Dangerous patients

Specialties Geriatric

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BrandonLPN, LPN

3,358 Posts

LPNs can give IM injections. That's not the issue. The issue is that we cannot by law (at least where I live) give powerful IM sedatives or use restraints. ER departments can. That's what I meant when I said the ER has more resources.

AngelRN27

157 Posts

I see the logic behind both sides of the "dumping" debate, however, I would like to know what an experienced ER nurse would suggest we in LTC do with these patients? An assessment of a problem is no good without a plan for a solution.

sweetlilwolf

179 Posts

Ah i see. Like i stated i do not have much knowledge about LTC. Like i stated in my previous post those are some suggestions, because if that one resident is making it unsafe for the rest of the residents wouldnt the DON or or Director of the Facility have to keep the majority of the residents safe, meaning tell the family they have to find a more suitable place for that person (not sure if like a title 19 facility can do that or not?). Either way, Im not sure if anyone else has any suggestions besides what i stated above?

Blackcat99

2,836 Posts

My experience is that if a LTC patient is well to do and is "private pay" they can hit the staff all they want. Those patients are not asked to leave the LTC no matter what they do.

IowaKaren

180 Posts

Specializes in Assisted Living nursing, LTC/SNF nursing.

9:10 am by Blackcat99 My experience is that if a LTC patient is well to do and is "private pay" they can hit the staff all they want. Those patients are not asked to leave the LTC no matter what they do.

I hear you and understand. Sounds like they needed a psych consult done "like yesterday" and work closely with the Psychiatrist along with trying to reason with the family.

LoMo

40 Posts

Check with the Labor Board in your state...notify appropriate management personnel, make sure the police report is documented correctly (include notification of management by name and other witnesses), contact an attorney. Nurses are now suing their patients along with the employer.

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!

merrywhiterose

286 Posts

I work in a LTC facility & we have residents that kick, bite, pinch, grab private parts, & hit staff. Why can't we be allowed to inject Haldol, instead of forcing the staff to put up with this? They have mental issues--Alzheimers, advanced Parkinsons, etc. that cause this, but shouldn't staff be protected?

chevyv, BSN, RN

1,679 Posts

Specializes in Acute Mental Health.

Why is the doc at your facility not ordering a psych eval? If the pt continues to attempt or to hurt staff, document document document. Request prn meds (ativan can act like giving someone a martini so be careful with that one) geodon works well and the all to familiar cocktail of benedryl, haldol, and ativan help as well. I work psych and go through this on a daily basis. I can't stress the need to document enough. Each time this pt is assaultive, call the police. Eventually, the powers-that-be will have to deal with the behavior. It helps to get to know the signs before the pt becomes assaultive. Is this like a sundowning thing? Does the sight of one particular person send then into violence? Do they have a UTI? Be consistent and watch your back. It helps if the rest of the staff can get on board and document as well.

I'm sorry this is happening to you. At least where I work I can utilize restraints if necessary and give IM's.

Dan McFeeley

4 Posts

In your second post you said "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" -- that sounds to me like grounds to send the patient out again.

I'm employed at a local ER as a crisis worker and have been on the receiving end of situations like this. We're required to call a psychiatrist for disposition, either the patient's own psychiatrist at the LTC, if s/he has one, or the psychiatrist on city call. I've been in situations where the psychiatrist elected to send a patient back, but when I called the RN at the facility to give report, the RN would respond with something like, "I talked with our DON and we simply cannot accept the patient back because of the risk to staff/residents," or "don't send the patient back until I talk with the DON" after which the RN will say the same, the DON says we can't take the patient back. It can get awkard -- on the one hand a nursing home can't refuse a patient, on the other hand a nursing home can't accept a patient that poses a significant risk to staff and/or residents.

I've also been in situations where a patient was sent back after the psychiatrist decided it was a one time kind of thing, the patient had a similar behavior outburst and was sent back, and I would tell the psychiatrist "the patient was sent back but is still being aggressive, we need to admit the patient this time." Sending the patient back ER for continued aggressive behavior after previous ER admits for the same sends a signal that this is not an issue that the facility is supposed to deal with.

If the patient is being seen by a psychiatrist at your facility, and the psychiatrist has admitting privilages at a nearby psych unit, call the psychiatrist before the patient is sent out. If the patient doesn't have a psychiatrist, see if you can get one.

It can be a problem in admitting a patient for aggressive behavior when underlying medical causes are ruled out, or if they can't be attributed to a psychiatric condition. None the less, an LTC facility can be liable for continuing to house residents who are a threat to staff and other residents. If a serious injury happens to one of the residents or your staff because of your resident, and there is continued documentation of aggressive behaviors in her chart, a lawyer feeding frenzy will likely ensue.

If your doctor had given an order for psychiatric evaluation, and the documentation you've been able to find shows that it wasn't done then I'd call the doctor and have him/her look into the matter. Did the ER call you with report before the patient was returned? If not, then maybe that is something your DON should look into.

Hope this is helpfu!

-- Dan M.

trufflelilyRN

39 Posts

I have certainly not worked in all states, but in states where I have worked, any citizen can call the police regarding a person (patient) who is in danger of hurting himself or others. The person (patient) is then put in a secure facility--usually a 72 hour hold--for a psych evaluation.

If a person threatened or injured myself or another person, and I was unable to administer a prn, I would call the police.

trufflelilyRN

39 Posts

In states where I have worked, most public jurisdictions have a secure facility for lock-up psych evaluations. Rules vary from place to place. Sometimes it may be the community hospital with a couple of lock-up rooms, a public funded crisis intervention center, perhaps the nearest state hospital--but anywhere I have lived/worked, there ARE facilities available. Maybe in your area call city/county sheriff dispatch and ask where they send psych evals.

sweetlilwolf

179 Posts

OP what state are you in?

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