Dangerous patients

[dallet6]

Just looking for some help to find written law for a situation. I work in LTC. We have a new resident who on their first day on the hall attacked one of our nurses by strangling them and telling them they were going to kill them. They also took their stethescope and threw it into the nurses' chest. Our facility got an order for an IM med, which the resident could not be given.

Eventually, EMS was called and the resident was sent for a psych eval at hospital. The hospital sent them back just a few hours later. So, two questions--if someone attempts to strangle someone and says they are going to kill them-isn't that one of the qualifications for a mandatory 72 hour psych hold?

And 2--isn't our facility liable if they readmit this resident and they then attack someone else? It could just have easily been another resident. Am I wrong to say that I would have filed charges if someone attempted to choke me and threatened to kill me? (it wasn't me it happened to).

When I came in today and read the chart I went and told my charge nurse that if this resident did this again today that I wanted them sent back out. And that I would call the police if this happened.

Anyone know the legalities here? thx!

[Music in My Heart]

"More resources," sure...

Adequately equipped and staffed to safely handle these people? Nope. Sure, I can strap them into the bed but we have nobody to interact with them, no activities, no ability to shower them, no TV, no music, no nothing... strap 'em down and wait for placement...

Just because they pose a risk to your staff or your other patients doesn't mean that they belong in an ER.

Dumping? Yes... because we have no choice but to take them and they often have no treatable medical condition...

Unprofessional? I don't see how.

Rather than being mad at me for stating the truth, you should be mad at a system that provides no place for these people to go.

They belong in the LTC with whatever is needed to provide a safe environment... and if Haldol (which isn't generally helpful with the demented old folks) and restraints are what it takes, so be it.

They're not legit ER patients.

[CapeCodMermaid, RN]

If a resident goes from placid and sweet to vicious and assaultive in under 60 seconds, there IS an underlying medical problem. We can't forcibly sedate someone to do labs or get a urine. The ER can.I don't think this post started out as an us vs. them. The REAL problem is the system which ties our hands in LTC when it comes to dealing with dangerous residents.

[Music in My Heart]

If a resident goes from placid and sweet to vicious and assaultive in under 60 seconds, there IS an underlying medical problem.

There can be... and often, it's simply that the patient has acute dementia and their demons have interacted with their environment to provoke an outburst.

I've seen it in my family, seen it while on the m/s floor, and seen it in the ER.

Agreed that the problem is the system... simply pointing out that we often get patients who are demented, only demented, and without emergent medical conditions... in what appears to be simply a matter of "we can't deal with this... here" and that we can do little to address the problem...

...which is that our society neither wants to pay to care for these people nor is comfortable with the idea of letting them go...

Emergency departments have become the dumping ground and catch-all for all sorts of social problems, this one included, and we are not resourced to deal with it.

[Nurse SMS, MSN, RN]

I am confused that their entertainment (tv, activities, music, interaction) would come over safety for those who have to care for them. The LTC does not have a restraints option! ER does. Showering? Easy. Bed bath.

Hierarchy of needs. Safety comes way before social needs.

Is the system broken? Yes. That does not change the fact that in the brokenness, the ER is less broken than the LTC.

[TeleRN44]

I work in the ER and have several times been on the receiving end of these patient dumps. We have no magic pipeline for them into a bed and the few inpatient psych faciliities won't take (a) violent patients or (b) patients with medical problems.

All you're doing is dumping the problem on us... and taking our resources away from people that we can actually help... and putting us at risk...

This is a financial and political issue, not a medical issue.

Ouch, while I can understand this point of view, I don't feel that this response is at all fair to the OP. She, too, is trying to do the best for her patient population and her co-workers. If there is blame to be directed at someone or something, then blame the system. I realize it sounds like a lame response but I seriously doubt she is attempting to "dump a patient" on you. It sounded as though she was attempting to have a patient who who wasn't appropriate for HER level of care and whose needs could not safely be addressed at HER facility get the care they needed.

Unfortunately, it meant filtering them through a ED first, so they COULD receive a higher level of care. Surely, it is not being disputed that a Nursing Home is the appropriate venue for this kind of violent individual? I know that the Nursing Homes I've seen are poorly equipped to deal with this type of patient that any ED I have to in recent years.

That's the sticky wicket of using the word "you're". There are rules. We all, more or less, are forced to play by these rules. That means that we're all on the SAME team. Why nurses tend to forget this annoys the heck out of me...it's futile to rip into the OP for following the rules and trying protect those in her care. If we don't like these rules...GET INVOLVED. Don't be bystanders when it comes to state/local legislature. For example, when they start making noise that they're going to close a local inpatient psych facility...start writing your local reps/congress-persons...instead of simply wondering what and how you're going to cope or who you're going to blame when someone in your ED gets the tar beaten out of them by one of the crazies.

Shredding a fellow nurse for venting her frustration and blasting her that she is in turn making your work place unsafe? Not playing well with others...for shame.

[TeleRN44]

In my experience, dementia seems, more often that not, to exacerbate the less flattering attributes of an individual's personality. On our floor, when they start to sundown...they hit, scratch, kick, bite, scream, punch, kick or weep hysterically without end. Some of them are just pleasantly demented...kindly and confused.

I hate to be tongue in cheek about it, but in so many ways it is like Forrest Gump's box of chocolate...you never know what you're gonna get. LOL

[Blackcat99]

I knew a LTC patient who said she was going to explode and tear the place apart if they didn't find her a new place to stay ASAP.

They kept telling her that they were trying hard to find her a new place to stay. After 2 weeks, she finally exploded and did tear up the LTC-breaking windows destroying furniture. It was amazing that no one was injured during her rampage. Of course, once she did that they were able to find her a new place immediately. I believe she went to the state psych hospital.

[Simply Complicated]

I will say speaking from a psych perspective, violent behavior does not automatically mean psych. We frequently get referrals from ER's and floors trying to give us patients when there is no psychiatric problem, as dementia and especially aggressive behavior related to Dementia is NOT a psychiatric problem. IM haldol isn't necessarily going to fix the behavior, and in many cases can make it worse in the elderly.

I agree it's a system failure. While the LTC is only equipped to handle so much, and has their protocols to follow, the same goes for ER and the psychiatric units.

[Music in My Heart]

Shredding... blasting...

You have very low standards for such extreme labels... You should hear me shred and blast... it contains a whole lot more energy and color than anything you've read here by me.

I will point out that (1) the OP's resident had been at that SNF for a day or two, (2) evidently had no emergent medical problems (as they were returned in a few hours), and (3) she had a gripe with the ED for not holding the resident for 72 hours.

It doesn't sound like "UTI psychosis" or acute schizophrenic decompensation... just a nasty and/or demented old person who didn't want to be where they were and decided to act out...

[**12XY**]

Defintely call the police. Bodily injury is not ok, even if lots of folks think because it's a nurse that was attacked it doesn't count. There are laws out there that protect EMT's if they are attacked doing care, I believe it is a felony. I would think the facility who knowingly puts an employee in danger would be liabile for harm. Most facility's will not accept someone who is dangerous due to worker comp issue and liability. Defintely do not put yourself in harms way. Call for help!

[dallet6]

Well to clarify to the person who thinks I'm blasting an ER...I wasn't. This resident was sent to the ER on Dr's orders for a mental health eval. This ER she was sent to has a special mental health section and and an in patient psych ward, both geriatric and regular. She was not being sent to a run of the mill rural er or such..and it was dr's orders. She was returned without having the mental health eval done, no documentation whatsoever. I found out today they actually tried to stick her in a cab and send her back to us. Obviously that did not happen. Since my original post, this resident has not had a behavior change unfortunately but has continued to hurt staff and did have resident-resident altercation. When she "acts out" our facility has zero we can do for her. All we can do is move other residents out of harms way and hope we can keep her from accessing things to hurt others with. The family wants us to keep her, but we are trying to direct them to other LTC facilities in the area that are made for this type of situation. These BX are apparently not new, but the family lied to us when they brought her --leaving her, the staff and other residents in an unsafe situation.

Anyway, I'm so tired after dealing with her today that I can't even remember what my point was.

[sweetlilwolf]

Im also an ER nurse. The only person that can place a patient (any patient) on a 72 hour emergency detention is a police officer or sheriff. EDs cant we do tests and say well nothing medically wrong, and send her back.

Im not sure if the hospital the patient was sent to has a inpatient mental health area or not, but even then maybe the doctor needs a suggestion for a direct admit for a inpatient psych eval? not sure how well the doctors take to suggestions but its worth a shot... Im trying to think of any other suggestions... Are you an RN or LPN? Because (i dont know all the LTC rules), but i dont see why an RN couldnt give an IM med... Perhaps shes needs a daily medication (geodon? ativan? Valium?), perhaps a daily PO med will help curb her outbursts? Also sounds like its time for a meeting with staff, family and doctor to discuss these actions.

I know in my area, nursing homes or LTC can "kick" a patient out for behaving in the way you are suggesting because she is unsafe. I would completely call the police and file charges if she would act that way towards me, i have on ED patients. Luckly, there are sheriffs close by always.

Just because we are nurses and there to care for the patient does NOT mean we have to take abuse; even from elderly patients. There is a law against attacking healthcare workers, it includes nurses not just EMTs and it is a felony.

Im very sorry you are stuck dealing with her on your shifts is exhausting to anyone...