Long time lurker, second time poster here. I guess this post is more of a vent / advice post since It's probably going to be long. I currently work in a SNF/LTC and we have this one resident who is notorious for her abusive behaviors. On our MAR we have to count her behaviors concerning being demanding, manipulative, slapping/hitting, and being verbally abusive to staff.
To paint a picture of her: On average she has ~350 of the above behaviors a month. She is incredibly (read: impossibly) specific about her medications and how the CNAs take care of her, and often keeps them in her room for 30+ minutes screaming abuse at them because she thinks there is a wrinkle in her brief. She is A/Ox4. On multiple antipsychotics and anti anxiety medications along with two narcotics for chronic pain. Her antidepressant has recently been stopped because she didn't like it. No psychiatrist will take on her case because of her behaviors anymore. She is on the last doctor at our SNF because she has "fired" all the rest. She has multiple physical ailments along with a generalized psych diagnosis of "anxiety." She has had ~90% of CNAs come crying out of her room by now.
First offense: She takes eye drops hourly when awake. She demands you come in exactly at 0600, 0700, etc to give her the eye drops. I had another agitated, confused patient I was trying to deescalate at that time and had to give her eye drops at like 0610 or 0615. I made a rookie mistake of telling her the actual time instead of just saying 0600 and she looks at me and asks if there was an emergency. I say yes, I needed to help another resident. Then she starts yelling at me, "NO! You come in here EXACTLY at six to give me my eye drops and I DON'T CARE what else is happening" etc.
Second: She takes a weekly medication and the routine for her is to go in at exactly 0515 to wake her up, have her take the medication at 0530, then come back in at 0600 and give her the rest of her medications (This weekly medication has to be taken a half hour before eating/other meds and she has to sit up for a half hour after to prevent GERD.) I don't take care of her all the time so I actually had messed this up about two weeks ago and she accused me of trying to kill her when I went in with her weekly med and her routine meds all together at 0600 since I didn't notice in time that day was her weekly med day. (FYI: The MAR doesn't specify that she can't take this med with her other meds)
Fast forward to two days ago. What had happened was she called in the CNA to tell me she wanted to take her weekly med at 0300 this morning. She has NEVER asked for this before and we have never done her med like that before either. Since I can't legally give the medication until 0400 at the earliest I didn't go in because I was trying to let her sleep, and frankly I didn't want to go in there and have her scream at me because I couldn't get the medication at the time she wanted she since had yelled abuse at me about messing up her routine with that weekly med before. She ended up calling around 0345 asking the CNA why I never came, so I went in there to explain and of course, the yelling and abuse starts immediately. I am there calmly trying to explain that she can't have it at 0300, why she wouldn't even want it at 0300 anyways, and why I didn't come in when she requested. But she won't listen to reason. She's yelling at me to do things for her like take her blanket off of her, telling me I'm putting words in her mouth, its her decision and not the doctor's when to take this medication, and how rude and disrespectful I am to not come in at 0300, and that she's been taking this medication FOR MONTHS at 0300, which just isn't true.
Basically, I was trying to calmly talk to her but it wasn't working. I will admit I became defensive but was still just trying to explain that I couldn't give the med at 0300 so why should I have gone in to wake her back up and tell her I couldn't give it at 0300 anyways. I do believe our supervisors have talked to her before but I don't know how long ago that was or how often they try to talk to her. She is demanding and manipulative like that nearly every shift every day.
How would you have approached this? Be more firm? Set more boundaries? Tell her you're going to leave until she can treat you like a human being? Tell her to stop being such a.... witch? Should I have gone in at 0300?
Even though it was two days ago I am still so mad and upset that I have been treated like this!
She is upping the ante any way feasible. So don't make it feasible.
First I would ask for a case conference. A full team approach would help with consistency. Your nursing director needs to have a meeting with this resident. Outline the medication administration times. Be firm on when she will be receiving meds, period.
When the yelling starts, I would all have a consistent "You are not prepared to take your meds. I will return in 15 minutes and we can try again". Is there a reason that this resident can't be on a toileting program? That she doesn't have PT/OT to get her out of bed? This would cut down on the "my depends is wrinkled" theory.
This resident is A&Ox4 and significantly mentally ill. Perhaps another thought is to send her out to med/psych and have all of her meds readjusted. She could be suffering from anything from personality disorder to tourettes, to pain that is not controlled to a chronic UTI, to a brain injury to dementia....the list is endless. So to have a re-evaluation of her condition would benefit her.
And even a skilled care facility that has a psych component to it.
Do not personalize this. Don't be brought to tears on her lack of symptom control. The current plan is not working, so you need something that does. And that can only be done with a team approach with everyone on the same page, and your manager and director on board.
I would also be curious why you are documenting and counting behaviors? What is the goal of that? In other words, what is to be done with that information? To document such without a goal or a plan ie: a behavior management plan for instance, is useless and in fact documents the fact that this patient was allowed to continue this red flag behavior and nothing continues to be done about it. Could be a legal nightmare when her family suddenly comes streaming out of the woodwork......like for some "wrongful death" lawsuit or some other nonsense.
Specializes in Psych, Addictions, SOL (Student of Life).
If she is a long term patient Medicare is likely not paying anything for her care as Medicare does not cover long term custodial care but someone is paying between 6 to 10 thousand dollars a month for her to be there.
This is one of those patients where you need to implement a behaviour contract. If behaviour charting does not show there is an unmet need (toileting, pain, hunger etc), then this patient is clearly acting like an ******* just for the sake of it, or has anti social personality disorder (which is practically incurable). Nurses don't have to accept inappropriate behaviour, and other residents shouldn't look to that patient as acceptable behaviour. Behaviour contracts should be implemented and enforced by everyone, and it would empower staff to leave the patient alone when you or other staff are at the point of tears.
A psych DX of "anxiety", but she is on antipsychotics, antidepressants, and anxiolytics? How can the psychiatrists refuse to treat her? If she has psych disorders that are being treated with medication, then the psychiatrist needs to diagnose her properly and see her regularly.
Has anyone spoken to her family? Are these behaviors new? What could be causing her to be so demanding? Unmet needs? Medication side effects? I'm just speculating.
First offense: She takes eye drops hourly when awake. She demands you come in exactly at 0600, 0700, etc to give her the eye drops. I had another agitated, confused patient I was trying to deescalate at that time and had to give her eye drops at like 0610 or 0615. I made a rookie mistake of telling her the actual time instead of just saying 0600 and she looks at me and asks if there was an emergency. I say yes, I needed to help another resident. Then she starts yelling at me, "NO! You come in here EXACTLY at six to give me my eye drops and I DON'T CARE what else is happening" etc.
have gone in at 0300?
:
"I'm sorry that I wasn't available to bring your eye drops at 0600. I am here now, would you like them now or do you want to wait until 0700 for the next dose?"
Documenting behaviors is necessary if someone in that facility gets it at last and decides to evict the patient, or for transfer to geri/psych lockdown house, where many of these patients end up.
It is also God-given info for hospitals. If I get a yelling, screaming, slapping LOL, I most definitely want to know if it is what she is, or she is going into acute psychosis for some purely medical reason, which can be corrected before the patient starts circling the drain for sure.
Gosh I've worked in long term care for a long time, and I've dealt with a lot of demanding patients. But those cases don't sound as severe as this one. What works the best for me when I'm dealing with a demanding resident is just grin and bear it! As the nurse, you must establish rapport. That's the most important thing. Sounds as though this patient uses these demands as a way to control her environment. I feel like a lot of times geriatric patients feel as though their losing control. Their bodies are slowly shutting down. They're physically impaired, some are becoming incontinent.. They're losing their independence. So, this is their way of controlling their surroundings. I have a patient who will tell me every day that she likes her medications at a different time. Every day I'm either too early, too late, she's too tired, she hasn't had her juice yet, etc. We've changed her meds around multiple times, but no matter what she's unhappy. So every day (with a smile on my face) I tell her that these are the medications her doctor has ordered, and the time he has requested them to be administered. I explain that we stopped giving these meds early in the morning per her request, so now they're ordered at 10 a.m..... PER HER REQUEST! Sometimes she call early, sometimes she calls late, but every time I clearly state the time periods in which I can legally administer give these medications to her. Now if she refuses to take the meds within the ordered time period I explain, again very clearly, that I will not be able to give these medications to her today because it will be out of the given time period. Usually she sighs and says ok and takes them when ordered. Other days, she's stubborn and refuses them all together. Either way, I document document document the conversation we had very thoroughly and any non-compliance.
As for her verbally abusive behavior, your manager/DON needs to handle that. Like I said, you need to establish rapport as her nurse. Do your best to please her, then get the hell out of that room and visit one of your favorite patients (this always makes me feel better). Your manager needs to set the boundaries with her and address her abusive behaviors. And, like I said, always document everything she said. Sounds like you're doing that anyways. But this sounds like the type of patient that would twist your words to get what she wants. So always document, and if you have to, bring someone else in there with you to witness the conversation. And if she does become to verbally abusive, it is always okay to say "I am more than willing to discuss your concerns with you, but you may not speak to me in this manner." Say things like "I care about how you feel and I want to help, but I cannot be spoken to this way." Have her take a deep breathe and say "Ok, I'm all ears".
Psychotics are very hard to deal with. and it's normal for you to flt that way because you are only a person. The best thing you can do is to understand more of her behavior. She's sick and she's not normal. Eventhough, how hard you explain it to her. the sad part is she will never understand it. :)
Should I have gone in at 0300?
CTtoRN, ADN, BSN, RN
29 Posts
So, I was reading an article about "difficult" NH patients who get admitted to the hospital and the NH refuses to take them back...Bingo #options
Nursing homes turn to eviction to drop difficult patients