Integrity and abuse vs Safety

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So in my SNF in California, there is a patient in a wheelchair with bipolar disorder, borderline personality disorder, and can be immensely verbally and physically abusive. Our facility received an IJ for safety from state a few years ago because the patient showed the state surveyor that she had a lighter.

Smoking policies have been implemented, scheduling smoking times that are supervised, smoking apron, etc. Of course, no patient should have a lighter.

Cut to now, patient is attempting to unlock the front doors at 9:30 PM, after visiting hours to go smoke. She has a lighter and cigarettes.

The dilemma is, 1) the patient should be prevented from smoking to prevent self injury- Safety

2) if we stop the patient, then the only way to get her away from the doors is to push her in her wheelchair against her will- Abuse and Integrity

In addition, any attempts to keep her from the door leads to an onslaught of verbal and physical abuse which also deviates nurse from their work from their floor.

Normally, we would have someone stand with supervise, however, at the situation, it was change of shift and clinical emergencies were happening on the floor and staff could not take the time to supervise her as she usually smokes more than one cigarette.

What is the correct course of action? Do we just bite the bullet and have someone leave the floor to supervise her with all the clinical stuff going on?

This is an ongoing issue and I understand we have reached out to many resources in attempts to manage this situation.

Any idea or tips to or resources that can help manage the situation?

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Specializes in Infusion Nursing, Home Health Infusion.

Make sure your doors are very secure. Do you have a system of patient safety alarms. This patient needs one then they can sit by the door all they want. Why does the patient have a lighter?

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Family members bring it to her. They're all aware not to do so but they do anyway. Let me know she has things like that are social services department search her belongings and confiscat them but she keeps getting more. Same with the other residents but she's the only one who reacts as abusively and explosively.

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Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.

The administration needs to get serious about this. They need to tell the family that the rules are that patient's are not allowed lighters for the safety of ALL patient's and staff and if they continue to provide them, they will be unable to visit without supervision. The facility can also be changed to non-smoking, almost all of the LTC in my area do not allow smoking on their grounds by visitors or patients. And if a patient won't abide by the policy, they are given a 30 day notice to vacate.

And if the patient is not demented, but continues to be physically abusive, staff can press charges with the police each and every time.

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We have 5150 her multiple times but police arrive she stops and police do nothing . We changed out facility to non smoking but then it was changed back. Apparently it was illegal to revoke that right? We tried to get her to leave but no facility will take care. I'm told we can't just boot her, she has to have a place to go. She's not demented total care with muscular dystrophy.

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Specializes in Hospice.

Has anyone offered her a nicotine patch? What about an E-cig? Maybe careplanning with family that they need to be the ones supervising. Can you put her on a smoking schedule? Maybe explaining to her that you will have someone supervise her when the crisis is over.

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All of that has been offered and refused. And when she wants to smoke she wants to smoke NOW. Heh. Typically we can get someone to supervise when she goes against schedule to prevent a problem, but there are many occasions where things are so hectic on the floor with other residents it's hard to step away.

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Specializes in Psych, Addictions, SOL (Student of Life).
We have 5150 her multiple times but police arrive she stops and police do nothing . We changed out facility to non smoking but then it was changed back. Apparently it was illegal to revoke that right? We tried to get her to leave but no facility will take care. I'm told we can't just boot her, she has to have a place to go. She's not demented total care with muscular dystrophy.

As A Psych nurse who will be designated to assess for and write 5150 holds in December 2017. I must state that you as a facility cannot 5150 someone. Only persons or entities designated under the Lanterman, Petrie, Short Act can assess for and write a 5150 . The criteria for 5150 is very specific a person must by reason of mental disease be a danger to themselves, others or gravely disabled to be placed on 5150 and that is only a 3 day solution. In other words you can't put someone on 5150 for being a jerk. In the past when I was designated the resident you describe would not qualify for a 5150 which is most likely the reason the police have done nothing when called. Would sending her off to a psych facility make her any better? I doubt it! If she is being seen monthly by a Psychiatrist to manage her meds (which she should be with her diagnoses) that doctor can change, adjust or add to her medication to achieve better behavioral control. Her behaviors need to be counted daily (required in California) so that the Psychiatrist and the licensing agency can accurately see what's going on. If her behavior is putting other residents in jeopardy you can in fact serve her or her designated decision maker with a 30 day notice to vacate and when the SHTF - tell the decision maker that she will have to quit smoking or leave. The average monthly cost for SNF care is somewhere between $5,000.00 to $10.000.00 depending on the services being rendered and most of that is not covered by Medicare. So your facility is likely making a lot of money on this resident. The first thing to do is to call an IDC team meeting including the designated decision maker to discuss the problem and possible solutions and consequences if a solution cannot be identified. It's possible that this resident could be happier in a smaller ICF type felicity that works with individuals with challenging behaviors. Plus it would be a lot cheaper for the family.

Hppy

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Specializes in SICU, trauma, neuro.
We have 5150 her multiple times but police arrive she stops and police do nothing . We changed out facility to non smoking but then it was changed back. Apparently it was illegal to revoke that right? We tried to get her to leave but no facility will take care. I'm told we can't just boot her, she has to have a place to go. She's not demented total care with muscular dystrophy.

Plenty of facilities are non-smoking -- mine is, and the hospital is well over 100 yrs old, so clearly at some point was MADE non-smoking. And the PP didn't suggest "just booting" her -- she said given a 30 day notice. The family can bring her lighters, but not research SNFs?

Plus, plenty of apt complexes are non-smoking. Does anyone really have the right to smoke on property that isn't theirs? Just asking, I'm not an expert.

What about family's bags being subject to search, since they have failed to comply with safety rules? And/or resident belongings searched immediately following visits?

Lighters simply cannot be allowed to be unsecured. What if she decides to smoke in bed? She is putting everyone at risk.

How about contacting the fire marshall?

And DEFINITELY contact the state. I have a feeling admin will start to take the issue seriously, esp since they have already been cited.

Police should be taking statements each and every time staff is assaulted and they are summoned. No reason a paper trail shouldn't exist. Personally if I were being assaulted by an a&o pt, I would inquire about it with the DA. I wouldn't want to rely on do-nothing police to act.

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Specializes in SICU, trauma, neuro.

Or offer to secure the family's bags during the visit, to avoid a potential illegal search issue?

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State has been notified ombadsman is aware. It seems like any intervention we try to turn to, we seem to be stuck with her. We've tried moving her, transferring her. We're all stuck in a rut heh. At least that's what management and social services department tells me

Trust me, everything is documented. She tells her family I punched her in the mouth and stole her tooth.

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Specializes in Psych, Addictions, SOL (Student of Life).
As A Psych nurse who will be designated to assess for and write 5150 holds in December 2017. I must state that you as a facility cannot 5150 someone. Only persons or entities designated under the Lanterman, Petrie, Short Act can assess for and write a 5150 . The criteria for 5150 is very specific a person must by reason of mental disease be a danger to themselves, others or gravely disabled to be placed on 5150 and that is only a 3 day solution. In other words you can't put someone on 5150 for being a jerk. In the past when I was designated the resident you describe would not qualify for a 5150 which is most likely the reason the police have done nothing when called. Would sending her off to a psych facility make her any better? I doubt it! If she is being seen monthly by a Psychiatrist to manage her meds (which she should be with her diagnoses) that doctor can change, adjust or add to her medication to achieve better behavioral control. Her behaviors need to be counted daily (required in California) so that the Psychiatrist and the licensing agency can accurately see what's going on. If her behavior is putting other residents in jeopardy you can in fact serve her or her designated decision maker with a 30 day notice to vacate and when the SHTF - tell the decision maker that she will have to quit smoking or leave. The average monthly cost for SNF care is somewhere between $5,000.00 to $10.000.00 depending on the services being rendered and most of that is not covered by Medicare. So your facility is likely making a lot of money on this resident. The first thing to do is to call an IDC team meeting including the designated decision maker to discuss the problem and possible solutions and consequences if a solution cannot be identified. It's possible that this resident could be happier in a smaller ICF type felicity that works with individuals with challenging behaviors. Plus it would be a lot cheaper for the family.

Hppy

I might add that my own mother who suffers from Alzheimer's was hospitalized in a Gero-psych facility for 83 days. She tried to kill another resident with her walker and police were called they refused to 5150 her but sent her to the local hospital for evaluation and determined that she had a raging UTI. While she was in acute hospital the memory care facility served us with a notice that she could not return. After her stint in gero-psych where she was attended by a doctor I know well we were able to get her into an Alzheimer's facility. We currently pay around $8,500.00 a month for her care. None of which is covered by Medicare. Luckily my father left about 3 million dollars in a trust for her care should she need it.

If there is anything left after she passes it will be split equally among the 5 siblings. I can't even tell you the aggravation this idea of money has caused among my family!

Hppy

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