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.
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.
That is why every facility i know does a skin assessment upon admit.......should be pretty easy to find out 'where' it happened.
Specializes in Gerontology, Med surg, Home Health.
"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."
Amen, sister. Haldol works quickly. You have to consider risk vs. benefit with ALL medications.
Thank you for all your advice, I have spoken to the administration as well as DON and was not able to obtain any info, other than they are willing to pay for his broken glasses. I requested his medical records and at this time have only recieved his admit notes, doctors progress report and therapists reports. NO nurses notes ect. They said they will not release those for at least another 30 days. There was nothing in any of those notes that document his injuries.
He was hallucinating but was never combative during the 12 days of inpatient care. I had to bring him down a floor for a cardiology check up the day before these changes started to take place. During our wait he was very verbal and was able to ask me about his stocks, explained how earthquakes occur and why didn't I sneak him in a donut. That day he was started on low doses of Abilify and Geodon. The next day when I visited he was only able to moan in response to questions and was very ridiged. Glasses were intact and no trauma was noted with the exception of typical Coumadin bruising on arms from blood draws.
Within 24 hours he was found with all of the injuries that I mentioned in my orginal post. There is no way this happened in an 20 minute ambulance ride. He was diagnosised with Cellulitis of his lower leg that required IV antibiotics. Whatever has happened has been a huge setback for him both physically and mentally.
I was asking geriatric nurses what steps should be taken in this situation. I spoke with the psychiatrist, administrator and DON. Them not acknowledging that something happened is disturbing. I have pictures which would certainly clarify why we are upset.
Since all of this is new to me; dealing with dementia so suddenly and no experience with LTC, I was hoping to have some direction. I certainly am not expecting you diagnosis this as abuse or neglect, but based on the facts that I have stated what would be the most logical steps to take. I realized very quickly that I have to be his advocate and it kills me to think that he and his peers have to deal with such situations at this time of thier lives.
You would give this man, or someone similar, Haldol? Its contraindicated in the elderly, and he has alzheimers...
Yep, i would, and I would check your facts. Haldol is a standing order for our acute pts and i use it with caution and sparingly but i definitely do use it with the elderly and its a very successful medication. we do not use it only for agitation but it is actually a very effective nausea medication in small doses as well. there is a stigma out there about haldol because of its long term abuse by some in the ltc field but it is very much an appropriate drug in some situations. It doesn't sound like this man was combative though. Eta I would also use it for someone with active hallucinations.
If you believe this happened in the nursing home before his ambulance ride, I would ocntact the ombundsman for assistance if you are getting nowhere iwth the admistration in obtaining records. Yes, do call the State public helath and they will investigate. did I undertand you to say you do have photographs?
Specializes in LTC, assisted living, med-surg, psych.
If you have POA, you have a right to see any and all records associated with your father's care, except of course for incident reports. If the administrators of these facilities are not forthcoming, and if they don't produce the requested documents within a reasonable time frame (I think 72 hours is considered "reasonable"), I would strongly suggest obtaining the services of an elder law attorney. No one else is as qualified to guide you in matters of this type, and frankly, for us to give you advice of any sort here is beyond our scope of practice as nurses.
Please accept my sympathies for what you and your father are going through. I've worked in LTC for most of my career and I've seen it from almost every possible angle, so I have a vested interest in the welfare of our most vulnerable citizens. I wish we could offer more than theories, but we weren't there when the injuries occurred and thus cannot do more than that.
I'm closing this thread because we really cannot give you medical or legal advice in this forum. PLEASE see a lawyer who specializes in elder law ASAP, and let us know how you're coping. We care. :redpinkhe
evolvingrn, BSN, RN
1,035 Posts
That is why every facility i know does a skin assessment upon admit.......should be pretty easy to find out 'where' it happened.