Published May 19, 2009
My medical director asked me to find out what other facilities are doing about one on one supervision for those residents that have been abusive to other residents. Currently our facility has at least 10 who require one on one due to their bad behavior. The reasons I feel we have so many is we are the county home, 90% public aid, and many of our families have no idea what kind of problems their residents had in the past. If anyone could help me answer these questions I would greatly appreciate it. How many residents do you have on one-on-one supervision? How long do residents remain on one-on-one supervision? What criteria do residents have to meet to be removed from one-on-one supervision?
We have a 75 bed facility. We are the only one in the county that will take behavior residents. We have appx 15 with some sort of mental illness with occasional behavior problems. We put them on one on one only if they have caused harm or are seriously threatening to do so. We immediately begin to make arrangements to get them transfered out for in house psych treatment. They are placed on one on one until they are transferred. This usually takes 2-4 hours. However, if we can't get them out for a day or more, we call our psych doctor and get extra meds for them. Once they are sedated enough to go to bed, we can take them off one on one. We will go through this appx 3 times. By the third time, we ask the psych unit to find placement elsewhere, which is usually the state mental unit. If they seriously hurt another resident, though, the first time, we do not take them back. Hope this answers your questions.
In Massachusetts if the resident is in your facility under Medicaid, you pretty much have to promise to take them back after their psych admit or none of the psych facilities will take them. At my last facility we had a lot of behavioral patients and usually one or two on 1:1. We kept a close watch on the violent ones but it was always tricky about taking them off. We had one guy who was so bad we kept the 1:1 even when he was sleeping and since his wife had lied to me before we admitted him by telling me he had no behaviors, we sent the bill for the extra CNA to her.
How in the world do you do all those 1:1's? Where does the staff come from? I cannot understand the rationale for closing phych/mental health facilities and placing the folks in nursing homes. I do believe there are some that are appropriate...but good grief 10 people who are violent or have behaviors that warrant 1:1 in a nursing home is scary- for the other residents, the staff, and the ones who need the help. How in the world do you do it?
It does cost alot when it has to be done, but the cost of having them injure someone is more. And as noted, families and even hospitals are not always honest about behaviors and mental problems.
CapeCod, we have an agreement with the behavioral health unit in town. When they have a patient that they are unable to place b/c of mental illness, we try to take them to help them out. And then when we cannot keep them, and they cannot make them better, they agree to send them elsewhere. This place only takes medicare. When they are medicaid, it is more problematic. We usually have to call the crisis center, which I think is worthless. They are supposed to call and find a place for treatment. This does not usually happen. I have to do it. Sometimes the cops will help and transport to the state mental hospital. We've gotten real picky about taking residents who are mentally ill and have only medicaid b/c no one wants to help us.
Part of the problem started when the government closed all the state mental hospitals. There are some people who are truly beyond most help and shouldn't be housed with elderly, frail residents. We have no choice since there is no place for these people and we, as long term care providers, shouldn't be forced to take residents who put our other residents in jeopardy. I am extremely careful who I admit and fortunately my ED lets me make all the clinical decisions. I also check the sex offender registry before I let them in. There is no regulation that says we HAVE to admit someone, but there are regs which say we can't take people we can't care for and we are pretty much stuck with them once they are in the doors.
All the more reason for doing your homework before the admit and checking out the potential resident if you are equipped to handle him or not. If not , dont admit him....
Unfortunately if we are stuck with such a pt and cant send him to the psych hospital (which we almost always do- the medical director there is our in-house psych consult so we have an in)- we then put him on medications to control the behavior- not the best solution but we lack the staff for 1:1 unless the family pays.
We have to call in agency to cover, sometimes we put 2 residents who can be watched with 1 CNA, but it has really caused staffing issues. That is why we are trying to come up with alternative solutions.
Once they are admitted we can not seem to find another place, no one wants our problems. There is only 1 psyc nursing home here in town and they are always full. Families are not always honest either, and once admitted they admit the resident has had problems in the past. When things go bad we call the family but usually they do not come, that is our job which puts us in a bad position
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