Cognitive stable and cognitive impaired residents' living arrangements

[Norubit15, ASN, BSN, CNA, LPN, RN]

Hello! I am curious to hear others' opinions on the co-mingling of residents with cognitive impairments with those that are cognitive aware/stable. By this I mean that there are no separate wards or units i.e. "lock-down" units for those with cognitive impairment.

I have observed this in my career and it seems to me that although it allows the cognitively impaired resident to have a more home like environment that in the long run it is not safe nor effective for either resident.

An example: An Alzheimer's patient who wanders around and goes into other resident's rooms. Once there the resident picks up or removes personal objects belonging to another resident in the room, sometimes destroying the object or personal property of that other resident. I have observed this many times and it ends up causing extreme anxiety in the resident who is cognitively aware - to the extent of causing emotional distress, nervous anxiety and very often extreme agitation which often requires medication to calm.

Now...imagine this happening with about 10 "like" situations on the same shift - say a second shift where the staff you have in the 60 bed facility (which is fully occupied) is one nurse and 4 CNA's. This is a SNF in which about half of the residents require 2 person assist with all of their ADL's, are using a personal body alarm (not a wander guard type bracelet) and are at risk for falls!!

What are your feelings on this? What would be your plan of care?

I would really appreciate your comments. Thanks!

[shiningstarinpa]

You will find out that when a resident is admitted they will go to wherever there is an empty bed. If roommates don't get along for whatever reason they can change rooms later.

I have seen roommates of different cognitive abilities get along very well. Sometimes the alert, oriented resident gets a sense of purpose by "watching over" the cognitively impaired resident. And the cognitively impaired resident can get extra attention from a roommate.

I have also seen many problems between alert, oriented residents sharing a room.

So finding people who make good roommates is not predictable basing solely on cognitive abilities.

[Norubit15, ASN, BSN, CNA, LPN, RN]

Thank you for commenting! :) Yes, I too have seen many cooperative roommates where one was cognitively aware and the other was not.

I am speaking of those with advanced mental decline that wander A LOT. Those that continuously go into rooms and bother residents and their belongings and with little staff to redirect at every second, these residents are being affected by this "wanderer" both emotionally and physicially and in return many of them are returning angst and even physical behaviors back to the other.

This is my concern... the welfare of both and how to effectively care for them with minimal staffing?

Have any ideas?

[MarggoRita]

To prevent our wanderer s from entering others rooms, we placed Velcro and about 18" of fabric across the doorway at chest level. These were made by our wonderful laundry lady and care planned for those residents who desired to have them on their doors. They actually work since the wanderer could not problem solve to get beyond the barrier if the door was open, or see the doorknob if the door was closed, but the cognitive residents where capable of managing the Velcro gate on their own to prevent loss of independence but provide protection of privacy and property.

[Norubit15, ASN, BSN, CNA, LPN, RN]

Hi. Thank you for your reply.

Yes, we have door gates and alarms in use for some of the door ways. That does work for some wanderers, but some have figured out how to manipulate the velcro and/or latch assembly and even if the alarm goes off this does not stop them. Conversely some residents did not wish to have them. One in particular is sight impaired and was afraid of not seeing the door flag in place. Has tried shutting the door, but the resident just pushes the door open and goes in. And again, the resident is concerned about running into her own door.

This is a challenge for nursing on every front - safety first and foremost. I am looking for solutions to the wanderers and "touchers" in our common areas and hall ways as well. When nurses are using carts with medication and/or supplies on them and must leave them in hallway otherwise have cross-contamination - this leaves the resident and cart vulnerable to injury.

I appreciate every post here. Good to know that we are doing some things already that have been suggested.

[ktwlpn, LPN]

Something else you can try is a black rubber mat on the floor in the doorway which can sometimes deter a wanderer-they see the dark space and think it's a void in the floor. Or try a large un-breakable mirror on each side of the door-some will see their reflection and they can't relate it to themselves, they seem to think it's a sentry and will turn away. Regular toileting,pain control,snacks and drinks seems to help cut down the wandering. Also keep the environment calm with quiet music. I would also try to get boxes, containers and cupboards for the higher functioning residents to use,also child-proof locks.In-expensive shadow boxes can be found at most large craft stores,painted or decoupaged as an activity and thenhung and used to display keepsakes.

Housekeeping should not have to try to clean around a bunch of crap on the tops of the furniture.I realize it is their right to have all of that crap but if it's such a source of anxiety that someone needs a xanax because a wanderer picked up their crap then maybe they really need something to put that crap in for safe keeping.

I don't think there are any easy answers,what works for one resident will not work for another,you have to be flexible and creative. I sometimes have to actually cover the top of my med cart with a clean towel during my med pass to stop a touchy feely resident.We have had to assign 1 to 1 at times when safety was an issue .I do work on a secure unit (we have two) and this still does not solve the problems you relate.There are always conflicts between residents of different cognitive abilities. We have a strong activity schedule to keep the higher functioning folks busy,we have cna's and also resident service techs.They do not perform hands on care,they do activitities,make beds,hand out nourishments, and ice.

Certainly there is more going on with these folks in some of these situations.The higher functioning folks look at the others and really fear becoming like that.We have a group therapy once a week lead by a social worker that many of the higher functioning folks attend and it has really helped them,they verbalize their fears,talk it out and seem to have developed more patience with the others.The folks freaking out over things being touched to the extent that they need a pill are getting something out of the scenario and your challenge is to figure out what it is they are really seeking or fearing.

I just love the challenges of my job...I hope this helps.

[ktwlpn, LPN]

sorry for going on and on and on.....I'm very passionate about dementia care.I love the challenge of enticing a resident to do exactly what you need them to do.It's an art form.Maybe some dementia training for staff is in order for your facility,too.

[ktwlpn, LPN]

i'll stop now