Is it ever ok to force a resident to change?

bargainhound, RN · Mar 12, 2006

You have to keep the patient clean....at some point it requires how ever

many people to do the job and get the patient clean......just a hold long

enough to do the care and then release....making sure patient and all staff

are clear from potential for harm.

Bird2 · Mar 12, 2006

This is being asked from a CNA that works in an assisted living facility (that has residents that SHOULD be in a skilled nursing facility).
Resident with Alzheimers refuses to change heavily soiled depends. Skin is becoming raw to the point of almost bleeding because of this. Reapproach several times throughout the day/evening. Still refuses and each time becomes combative by hitting, scratching (to the point of making a CNA bleed), cussing, etc.
Family members have no luck either and tell you that they WANT him changed.
Is there EVER a time when it is ok to restrain a resident to change them?

If I were you I would get the ok from the D.O.N, Social Services, and the family. I clear plan should be in place to protect you, the pt, and your facility. All interventions need to be clearly documented.

Long Term Care Columnist / Guide · Mar 12, 2006

If you haven't done so already, please let your facility nurse know about these problems. It's her job to know what's going on with each resident and to assist with the development of his/her individual service plan, which involves the resident, the family, the staff, the administrator, and oftentimes an outside agency (such as the local branch of your state's Senior Services division, hospice, home health and the like). This interdisciplinary team works together for the good of the resident, who may or may not be capable of participating in decisions about his/her care.

This particular resident sounds as though he may no longer be appropriate for assisted living, although most facilities will do their best to allow residents to 'age in place' and provide services as their needs change. There are many interventions that can be tried; the resident's doctor should be notified of the problem, as there are medications that can help manage both his urinary and behavior issues. (For this gentleman and his family, I would also write up a Managed Risk agreement, in which they would be required to sign a paper stating that they have been advised of the risks of refusing bathing and incontinence care and that the facility will not be held liable for any issues arising from such refusal.)

For your part---DOCUMENT, DOCUMENT, DOCUMENT every refusal and every incident of combativeness. In the meantime, it is never OK in a community setting for caregiving staff to restrain a resident in order to change a wet Depends.........this could set you up for allegations of assault and battery, which are CRIMINAL offenses. You may protect yourself in a reasonable manner from being hit or kicked, but you can't "hold him down" to give him a bath or a change against his will.

I hope this helps clear some things up. I'm an RN Health Services Coordinator in a small ALF, and I know how hard it can be sometimes when our residents decline. You sound like a conscientious caregiver; I wish you luck.

dekatn · Mar 12, 2006

Document, document and document some more. The M.D. will need to be notified also that pt. is refusing even the most basic care, he or she can give orders to restrain if needed in order to perform these basic needs. This will definitely have to be care planned as stated before. Even though a pt. refuses, we are responsible for keeping pt. safe and free from harm, we can't just ignore them and allow skin breakdown and/or infection related to lack of cleanliness. You have to be very inventive in situations like this so as not to cause harm to pt. while giving care. Just make sure all parties are aware of situation and measures are put in place to protect staff and pt. And, I would never attempt care w/o a nurse present to observe and assist. We had a pt. at one time that was similar to what you are describing, we had careplanned with family, M.D. SS and DON, what we worked out was, it took three staff members each time this pt. required care. There was always two CNA's and one nurse in the room. This worked out good for everyone concerned, the pt. was taken care of in a safe efficient manner and staff was safe from harm and potential lawsuits. Good luck and thank you for caring.

**SKM-NURSIEPOOH, BSN, RN** · Mar 12, 2006

i agree with all of the advice given above...especially the part referring to obtaining a md order to restrain & documentation. particularly since the resident/patient in question is having mental status changes due to alzheimer's. the question now is just how competent is the resident in making judgment decisions for themselves? and when it is deemed that the person no longer is capable of redeeming such decisions...then either an appointed family member will decide or an appointed guardian will decide. in either case...you'll need a physician order to do any sort of restraint (physical or chemical)...but first...all possible non-restraint interventions must be tried/exhausted.

good luck - cheers,

moe

NicInNC, CNA · Mar 13, 2006

I did not cange my resident once during my 3-11 shift tonight. There is no nurse on duty at my facility. Just a med tech. The nurse is only there on weekdays from 8-5. There are 2 med techs and 2 CNA's on my shift. We ALL tried all day/night long to change him. He's also been refusing all his meds and hasn't slept in his bed for the past 3 nights.

The reason I asked this question is because the day I went in for my interview, the nurse that hired me (the only nurse at this facility) specifically asked me if I knew the difference in skilled nursing and an assisted living facility. I told her that at an ALF, we ASSIST....not force. She said I was right.

This particular resident screamed at us all night that he had rights and if he didn't want to change, he wouldn't. He kept telling us "I HAVE RIGHTS AND YOU CAN'T MAKE ME DO ANYTHING! I CAN LIVE MY LIFE THE WAY I WANT TO".

He's right. If he was in a skilled nursing facility, he could probably be forced. I do NOT feel right forcing him and I WILL NOT hold him down with him yelling, hitting, scratching, cussing at me and him risking falling. He's very unsteady on his feet.

His family made the comment "do what you have to do". The daughter even said that she bruised him by trying to prevent him from hitting her and said she understood if he got a bruise. Well, I'm sorry, but I am NOT going to do something that may bruise my resident!:

:angryfire

Maybe he's really not in his right mind when he says he has rights. But then again, maybe he is. I'm just not risking it.

So, I documented that I went in there every HOUR (it was more often than that though) and he flat out refused. I hated to leave him there soaked, but I just did not feel right forcing him when he specifically repeated that he had rights. I'm not going to chance losing a job that I love at a facility that I like.

From what I understand, if he continues this way for 2 more weeks, then they're going to kick him out.

NicInNC, CNA · Mar 13, 2006

If you haven't done so already, please let your facility nurse know about these problems. It's her job to know what's going on with each resident and to assist with the development of his/her individual service plan, which involves the resident, the family, the staff, the administrator, and oftentimes an outside agency (such as the local branch of your state's Senior Services division, hospice, home health and the like). This interdisciplinary team works together for the good of the resident, who may or may not be capable of participating in decisions about his/her care.
This particular resident sounds as though he may no longer be appropriate for assisted living, although most facilities will do their best to allow residents to 'age in place' and provide services as their needs change. There are many interventions that can be tried; the resident's doctor should be notified of the problem, as there are medications that can help manage both his urinary and behavior issues. (For this gentleman and his family, I would also write up a Managed Risk agreement, in which they would be required to sign a paper stating that they have been advised of the risks of refusing bathing and incontinence care and that the facility will not be held liable for any issues arising from such refusal.)
For your part---DOCUMENT, DOCUMENT, DOCUMENT every refusal and every incident of combativeness. In the meantime, it is never OK in a community setting for caregiving staff to restrain a resident in order to change a wet Depends.........this could set you up for allegations of assault and battery, which are CRIMINAL offenses. You may protect yourself in a reasonable manner from being hit or kicked, but you can't "hold him down" to give him a bath or a change against his will.
I hope this helps clear some things up. I'm an RN Health Services Coordinator in a small ALF, and I know how hard it can be sometimes when our residents decline. You sound like a conscientious caregiver; I wish you luck.

One thing in your post stood out. I'm not familiar with the med names, so forgive me, but I DO know that they took him off some kind of alzheimers medication and also his anti-depressants. Why? I have no idea. I was told that the daughter wanted to try him off of them and that the doctor ok'd it. This particular resident currently has pneumonia and has refused his meds for the past 3 nights that I know of. I know that he also didn't take them this morning. Not sure about the other mornings though. He was VERY sick 2 weeks ago with the pneumonia and also a stomach virus on top of that (1/2 the facility had the stomach virus).

WHY would a doctor ok to take someone like him off the other meds though? He was a pretty pleasant man before this.

**SKM-NURSIEPOOH, BSN, RN** · Mar 13, 2006

one thing in your post stood out. i'm not familiar with the med names, so forgive me, but i do know that they took him off some kind of alzheimer's medication and also his anti-depressants. why? i have no idea. i was told that the daughter wanted to try him off of them and that the doctor ok'd it. this particular resident currently has pneumonia and has refused his meds for the past 3 nights that i know of. i'm know that he also didn't take them this morning. not sure about the other mornings though. he was very sick 2 weeks ago with the pneumonia and also a stomach virus on top of that (1/2 the facility had the stomach virus).

why would a doctor ok to take someone like him off the other meds though? he was a pretty pleasant man before this.

the yelling, the change in mental status, & refusal of taking meds seems to stem from the daughter & the m.d. taking the resident off of their anti-depressants & alzheimer's' medication. you say that the resident currently has pneumonia & is refusing to take his antibiotics...i bet he also is refusing to take in adequate amount of fluids too. bet 10:1 he's going to become dehydrated & eventually septic. the physician really needs to re-start this resident back onto his psychotropic meds asap so that he can return to his baseline mental status. otherwise...this resident will be transferred to a skilled ltc facility.

cheers,

moe

NicInNC, CNA · Mar 13, 2006

the yelling, the change in mental status, & refusal of taking meds seems to stem from the daughter & the m.d. taking the resident off of their anti-depressants & alzheimer's' medication. you say that the resident currently has pneumonia & is refusing to take his antibiotics...i bet he also is refusing to take in adequate amount of fluids too. bet 10:1 he's going to become dehydrated & eventually septic. the physician really needs to re-start this resident back onto his psychotropic meds asap so that he can return to his baseline mental status. otherwise...this resident will be transferred to a skilled ltc facility.

cheers,
moe

i brought him cranberry juice all throughout the day/evening yesterday. he is drinking fairly well. so, that's a plus. when i would take him his drink, he would scream at me to get out of his room. so, i would hurry and put it on his nightstand and leave. i quietly peaked in his door a few minutes later to find him drinking it each time.

this is a man that has always done for himself up until about 3 weeks ago when he got sick. he would walk the halls all day and occasionally he would get irate, but for the most part, he was pleasant natured.

he has been yelling out in pain occasionally and holding his left side. could that be from the pneumonia? the family doesn't want to send him to the hospital.....yet. i hate to see this man like this. and i'm still confused as to why they took him off his antidepressants. how stupid!!!!

i'm just all upset because i don't know if i did the right thing by not forcing him to get changed. he's very strong when he gets mad and the other day when they forced him, he ended up bleeding because a girls watch scratched him (he also scratched her and made her bleed). i"m so afraid he would get hurt or fall, so i didn't force him. the med tech that was my "supervisor" last night refused to also. she said that we weren't allowed to force him since it isn't a skilled nursing facility.

either way, i feel like i have failed in this particular case. it's really a no win situation.

Marie_LPN, RN, LPN, RN · Mar 13, 2006

For what's in the best interest of the pt.

However, an order from an MD, and he DON and SS should be involved in this, since you never know when this person might accused someone hold him down as abuse.

You've not failed, you've really not failed if you're trying.

bargainhound, RN · Mar 13, 2006

It sounds like this man is very sick and not long for

this world.