowing whistles.