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?
...the nurse is on weekdays 8-5, so make sure he/she knows the situation and maybe during those hours with the help of a sedative a routine can be established. During 8-5 a bath or shower could be offered and toileting established while the pt. is calmer. IF not, then he needs to be reevaluated by his doc.
...I know how hard it is with pts. who are not really pts. ie, in assisted living. And you have to protect yourself from battery charges, the advice above are all helpful. You sound like a caring person who is trying to help this person. Keep documenting...but make sure you stress to the nurse, and stress again and again and document that you talked to the nurse about your concerns, so that some routine can hopefully be established on day shift. The MD, nurse, family, med techs and other staff all need to work together.
...it sounds like he could also be going into drug withdrawal. Just my thoughts. Let us know what happens.
It is good that you are thinking so much of this patient but you also need to think of yourself. I have seen confused and elderly patients hurt nursing staff really bad.
I am not extremely familiar with assisted living but I am wondering why the nurse, social worker or family is not getting a mental hygiene warrant on this man. He is definately a threat to himself and others.
From what you have told me he needs a good medical examination by a doctor probably in a hospital setting where his behavior can be controlled and his needs can be met.
Unfortunately without a mental hygeine warrant an EMS crew will not take him.
It's my understanding that you don't have to get permission from the family to send to the hospital if that's what is needed, which from the way it sounds, he definitely needs to be hospitalized and then probably transferred to LTC. Is the nurse not on call on the weekends to deal with problems such as this? Something probably should have been done before all the powers that be left on Friday. Especially if he has been demonstrating these s/s for several weeks. There should be some kind of protocol to contact the nurse and SS after hours when there is a situation warranted such as this.
You do need to always get permission from the family or poa to send a resident to the hospital..the administrator or designee can also give permission to sent to the hospital if attempts have been made to contact the family...at least in PA.
As far as sending to the hospital for this? Okay. If the pt is lucky, they will have a geri-psyche unit that may be able to admit him and work on a plan of care, but other than that...in my experience, this type of pt might be sent to the er, maybe some labs will be done to get a baseline or see if there is some medical problem for there confusion or change in behavior, then this person is shipped to a LTC. LTC is prob more appropriate level of care.
Now at a ltc facility...all of this behavior will be care planned, a psyche eval will be done and the resident will get changed. It might not be pretty, but it will happen, of course all the interventions will be used to try and approach resident in calm manner, etc, but in the end care will be rendered and some staff might get roughed up.
Years ago, these type of pts were snowed at the slightest hint of refusal of care or combativeness with care.
The only thing you can do, Nic, is what you are doing....it sounds like a no win situation to me also. Just make sure that you document everything you do, (as you seem to be doing) and keep bugging your supervisor and the LPN on duty about this situation. This man sounds like he is seriously ill, or will be soon! Mental status changes also stem from infection, so his pneumonia could be getting worse, as he is not taking his antibiotics.
I don't work in LTC, but I think with ALF you can't just send them somewhere without the patient/family approval. It's like he lives alone as a free man but you are there to "assist" him as needed. They aren't really "patients" per se. Since he has an altered mental status and ALZ, the family has the right to decide what if anything should be done to further his life. If he was home alone and no one took him to see the doctor or to the hospital, what would happen? He would just sit in his filth for weeks. Well, the same thing can happen there. If he doesn't want to be changed and the family does not want to force the issue (while providing for staff safety), then I guess he will just get septic and die. I would not risk getting hit, bit, spit on, scratched, etc. If he refuses and family doesn't want restraints- that's it. What they really need to do in this case is take him home (the family's home), make him a CAT III, stop all his meds, and let him go. Meanwhile, they are the ones that can smell and watch him decline because they are the ONLY ones that can do something about it- legally.
I don't work in LTC, but I think with ALF you can't just send them somewhere without the patient/family approval. It's like he lives alone as a free man but you are there to "assist" him as needed. They aren't really "patients" per se. Since he has an altered mental status and ALZ, the family has the right to decide what if anything should be done to further his life. If he was home alone and no one took him to see the doctor or to the hospital, what would happen? He would just sit in his filth for weeks. Well, the same thing can happen there. If he doesn't want to be changed and the family does not want to force the issue (while providing for staff safety), then I guess he will just get septic and die. I would not risk getting hit, bit, spit on, scratched, etc. If he refuses and family doesn't want restraints- that's it. What they really need to do in this case is take him home (the family's home), make him a CAT III, stop all his meds, and let him go. Meanwhile, they are the ones that can smell and watch him decline because they are the ONLY ones that can do something about it- legally.
The thing that I worry about though is that there is a nursing relationship in this case. Also where do adult protective services come in? If a patient is confused and not taking care of themselves APS can come in and take the patient from the home--at least I thought they could.
I had the BEST night last night! My resident is doing so much better. They have put him on Ativan for showers only. The stuff must have stayed in his system for a while though because he was ever so willing to change for me last night. He even kissed me twice on my cheek and thanked me. It was such a relief! He's still not himself, but he's doing a LOT better. He was even back to walking the halls again and not sitting in his room all day. I was on cloud nine when I left work last night.....
I have worked as DON in an assisted living facility. The Adm, DON, SS (if you have this),MD, and family must all be aware of the problem and the risks of skin breakdown that could lead to infection that could lead to sepsis that could lead to death. You see, there is more involved that just this man wearing wet garments. He does need to be reassesed for appropriateness to the facility. I can't tell you how much you need to consistently document. Include in your documentation what you observe, family comments, and resident behaviors. The documentation will save you.
psalm, RN
1,263 Posts
...the nurse is on weekdays 8-5, so make sure he/she knows the situation and maybe during those hours with the help of a sedative a routine can be established. During 8-5 a bath or shower could be offered and toileting established while the pt. is calmer. IF not, then he needs to be reevaluated by his doc.
...I know how hard it is with pts. who are not really pts. ie, in assisted living. And you have to protect yourself from battery charges, the advice above are all helpful. You sound like a caring person who is trying to help this person. Keep documenting...but make sure you stress to the nurse, and stress again and again and document that you talked to the nurse about your concerns, so that some routine can hopefully be established on day shift. The MD, nurse, family, med techs and other staff all need to work together.
...it sounds like he could also be going into drug withdrawal. Just my thoughts. Let us know what happens.