How to handle my father's possible elder abuse

[juliekerrmark]

I am stunned and not sure what I should do, or how to handle my father's situation. My father has a fast paced onset of Alzhiemers and due to his height (6ft 6in) aand very limited mobility, we have had to place him in a LTC. The second week he began to be verbally agressive and struck out at a nurse. He was also hallucinating, dellusional, and paranoid. The LTC requested a psych consult and it was determined he should be placed in a Geriatric Psychiatric hospital for evluation and medication adjustment. I have no experience with LTC and felt overwhelmed by the turn of events. I have POA and approved the transfer. He was on this unit for 12 days. On the 11th day I saw a significant change in his ability to communicate and had severe muscle rigidity. I expressed concern and was told the Cogentin would be given. For some unknown reason I decided to look at his leg to be sure that his osteoarthritis had not flared up in his knee causing him to moan. Both legs were normal without any bruising or abrasions. The next day he was no better. The nurse called saying that his condition was the same. They had placed him in his bed and had him in front of the nursing station so that he could be watched. He also suggested that if I didn't want to visit it would be ok since my father would not know I was there. I became very anxious and insisted that the phychiatrist be consulted. The doctor was contacted and suggested that he be sent to the ER for evaluation.

I met the ambulance at the hospital and was SHOCKED by what I saw. He was totally incoherent, his tremors were so severe he was almost levitating off the stretcher, but what really threw me was the trauma that I found. Hematoma with 2 minor abrasions on forehead, large hematoma under left axilla and down flank, severe redness, swelling, abrasions to right calf with a toenail torn from the nailbed. Later in the week I retrieved his glasses which were stretched out and lens wont stay in frame. My father was admitted for tx of Cellulitist of his Rt leg, and regulation of his medicine. He is on Cumadin for Aortic Valve Replacement. His INR was 2.3

The psych hosp denies that my father fell, or was harmed by another patient. They are saying that this could have happened in the ambulance or maybe he hit his head on the bed rails in ER. Still doesn't explain the extreme bruising, hematoma, broken glasses, and torn toenail. The admitting doctor stated in her notes that he clearly fell or recieved trauma from an unknown source. The hospital did not report this. He was hospitalized for five days and was returned to the orginal LTC. They were also upset to see his truama and his nurse cried when she saw him. The DON told me they were never going to refer to that hospital again.

Now I am at a loss as to why no one has reported this and I am wanting to go to the next step. Please give me your professional opinion on how to handle this situation especially since he is my dad.

Sorry that this such a long posting, but I appreciate any guidance you can offer.

[Asystole RN]

In my professional opinion I do not see intentional physical abuse.

Your father does seem to have incurred trauma at some point from an unknown origin. From your assessments this seems to have occurred within a single day, possibly from a single event. The injuries described to me sound like the result of a fall, or near fall. His deteriorating condition seems like it may have been due to environmental changes, common with Alzheimer patients, possibly a biological cause such as a UTI (or other infection), or even the result of a fall.

Your father seems to be the perfect storm of undesirable qualities in a patient; confused, combative, and posses the physical ability to act.

I honestly do not think your father was abused, rather a combative patient who incurred injury. I would however be concerned why the trauma was not noted by anyone, poor assessments do not necessarily equal abuse however.

Be strong for your father and help those helping him.

[juliekerrmark]

one thing that I did not make clear when he was on the psych unit was that he was never observed actiing out on any agressive behavior that was seen before this admission. Nor was he physical mobile. By the 11th day, he could not talk, straighten up due to rigidiy. How he was injured certainly is important to me, but more importantly I was not told anything! Administrator pushing the blame to others. It boils down to something happened to my father and its still a mystery. Thank you for you insight. I appreciate your response.

[evolvingrn, BSN, RN]

Disagree.......... I deal with agitated , aggressive , combative pts at EOL on a fairly regular basis. and often they are dementia pts or they have brain mets. I never see bruising like that, when someone becomes agitated to the extent of hurting themself or others we get and order for SQ haldol, Never have i seen bruising on a pt from us physical restraining them. (and we don't EVER do physical restraints although we do use chemical restraints) Also if there is a fall even unwitnessed we document, document , document. So regardless somebody has been very very negligent.

Unfortunately this kind of abuse often goes unreported. My aunt had to deal with this with her MIL. The state wasn't contacted in her case either but a cna was fired. I would suggest contacting the state yourself.

And to the PP who said 'your father has the perfect storm of undesriable qualities in a patient...................That doesn't mean that he does not deserve to be treated with the upmost respect and dignity. this needs to be investigated and even if it was a complete accident the where is the report?

People who are not able to communicate are very , very vulnerable to abuse and more often than not people get away with it because of the attitudes like those above that tend to give people the benfeit of the doubt instead of encouraging investigation. I hope that you get some answers, but by launching and investigation , even if you don't get some answers about what happened to your dad you might stop it happening from someone else that goes to that facility.

[juliekerrmark]

You are right about the injuries could have been accidental. But where is the phone call to notify my family of his substantial injuries. This unit is full of medicaid type patients. Visiting hours are only from 3 to 4:30 These patients have very low family support and the advocacy for these patients are so important. hoping a wake up call comes for this unit.

[heartflutter, ADN, BSN]

Call your state health department and get someone to investigate this ASAP. If the psych hospital has nothing to hide, then they won't mind someone asking questions and looking through their facility.

[Asystole RN]

Disagree.......... I deal with agitated , aggressive , combative pts at EOL on a fairly regular basis. and often they are dementia pts or they have brain mets. I never see bruising like that, when someone becomes agitated to the extent of hurting them self or others we get and order for SQ haldol, Never have i seen bruising on a pt from us physical restraining them. (and we don't EVER do physical restraints although we do use chemical restraints) Also if there is a fall even unwitnessed we document, document , document. So regardless somebody has been very very negligent.

Many non-acute care facilities do not use haldol nor any chemical restraints at all. I have never seen bruising as described from the use of restraints but I have seen the type of bruising described from falls/near falls and also transfer/lift accidents.

We do not know if the incident was documented or not, all we know is that the daughter was not contacted about the incident and the DON had no knowledge of an incident (not to say a DON would in the first place). There is a degree of negligence somewhere with someone but not necessarily with the facility in question. We do not know if this was even a facility acquired injury or like the DON stated, possibly an injury incurred during transport. Having worked with closely with, and amongst, EMTs, Medics, and Para RNs I can tell you what happens in the bus stays on the bus.

And to the PP who said 'your father has the perfect storm of undesirable qualities in a patient...................That doesn't mean that he does not deserve to be treated with the up most respect and dignity. this needs to be investigated and even if it was a complete accident the where is the report?

Nor did I ever mention that anything less than the up most respect and dignity be provided, it is offensive you would suggest otherwise. That statement was meant for those of us who do fall risk assessments on a daily basis, the combination of confused, combative, and the ability to act equals an extreme risk of falls. I was implying that her father had extreme risk to fall or injure himself.

People who are not able to communicate are very , very vulnerable to abuse and more often than not people get away with it because of the attitudes like those above that tend to give people the benefit of the doubt instead of encouraging investigation. I hope that you get some answers, but by launching and investigation , even if you don't get some answers about what happened to your dad you might stop it happening from someone else that goes to that facility.

I never once suggested she not investigate or report the incident, in fact I never recommended any action. I simply stated my opinion that I did not believe that there was abuse.

All this being said I do believe that someone somewhere dropped the ball, I just personally would not jump to conclusions until all is said and done. If this was my father my first instinct would be to request the chart from the psych hospital, the acute care hospital, and the LTC and read the nurses notes.

[TopazLover, BSN, RN]

First, I am sorry this happened to your father. Dementia is a terrible thing and those folks who are large often are labeled as being aggressive only because people are frightened of their ability to cause harm IF they became aggressive. Certinly your father would have been frightened by the new surroundings, the trip in the ambulance, and finally being placed in the hospital. Unfortunately many people along that chain are not well equipted to handle the fears that folks with dementia have.

What is shocking is that you don't know the origin of the injuries. You could accept that things happen if you were told (as you should have been as POA). Report it to the state for review. I would not call it abuse, yet. I do see clear negligence in not informing you of his injuries. I am also concerned that the rigidity was allowed to continue without immediate intervention. Certainly this would not happen if he were younger. Or more able to speak to his own needs. That again is the crisis we face with elders. It becomes abusive and is under reported as we don't want to call it by it's name, abuse and neglect due to age and diagnosis bias.

I am glad you are there to advocate for your father. Be strong and get support from folks here at AN.

[CapeCodMermaid, RN]

I'm truly sorry you are having to go through this. It is hard enough to decide to put a parent in long term care without having to worry constantly about their safety. In long term care, we are required by regulation to inform the responsible party about any accident or incident and can be cited if we wait too long to report. We are also regulated to investigate any injury or bruise. I'm not sure the hospitals operate under the same rules.

If I were you, I'd ask to speak to the DON of the hospital or the Administrator and try to get a straight answer from them. They might have nothing to hide....on the other hand, they really might be trying to cover something up. Again, I'm not sure how psych hospitals operate and what the DON knows or doesn't.

[traumaRUs, MSN, APRN]

I think all of us agree that we are so sorry your father has injuries. We can't guess as to why or how they happened though.

Suggestions:

1. As his POA, obtain ALL of his medical records from the hospital.

2. Talk to the DON of the hospital to discuss your concerns.

3. Report the suspected abuse to their regulatory agency.

[ObtundedRN, BSN, RN]

I never see bruising like that, when someone becomes agitated to the extent of hurting themself or others we get and order for SQ haldol...

You would give this man, or someone similar, Haldol? Its contraindicated in the elderly, and he has alzheimers...

Many of these injuries sounds like they are consistant with a fall of some kind. They don't neccessarily sound like abuse, but if it was a fall (or abuse) the injuries were not reported. Or were they reported, but never reported to you as the POA? I would first request medical records to review and see if there are notes about how these injuries happend, instead of jumping to conclusions and making the state investigate. If after you get the records and maybe even consult with an attorney and find something, then you could possible get the state involved.

[shiccy]

First off, as someone else posted, Haldol is *NOT* contraindicated in the elderly, as with *all* antipsychotics/anxiolytics/narcotics/etc it should be used under extreme caution and with strict monitoring. It's better to have a closely monitored patient WITH Haldol than a person without that is throwing punches, abusing staff, and possibly hurting themselves/loved ones. To be quite honest, many if not all practitioners will use Haldol hands down first choice over any other benzo's. The main reason is it just plain works for those that you can't get calmed down. The other is that benzo's actually can INCREASE anxiety/restlessness in those that have dementia.

As for the original poster, I'm sorry but I'm not going to be any help in this circumstance other than saying that I'm sorry this happened to your loved one. It's hard to go through the mental anguish on BOTH sides with dementia/etc. This being said, this is kind of a "medical advice / legal advice" thing I wouldn't touch/comment on with a ten foot pole (and quite honestly dances on the lines of violating the TOS asking "what you should do" about possible "abuse" or "negligence" of a loved one.) I'm honestly quite surprised the topic is still open, because I've seen many other topics closed for much less, but all done appropriately so.

I guess the only thing I can suggest is to ask questions. Also an INR of 2.3 is therapeutic for most patients. This said, please look at the common side effects for medications he's taking. Trauma doesn't have to be very much when you're talking about altered coag times.

Hope his condition improves!