Geri-psych?

[PeachPie]

I used to work in a seedy nonprofit Catholic nursing home, and quitting was one of the smartest things I've ever done. One thing has lingered on my mind: Where does LTC care end and geri-psych begin? Keem in mind that I don't know squat about geri-psych.

I took care of some very violent residents with behavioral problems and even mental illnesses. There were several violent residents. some of who would scream about their delusions (one woman would scream and panic every day that her sister was being murdered down the hall and that we had to save her, crying till she vomited). The most extreme case was a severe schizophrenic who left scars on every CNA who worked on her. In addition to being an extremely paranoid schizophrenic, she was a spoiled brat who would hit, cuss at, and throw things at anyone who came near her except the charge nurses, social workers, and administrators, whom she would act sweet as pie around and blame us for molesting her and other hogwash. When reporting her behavior, we were told that we'd simply have to keep trying and that we'd have to be patient with her. Patient? Even the most seasoned CNAs had to talk to her about 20 minutes and play along with her delusions and never, ever go a step above her (a brief change usually took 30 minutes and being hit was inevitable). She definately didn't belong in a regular LTC facility (I was jsut a CNA and I could see that), but money talked.

Do most nursing homes let in people who are in need of trained psych staff? I swear, this is so reminscent of my dad's teacher stories of kids who were mainstreamed depite severe problems and created nothing but stress and problems for everybody yet the teachers were blamed for not being more patient and not doing their jobs right.

[SitcomNurse, BSN, MSN, EdD, RN]

This is a big nerve. Its a costly one too. Many places base admissions on the PRI(Patient Review Instrument) and how much therapy the person needs is a great draw. The only question that PRI needs to answer about behavior is ..... has this behavior been displayed in the last 7 days.. it lists hallucinations seperately, and it lists "Disruptive, infantile or socially inappropriate behavior". It dosent say.. resistive to care and it dosent say physically abusive. AND understand, disruptive to other patients is not the same as abusive to staff. Many facilities base their actions on this, and therefore cannot tell if a person is like that untill they are in, as they are also only required to send 7 days of notes with the patient. You can request more, but even with the current state of documentation, we no longer write...patient hit/struk out... it is now written, pt swung arms in direction of, patient's open hand came in contact with arm of X person. So... ya still cant tell. Now, once they are in, and the staff is 'dismayed' that the pt is there, you either 2PC them, or..get the staff to stop writing 'bad' things so you can transfer them. How do you think you ended up with that person?

Waiting for the next decline is also a 'strategic intervention'.

Or, hoping the patient adjusts, even in a psych setting, adjustment is not impossible.

[sanctuary, BSN, MSN, RN]

From the other side of the aisle, psych gets stuck with many people who are behaviorally disordered due to brain damage (age, injury) and who have no hope of progress. Psych nurses should be asked to consult on a problem behavior, but that does not mean that all aggressive behavior is a psych symptom. It can, however, be medicated. And don't start with the "That's chemical restraint" chorus, because it clearly isn't. Agitation and aggression can be medicated. Hall wandering cannot.

[PeachPie]

Those are somm extremely valid points. Sanctuary, I wish more people realized your perspective. Whenever a resident hits you, it's always the same lecture from the administrators and directors about how we should consider the persepctive of the resident and that we probably did something to trigger it. This makes me think about how life would be if 911 was staffed by dispatchers who, instead of directing emergency services, simply gave a lecture on how we could have prevented it, and that it's our fault that we're hurt. Geriatric residents get away with far more than others, understandably so because of dementia, but this still does not justify abuse from them. If reason can't be used to temper it, drugs must be used to control what they cannot.

Once, when a particularly snitchy goody two-shoes CNA once lectured me on how the residents were scared and frustrated and that I shouldn't blame them for hitting me, I was sooooo tempted to ask her if she was willing to be a victim for rapists to "take out their frustrations," or let physically abusive men batter her in order to work out their insecurites or if she was one of those women who send love letters and marriage proposals to men like Scott Peterson offering to love them and show them how wonderful life is. Yes, I know that it would have been a horrible thing to say, but my point stands. She would actually let residents slap her and then calmly ask them if that made them feel better.

[Natkat, BSN, MSN, RN]

I'm new to the patient care end of health care, and I'm shocked at how much crap we're supposed to put up with from patients. It feels dysfunctional to me that we're supposed to let rude markets and emotional abuse just slide off our backs. How did we come to this?

[violetrose]

In our facility propective residents are screened very carefully, we don't accept them if they have combative or disruptive behavior. We were sited big time by the state when we had a resident transfered from our Alzheimers Unit to the SNF because he was nolonger appropriate for that unit due to his decline. He became disruptive, threatened other residents and staff, actually didn't hit anyone, but did shake his fists made foul sexual comments. So we are very careful now!! These people with alzheimers/dementia/mental illness fall through the cracks, no one wants them, we can't find placement in LTC geriactic Psych units. We have had residents that when there disease advanced and developed inappropriate behaviors, there is no place to transfer them to, so now what do we do with them???

The bottom line is we have to train front line staff as how to deal with difficult behaviors, psych evals, medicate appropriately, offer deversional activity, get family involved if they will and document. It's a problem we need more advanced LTC alzheimers/mental Ilness units that aren't so restricted by the states/feds and trained appropriately. These are human beings with a a terrible disease and no one seems to want them or care for them.

[Cheyenne RN,BSHS]

whenever a resident hits you, it's always the same lecture from the administrators and directors about how we should consider the persepctive of the resident and that we probably did something to trigger it. this makes me think about how life would be if 911 was staffed by dispatchers who, instead of directing emergency services, simply gave a lecture on how we could have prevented it, and that it's our fault that we're hurt. geriatric residents get away with far more than others, understandably so because of dementia, but this still does not justify abuse from them.

isn't that a little like the way society wants to "blame" the victim for being raped or blame the victim's clothing, location, reputation, etc?

demetia not with standing, some people are just mean and as they age they can become meaner and use age as the excuse. i have seen patients who are completely alert and fully oriented x 4 and they will cuss the socks off you and pinch or hit or spit.

some behaviors are allowed and is not always a matter of them having dementia or the aging process, or of a patient having psyche issues... although behaving anti social is an issue.

imho staff should not have to be abused and then blamed for the abuse.

[PeachPie]

Yep, I've met A&O residents who would hit you and feign dementia very badly, or not even bother and just call you names in front of the charge nurses. I was not condoning allowing them to in the least, but if they are indeed demented and imagining that they're being raped every time you come into their room, it's a no-fault and measures should be taken to protect themselves and staff from what cannot be controlled.

[anndoodle]

I have worked both LTC and Geri/Psych, am still currently Geri/Psych. In the LTC setting, nurses are encouraged to chart accurately, which means if a resident pinched you, cursed you, etc. then you chart exactly what happened and what was said. To do otherwise would be falsifying medical records. We had several residents that we had to do "behavior charting" on every shift. The DON was to be infomed of all behaviors so that we could track those residents with a violent temper, etc. We have a geriatric psychiatric inpatient unit in our town, which comes in very handy (where I currently work) and we get patients from all over the surrounding counties. Agreed, sometimes we have a patient come in and the nursing home refuses to take them back due to their extreme behaviors. However, unless it is a physical event (direct harm to another resident, causing a police report and LTC report) the nursing home must take them back, according to state law....unless the facility has sent the resident's family a written 30 day notice of expulsion. I mean, you can't just boot these people out with no notice and no where else to go live!!! That's one of our biggest problems. Sometimes LTC sends them to us and then refuses to take them back, and it takes forever to find these poor people new homes. Also, many times, we resolve the behavioral problem with new meds, and send the patient back to the nursing home, only to have the MD "continue regular nursing home meds & orders" and the nurses DC the meds they were on in the psych unit and resume their old regular meds. These are the ones we get back within the week, because they're acting out again. (duh...) Many times we have to send notice with their discharge papers to make sure they do NOT stop the psych meds....many of them must be on the psych meds daily to prevent their behaviors. And then pharmacy does their LTC reviews and recommend that the dosage is lowered, so they lower it and the problems begin again. It's just a vicious cycle that never ends. And the patients, and our tax dollars, are the ones who suffer for it.

[moomoo111]

And when these residents abuse you like I've experienced in the past week, verbally and physically, how do you work around these residents again and not hate them? This is my biggest obstacle with my new job as a Resident Assistant at an Assisted Living facility. I know they can't help it, but it is very hard for me to remain compassionate at times with some of the things they say to me. I try to do what I can for their certain needs but I'm on guard and it makes me say awful things to myself. Some of them are A x 0 x 4 and I know that these residents know what they are doing and just want to take frustrations out on us, but it is awfully hard to not feel good when I'm around these people. Something I guess we have to adapt to working with that type of patient. BB

[anndoodle]

Speak with your DON concerning this issue. If it bothers you to the extent that you feel you cannot give quality care, ask to be reassigned to another area. Or you can speak with the patient's nurse and ask whether a psych assessment is warranted. They may need some med adjustments or even an inpatient stay. It's amazing how much a little Klonopin, Depakote, or Seroquel can make a difference!

[PeachPie]

This is why I commend those of you who are in geri and LTC and love it. I could never do it because it's a job in which people are not held responsible for their own actions, yet you can't force them to do the right thing and can be subject to so much abuse. I worked as a CNA in LTC and loved many of the elderly residents, but the frequent abuse from management and violent residents was enought to make me go back to waitressing.