Involuntary commitments in LTC

[nurseebol]

We have a resident who really needs to be psychologically stabilized. She came to us homeless. She has angry outbursts and has latched on to another resident, making her incredibly uncomfortable. She can be found staring at her while she sleeps, kisses her all the time, and tells her that she loves her and "was raised by her grandma and would never hurt her" yet she paces in the room and talks about killing people. She throws things and sometimes won't let the nurse in the door. The resident spoke to me and I was able to manage a room change after I wrote a statement. The resident was discharged but sadly the son gave a false address and she came back. She has medicaid and I fear this may be part of the problem with getting her a psych stay. We are not trained to deal with her behavior. She has hit staff, and thrown stuff at us. She refuses insulin and asks for snacks all the time. I believe if she were stabilized on psych meds, we could then manage her better. I once called the doctor and asked if I could send her to the ER and he said no and to have her seen by the docs here. The docs here ordered a small amount of risperdal po, which she sometimes takes and sometimes does not. I believe she needs a dose of IM decanoate to get started. She hears voices also. I realize these drugs are now "taboo" in the elderly, because of recent studies, but what are we to do? How do we keep our residents safe? We are not trained on this and I feel helpless, sad and frustrated. When I tell my bosses, they say they say to do our best. Sometimes I feel like I should call someone else, but who?

[lindseylpn]

Do you have access to "mobile crisis"? It's like ems for psych patients. It usually has to be an emergency before they'll come out though. That could be an option is she gets too bad.

When I worked LTC we had several schizophrenics, some who could become violent. With the closure of so many mental institutions these patients are being put into LTC, which don't have the resources or staff to handle them. We frequently had to assign a CNA to sit 1 on 1 with these patients but, that left the other CNA to do the 54 other residents alone. 😕 The only real advice I have is document, document, document everything and hopefully the Dr will see that she needs to be admitted into a behavioral unit to get her started on some meds. Good luck.

[nurseebol]

I have heard of mobile crisis units, not sure if they would come out. The latest they are concerned about is her going AMA and she is not able to do that with her mental status. Then we are to call the ER and police and have her admitted. Kind of ironic that is when we are to do that.

[ltcnurse4u, CNA, LPN]

In our area, we have senior behavior units ( at local hospitals) and if they are not able to get stabilized there, they are sent to a psych hospital. In order for the resident to qualify to be sent to the behavior unit, we have to meet a certain criteria . We must have a doctor's order and in order to get that, our documentation must on point. The primary must also show they ruled out any medical issues that could cause behaviors; so we usually do a full work up on labs and once they come back, we update the doc and that is when we get the order to send to the behavior unit. 90% they just need their meds adjusted and at that point a full 8 hours of sleep.

[Neats, BSN]

Document every thing, if you need one to one then do it. Call the family to ask for assistance she may calm down if someone familiar shows up. Contact the oncall provider and tell them she is out of control and hurting others and maybe self, she needs medication she need placement in a mental health geriatric psy unit. She should not be able to come back until a Psy doc has a plan of care that is agreed upon by her PCP and facility where she will be going to.

If she is still there she should be in a single room for other residents are in jeopardy with her actions, need an updated care plan for one to one and or 10 minutes checks for her safety, resident/staff safety. Write up incidents reports, these go to the state too as these behaviors are reportable. By day two I am sure the DON and Administrator will be shipping out. Have an immediate care plan meeting with staff and family even if it is at 7PM do it. If the family will not participate then contact the ombudsman to be part of this.

[Here.I.Stand, BSN, RN]

Call the ombudsman/adult protective services ? Refusing insulin is one thing. ..the sexual battery she is committing against this other residents is a whole different animal. That woman objects to the kissing, and failure to protect her could mean big trouble for your facility.