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Discussion

fired, and questioning reason

I recently got a job at a nursing home. There was a resident who was out of control, hitting, biting, kicking, howling, and unsteady on her feet. I gave her ativan IM, the correct dose. In order to give the shot safely, I had help holding her still for 10 seconds. The med worked and she was fine. But, I and everyone else involved were fired for physcial restraint. I have never heard of anything like that before. Was I really wrong?

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  • Expert

I have no experience in LTC, but worked for several years as a surveyor/inspector in acute hospitals for my state and the Feds. CMS (and, probably, your state rules/regs, too) defines anything that restricts the client's movement as a physical restraint, even if it's only "10 seconds." In acute psychiatric settings, we regularly cited facilities for holding people down to give injections, or carrying people to a seclusion room, without getting an order for the physical restraint -- it wasn't that they had done anything inappropriate clinically in that particular emergent situation, but that they had restrained a client without a physician's order and following all the other steps necessary to use a physical restraint. Sounds like you were in a similar situation.

Firing seems a severe response to me, but, as I said, I know nothing about LTC, except that I know there are even more restrictions on using physical restraint than there are in acute care. I'm sorry you're in this situation -- any possibility you might get your job back? Best wishes.

You've got to be kidding me. The patient was assaulting staff, but you were fired for restraining them while you gave a shot? What should you have done? Continue to let the patient hit and kick everyone? Let the needle break off in the patient?

What are the facility guidelines for protecting staff and patients?

I agree with baptized by fire. What can you do in that case just let her/him go 51/50 on everyone??!.I question too on the policy on protecting staff members. I hope you find a better facility.

I'm sorry to hear that you and anyone else involved was fired. I know that hindsight is 20/20 and all that, but in the future if you encounter a combative resident... in addition to getting an order for a sedative to help calm them down, get a doctors order to restrain them in the event that you are unable to safely administer the medication.

I think it's unreasonable to expect the staff to endure physical abuse from a resident, but really think that the administration is trying to cover their butts in the event that someone files a formal complaint against those involved.

If I were in your position, my only real concern would be whether or not they planned on pursuing any disciplinary action against your license. You ought to find out from them what their intent is.

Good luck in finding a new job. I hope wherever you go makes more of a point to protect their employees as well as their residents.

  • Guides

As an LTC nurse manager, let me offer a slightly different perspective.

From the viewpoint of the State, residents of LTC facilities basically have ALL the rights, and caregivers are guilty of abuse until proven innocent. I'm not saying that's right, but it is reality; and under ordinary circumstances it's a good thing there are strict rules against restraining people against their will. But given the ease with which state surveyors cite facilities for the smallest of the most minor, petty violations (dust on top of a cabinet in the back of a closet that hasn't been used in years?), I can understand why your supervisors acted the way they did. Your actions could cost the facility not only a large fine, but cause it to be shut down altogether. I've seen it done.

That said........YES, there have to be procedures in place to cope with the situations that arise when you're caring for sick, psychotic, and/or demented human beings. What policies are in place at your facility for dealing with residents who come off the spool and start hitting, biting, kicking and so on? Is there a response team you could have called? What about security? Or the local police?

In our ALF, we had to call the city's finest twice last summer to subdue a particularly strong gentleman who was as nice as they come........unless he was full of booze, that is. (He has since been moved to a more secure level of care---we couldn't keep him since he was a danger to everyone around him.) He chased a med aide down the hall one night in a drunken rage; another time he yanked pictures off the walls and threw them at anything or anyone that happened to be in the way. It's pretty sad when you have to call the cops to protect other residents and staff from harm, but if you have no on-site security---or a few husky male CNAs whose presence alone might encourage the resident to subside---they're really your only choice.

Bottom line: you cannot pin down, sit on, hold back, or otherwise prevent the free use of a resident's limbs, nor can you force them to do something against their will (such as take medication). I know it stinks when you seemingly can do nothing to protect yourself. But I suggest that when you take your next job, read the policy and procedure manual and ask questions about what you are supposed to do when these sort of crises erupt, as they often do in LTC. There are many things that can be done to de-escalate the situation and avert a full-blown physical confrontation; most LTC facilities have a staff development person or other employee who can provide this education, and you can always find good information from your state ombudsman and your local Adult Protective Services.

I'm sorry you were fired over this, but knowing what I do about the rules and regs concerning abuse, I would at least have had to put you on suspension until I could interview everyone involved and get APS on board to review the incident. Please don't get me wrong, I'm NOT saying you abused your patient........just realize that the liability for the facility is enormous, they are going to save their own rear ends, and that any such incident is considered abuse until proven not to be.

Again, sorry this happened to you. Your best bet, of course, is to learn from this experience and apply what you've learned to your next position.

I wish you well.

I cannot understand; it seems as if they wanted you to throw the freaking needle like it was a dart so that the patient was not touched. I would see if this is against your license, but otherwise, I would be pissed off as well. What did the administration say to you when they terminated you?

So my question is if you have a resident having a full blown seizure and IM or PR diazepam is ordered you can't restrain to administer the med. Do you have to wait until the seizure passes until you can administer the meds, so the patient is relaxed and noncombative? Well that kind of defeats the purpose of having stat meds for seizure activity. The resident is going to be jerking and carrying on and you can get in trouble for restraining to stop the seizure. I would of done the same thing the other nurse did and I would fight the termination to the end. I wouldn't want to go back there, but I would damn well make sure that I didn't get into trouble with the state. If I'm going to get hurt or a resident is going to get hurt I will do what I need to do, right or wrong. None of us are out to intentionally hurt a resident, but if in the act of helping them it happens then you shouldn't get into trouble. Next time I think we as healthcare workers should just take the abuse and collect workman's comp for a while after the resident injures us, just kidding, but what are our options sometimes. Some of the regs they make for LTC are just plain ridculous. Example: The resident has the right to fall, what a load of bs. Like I said we do everything we can to avoid a resident ever getting injured or hurt, but if a situation arises, it may happen unfortunately. JMO

i would presume that it was documented that patient was retrained? if so, the obvious solution is to NOT document that fact......see the UNINTENDED sequelae?......when these rules/regs are put in place, it needs to be thought through.....

  • Author

Thanks for all your insight. The funny thing was the day before this happened, the DON was in the building when another resident did have a seizure, and she helped be hold him still to give the med. Also she watched as 5 of us secured and carted the resident to a safer environment.

I have always see people held still to get an injections because of seizures or contonrollable behavior. I always thought the reasoning behind injectable ativan for instance was for when a pt refused po ativan and need to have it injected. If they refuse po, it is an automatic that they will refuse an injection. So, the doctors who write these perscriptions are at fault as well.

In reading your posts, I see I have to accept responsibility for my actions, even though I was ignorant of the fact I was wrong.

I have another position in another place. I am happier there. The CNA's work hard, and care aboiut their work. That gives me a chance to do my job well, and relieves the stress of having to do my work and that of 3 cna's as well.

  • Expert
I recently got a job at a nursing home.
I have spent virtually all of my nursing career in nursing homes.

These places can terminate your employment for virtually any reason under the sun.

We all learn from mistakes. thank god you still have your license.

Sorry, but I don't understand this.

MJLRN...you say that it is against regs to hold down anyone to give an injection. It's basically considered restraint, I understand that. We would need an order to restrain said resident, etc.

But, in the "real world" I have gotten many an order for a psychotic, or demented resident who was acting out and hitting/kicking, etc, to give Zyprexa IM or Ativan IM. There is no WAY to give the injection without holding them down. I've seen nurses get hit and punched and get a needlestick from a Hiv+/HepC+ patient and got infected. I just don't understand.

So if a patient is unruly, and all other ways of de-escalating the situation have failed, and we have a dangerous situation happening, what do I do?? Even if I have already an order for a IM Zyprexa/Ativan, do I have to stop and call the doc and wait 20 minutes for him to call back and give me permission to restrain him for the injection, or am I not even able to get an order to do so?? Or do I just call the police and let them deal with it? Call 911??

I am not trying to be rude here at all, I am just reflecting on past experience in LTC and I can't count all the times help was called to hold down a resident to give a prescribed medication. I just don't understand what they want us to do. And I totally agree, the regs written for LTC are ridiculous (some of them). I understand they are there to protect the residents, but some of them are so archaic.

Take for instance, the recertifications that have to occur for those with mental illness. If they are on ANY type of psych med, whether for depression, anxiety, bipolar, schizophrenia, etc, we have to AUTOMATICALLY reduce and/or change their meds as proof we are not "chemically restraining" them. This causes distress for the resident, the nurses and aids who get hurt in the meantime, and the other residents who get hurt who have a right to live in peace.

I had to get out of LTC after many years there. It broke my heart. I love the elderly, but I hate the state and the regulations that cause so much paperwork and redundancy that cause nurses to spend more time writing than seeing our residents.

MLJRN, can you help me out with some of my questions? Or anyone else? I know there are some very knowledgeable nurses on here who are very smart and up-to-date on the laws of LTC. I would love to learn from you even though I am in inactive nurse due to cancer.

Thanks.

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