Define innapropriate?

[Antikigirl, ASN, RN]

So I have a patient that was always very 'touchy feely' with his female caregivers/nurses. Well he has taken a decline in health, and his wife is no longer able to care for him (she isn't in the greatest of health herself..and the stress is causing more acute probelms), so the caregivers must provide more assistance for him.

I had a complaint from a caregiver that the man grabbed her bottom, talked about his subsequent errection from the action, and then proceeded to show her. He does have s/sx of dementa...so she was offended but was very kind and just said that that wasn't appropriate. Then all the sudden, this man who claims he can not walk, or even have the strength to dress, heard his phone, jumped up and answered it totally 100% appropriately. Then spoke to his wife as clear as a bell about the converstation, while standing with no signs of faultering, and walked giggling back to his room where he proceeded to sit down and act like he couldn't move on his own!!!! A nurse was in the room at the same time and saw (thank goodness documented) on this!

SO I was talking with my DON, and she was talking about dealing with it because of his dementia...I disagreed and said no caregiver (she is a CNA) shouldn't have to deal with that, and that steps to avoid this should be taken. We both agreed that this was a grey area, and it depends on personal opinion on what is 'inappropriate'. And that some people find things 'cute' or "oh that is an old man for ya' or "no way that will happen to me, I would so chew him out". Then I reminded her, we needed clear definitions because what one person does effects others..and if I were to take it or another did..the next person may feel very uncomfortable with this and be very upset!

We talked to his spouse, and she is just so use to his...what she calls "flirtation" (yeah flirtation??? Okay he would be in jail in public for what he did!) that it doesn't weigh to heavy on her..something she has always had to deal with (poor gal..she is a dear, and to have to put up with this behavior all her life..oh I hurt for her!!!!!!!).

What do you think...just keep telling him he is innaproprite and leave it at that, or make a formal complaint that may not be listened to by the facility administration (I almost guarentee it would go nowhere!!!!!!), or go even higher???

Toughie huh? Even if someone didn't see him get up and do all that...still would be a toughy! What about Caregivers...should they have to deal with this, or should nurses who may be more trained for the psychosocial reasons behind the behaviors????

Any thoughts???????

[ERNurse752, RN]

"It was ok that he raped me because he's schizophrenic, and was off his meds."

A little dramatic, but same concept.

I think the matter should be looked into further and measures to keep staff safe should be taken.

[ayndim]

This isn't a gray area. This needs to be dealt with. If it isn't then the CNA can and should come back and sue the facility. There is nothing cute about it. And I doubt there is anyone who doesn't think this is inappropriate. This isn't a tough decision, it needs to be reported to the authority who will listen. It is not a caregivers job to put up with this. I am sorry but your comment of "should they have to deal with this, or should nurses who may be more trained for the psychosocial reasons behind the behaviors????" turns my stomach. Nurses and caregivers are people too and should never be expected to put up with this because of mental health problems. I agree with the previous poster. Mental health problems are no excuse for not keeping staff safe.

If this guy cannot behave himself then he needs to be discharged and let his family worry about him. And I have never heard of dementia causing someone to grab someone else in a sexual way. Maybe grab someone's arm out of fear or confusion. This guy is playing the staff and needs to go.

[boulergirl, CNA]

We had a guy who would pull his member out of his briefs and deliberately wet the bed, then act like he couldn't walk to the bathroom. He also treated the staff (all-female) like dirt on a regular basis. Someone asked him why he did this and he told her that we deserved to be treated that way. He ended up moving out, but until he did, we just had to deal with it. :angryfire

Now we have a guy who constantly takes off his clothes and wanders. It's part of his dementia and there's nothing we can do about it (except give him Lorazepam). One morning he masturbated in front of a CNA and asked her how she liked it. All I can tell my co-workers is DOCUMENT this stuff (make an incident report if necessary) so mgmt. and the family has written proof that this is going on, and we're not just making up stuff.

[lovingtheunloved, ASN, RN]

Oh, it would be nice to be able to discharge someone like that! Unfortunately, my facility is specifically for people like that. You work in AL, right? There's no way in Hades that the staff should have to put up with that. Boot the guy out. If I worked in an AL facility that allowed that kind of behavior toward staff, I'd quit and get a lawyer. If the behaviors are truly caused by his dementia, he needs to be in a facility that can deal with him, and not assisted living.

[webblarsk]

psych eval..............The facility I worked in would send the patients to a behavior unit to be evaluated. A person like that can't cont to do those things, not only is he a danger to the caregivers but what about the other residents? That's a big time law suit waiting to be filed! Family members jump all over that sort of thing!

[Antikigirl, ASN, RN]

Psych eval by my utter insistance...but like I said, I work in a facility where the nurses are much older and have the attitude of "he is increasing in his dementia...we need to be more sympathetic to the causes then blow off at him..." Which makes me very upset! It is like the other nurses and administration either don't want to deal with it and will go off on a caregiver/CNA if they blow vs the patient, or they feel dementia is an excuse for anything and live with it....both I find very risky, scary, and down right wrong!

And Ayndim: "I am sorry but your comment of "should they have to deal with this, or should nurses who may be more trained for the psychosocial reasons behind the behaviors????" turns my stomach."

Let me clairify because I must have worded that wrong trying to cut down the length of my post, Nurses are supose to be qualified to look a bit deeper into these situations than CNA's or caregivers. Not excuse making for dementia or inappropriate behaviors being labled as "old age, mental health, a process of his condition and such" although some do as I am finding out..NOT ME!)...but to look at the situations that put him and the caregivers/CNA's at risk for the particular behavior, perhaps take a blood glucose, VS, order a UA, or call the MD right away for a change in behavior? Perhaps come up with a working care plan that involves quelling environmental factors that increase risk of said behavior, or not allowing caregivers/CNA's to go in alone, or having his wife perform duties (if able) that seem to illicit 'excitement' from the patient? I don't know...I thought this was a Nursing duty, not a CNA/Caregiver duty to solve, chart, write up, communicate with other disiplines, and implement????

Consider if one works in a facility whos administration is allowing this behavior to occur with little to no regard..don't you think the Nurses should then take on this patient in absence of decent and appropriate action by administration??? I would much rather I work with this patient knowing his history, health concerns, and social behavior then putting in new caregivers or CNA's (we had a surge of newbies on swing) in his room! I feel it is my job to help with complex issues..IE the reason I went to nursing school not CNA. I seem to be the ONLY nurse that cares about the caregivers/CNA's and don't want them faced with a tough job as is..then THAT! The admin doesn't care..I do! So why not put a nurse that is more qualified to find the facts about why this may be occuring all the sudden vs not caring and telling CNA's/Caregivers just to 'deal with it'. NOW that turns my stomach, and it is common practice not only in my facility, but in so many others!!!

I talked to so many of the caregivers about this, and they said they would proably loose their jobs and some their licenses by telling or 'going off' on him. I simply told them at this point..do NOT go in alone...always have another caregiver go in with them..and that that is exactly what I am going to do! If he is inappropriate, provide a safe environment for him if you can..and get out and get ME or another nurse right away. Document EVERYTHING and do it factually with quotes, and us nurses will follow up.

Yeah..dementia...well when we have a demented patient sticking forks in light sockets we tell them no untill they stop doing it or take strides to lower the risk..this is NO different to me! But many caregivers/CNA's and Nurses at my facility think it is 'just something people do when they are demented'...well so is exit seeking and we don't tollerate that and have discharged them...why not this??? (why do I have the feeling this will all boil down to the mighty dollar factor? Makes me ill!).

Speaking of discharge also, okay...say that the administration is to discharge this patient...where will he go? To YOUR facility? That is really not solving any probelms is it...passing a declining patient around from place to place, infact it may increase behavior simply due to changing his routines and environment. No, I am compassionate in this regard frankly...better off to solve the probelm here, get him a psych eval, have him cared for by trained professionals that have dealt with this particular situation, meds and eval by MD, and try to lower situations where he may exhibit the behavior! We know him best..best we do it than some new place! Getting rid of him is the easy way out that really doesn't help him..and isn't that our job??? Yes, even if he is being innappropriate...doesn't mean they don't need a nurse to give him fair and compassionate help..just makes it a bit more tricky!

So you see..on the surface this is cut and dry. This is inappropriate behavior, no doubts about that..but how to solve/change it..oh look..JUST WENT GREY!!! Discharge him...oh well that can be a probelm, okay lets just talk to him...oh boy he is not going to remember or he isn't going to listen...okay lets do a service plan that only allows certain caregivers/cna's in...oh wait, how do we judge who should and shouldn't, okay we will have just nurses work with him..oh wait some feel it is just the dementia and will take the abuse to a point, or do the opposite which doesn't help patient or staff...okay we talk to his family..oh they just said to deal with it because they put their house in hock paying for this facility..okay let the doc handle it..oh wow, they don't care or are even returning our calls/faxes....what to do what to do!?!?! GREY!!!!!!

[obillyboy]

How about Depo and a trip to the local psych unit.

Much Peace

Billy

[obillyboy]

TriageRN..................

Wow, You go . I agree with defending the caregivers and not passing the buck.

Have you asked the CNA to go to the admin. and file a formal complait?

The belief that this is all part of thedementia is a poor way to deal with a problem.

Much Peace

Billy

[Antikigirl, ASN, RN]

LOL, I brought up depo, but he has serious cardiac problems as is and the doc won't go there. Oh that could help so much really, but alas..not going to happen.

Hopefully we will get a psych eval soon, takes forever in my place to get one! But lucky our Psych eval gent is awesome and works mainly with not only our clients at my facility (so he also knows our policies, staff, etc) but specializes in just Geriatrics! BONUS! I basically had to go off on my admin to get one (has to pass through them first), and I got the okay and had it set up for ASAP.

This man has always been kinda flirty, but not outstandingly so and never touching!...sweet comments here and there, nothing ever to do with saying sexually harrassing things..this is very drastic for him all the sudden, and in addition his health is deteriorating quickly at the same time. It totally clued me into something being very wrong both mentally, physically and spiritually (very religious man..this is NOT like him at all!)!

Now I am just at the point of finding out what we can do to lower risks of his behaviors, saving my staff from these behaviors, and finding the other issues that have caused such a drastic change in behavior to the extreme of a personality trait he has exhibited mildly in the past.

I mean my goodness he did this in front of his wife, and she just left the room!!! My poor caregiver was stunned, not like him to do this! Investigation time...and I don't have much support on this endevor at work! (the other nurses are more 'oh just deal with it, he is old and dying! Don't make an issue of this...let him be'..uhggggg!).

AND YES, I soooooo told the CNA to report it immediately to the administration..that is why I know that things are not really going anywhere! . Since things aren't being done with the admin..I can so see other caregivers/CNA's going 'why bother..they don't care about me!" and not charting or filing complaints! THAT is what I am really concerned about..that he will continue his behaviors and people will adapt the wrong mindset about this behavior in patients!

[ayndim]

And Ayndim: "I am sorry but your comment of "should they have to deal with this, or should nurses who may be more trained for the psychosocial reasons behind the behaviors????" turns my stomach."

Let me clairify because I must have worded that wrong trying to cut down the length of my post, Nurses are supose to be qualified to look a bit deeper into these situations than CNA's or caregivers. Not excuse making for dementia or inappropriate behaviors being labled as "old age, mental health, a process of his condition and such" although some do as I am finding out..NOT ME!)...but to look at the situations that put him and the caregivers/CNA's at risk for the particular behavior, perhaps take a blood glucose, VS, order a UA, or call the MD right away for a change in behavior? Perhaps come up with a working care plan that involves quelling environmental factors that increase risk of said behavior, or not allowing caregivers/CNA's to go in alone, or having his wife perform duties (if able) that seem to illicit 'excitement' from the patient? I don't know...I thought this was a Nursing duty, not a CNA/Caregiver duty to solve, chart, write up, communicate with other disiplines, and implement????

Okay that makes more sense. I'm sorry I misunderstood. Basically, you are asking if the more educated caregiver should take over. Yes, absolutely. It is much better if someone who has a little more authority handle the pt. Or better yet two people. Aren't there any male nurses who could work with this guy. Bet he won't grab their butts. Just a thought.

I am glad you weren't saying nurses should have to deal with this. :) But with the crap nurses are expected to deal with it wouldn't be an uncommon attitude.

[webblarsk]

Psych eval by my utter insistance...but like I said, I work in a facility where the nurses are much older and have the attitude of "he is increasing in his dementia...we need to be more sympathetic to the causes then blow off at him..." Which makes me very upset! It is like the other nurses and administration either don't want to deal with it and will go off on a caregiver/CNA if they blow vs the patient, or they feel dementia is an excuse for anything and live with it....both I find very risky, scary, and down right wrong!

And Ayndim: "I am sorry but your comment of "should they have to deal with this, or should nurses who may be more trained for the psychosocial reasons behind the behaviors????" turns my stomach."

Let me clairify because I must have worded that wrong trying to cut down the length of my post, Nurses are supose to be qualified to look a bit deeper into these situations than CNA's or caregivers. Not excuse making for dementia or inappropriate behaviors being labled as "old age, mental health, a process of his condition and such" although some do as I am finding out..NOT ME!)...but to look at the situations that put him and the caregivers/CNA's at risk for the particular behavior, perhaps take a blood glucose, VS, order a UA, or call the MD right away for a change in behavior? Perhaps come up with a working care plan that involves quelling environmental factors that increase risk of said behavior, or not allowing caregivers/CNA's to go in alone, or having his wife perform duties (if able) that seem to illicit 'excitement' from the patient? I don't know...I thought this was a Nursing duty, not a CNA/Caregiver duty to solve, chart, write up, communicate with other disiplines, and implement????

Consider if one works in a facility whos administration is allowing this behavior to occur with little to no regard..don't you think the Nurses should then take on this patient in absence of decent and appropriate action by administration??? I would much rather I work with this patient knowing his history, health concerns, and social behavior then putting in new caregivers or CNA's (we had a surge of newbies on swing) in his room! I feel it is my job to help with complex issues..IE the reason I went to nursing school not CNA. I seem to be the ONLY nurse that cares about the caregivers/CNA's and don't want them faced with a tough job as is..then THAT! The admin doesn't care..I do! So why not put a nurse that is more qualified to find the facts about why this may be occuring all the sudden vs not caring and telling CNA's/Caregivers just to 'deal with it'. NOW that turns my stomach, and it is common practice not only in my facility, but in so many others!!!

I talked to so many of the caregivers about this, and they said they would proably loose their jobs and some their licenses by telling or 'going off' on him. I simply told them at this point..do NOT go in alone...always have another caregiver go in with them..and that that is exactly what I am going to do! If he is inappropriate, provide a safe environment for him if you can..and get out and get ME or another nurse right away. Document EVERYTHING and do it factually with quotes, and us nurses will follow up.

Yeah..dementia...well when we have a demented patient sticking forks in light sockets we tell them no untill they stop doing it or take strides to lower the risk..this is NO different to me! But many caregivers/CNA's and Nurses at my facility think it is 'just something people do when they are demented'...well so is exit seeking and we don't tollerate that and have discharged them...why not this??? (why do I have the feeling this will all boil down to the mighty dollar factor? Makes me ill!).

Speaking of discharge also, okay...say that the administration is to discharge this patient...where will he go? To YOUR facility? That is really not solving any probelms is it...passing a declining patient around from place to place, infact it may increase behavior simply due to changing his routines and environment. No, I am compassionate in this regard frankly...better off to solve the probelm here, get him a psych eval, have him cared for by trained professionals that have dealt with this particular situation, meds and eval by MD, and try to lower situations where he may exhibit the behavior! We know him best..best we do it than some new place! Getting rid of him is the easy way out that really doesn't help him..and isn't that our job??? Yes, even if he is being innappropriate...doesn't mean they don't need a nurse to give him fair and compassionate help..just makes it a bit more tricky!

So you see..on the surface this is cut and dry. This is inappropriate behavior, no doubts about that..but how to solve/change it..oh look..JUST WENT GREY!!! Discharge him...oh well that can be a probelm, okay lets just talk to him...oh boy he is not going to remember or he isn't going to listen...okay lets do a service plan that only allows certain caregivers/cna's in...oh wait, how do we judge who should and shouldn't, okay we will have just nurses work with him..oh wait some feel it is just the dementia and will take the abuse to a point, or do the opposite which doesn't help patient or staff...okay we talk to his family..oh they just said to deal with it because they put their house in hock paying for this facility..okay let the doc handle it..oh wow, they don't care or are even returning our calls/faxes....what to do what to do!?!?! GREY!!!!!!

Good for you for sticking up for your caregivers! Sorry it's such a issue for you!