"Granny-Dumping" in Psyche Unit

Blackcat99 · Aug 17, 2005

My mother has Alzheimer's and I am going out of state for one week next Tuesday. It is costing me a fortune to hire good in-home care for my mother.

Just think of the money I could have saved if I would have just dropped off Mom at the ER? :rotfl: :chuckle No seriously, I really don't understand how people can just dump off their elderly relatives at the ER and take off. It's a disgrace. :angryfire :angryfire :angryfire

elkpark · Aug 17, 2005

I've been a psych nurse for a v. long time, and must say that I've seen plenty of "dumping" by LTC facilities. With some facilities, it seemed like anytime a resident raised her/his voice they would ship the person off to the local psych unit, and pop a new person in the bed immediately (often even before the person actually arrived on our unit) and it would then be our job to find a new placement when it turned out there was nothing psychiatrically wrong with the person and no reason for her/him to be on an acute psych unit. This often appeared to be just a way of getting rid of an unpopular resident (someone who complained a lot, or whose family complained).

I remember one woman in particular, who was admitted to us with dire accounts from the NH about how she had abruptly and dramatically declined, the main, specific symptom being that she had suddenly stopped eating ... When she arrived on the unit, she was A&O, v. pleasant and cooperative with us (although I gathered that she had not been so at the NH), and was able to explain to me coherently in the admission assessment that the reason she had quit eating was that she didn't like the food at the NH -- they deep-fried nearly everything, which she didn't care for, and refused to serve her anything else, so she was just eating what appealed to her on the trays (which wasn't much) and leaving the rest. This is a reason for an acute psych admission?? She ate fine for us, and our psychiatrist couldn't find anything else wrong with her, but when we called the NH the next day (needless to say, the admission took place after hours -- otherwise, we might have headed it off in the first place ... :rolleyes: ), they admitted that was she told us was basically the truth but they had already put someone else in her bed, so it was now up to us to find her another placement. I have seen more situations like this than I could possibly count, and have worked on psych units where they finally made it a policy that we wouldn't take clients from NHs unless the facility promised to hold the bed and take the person back at discharge -- but the facilities would say whatever we wanted them to in order to get someone admitted, and then turn around and give away the bed ...

The other problem I have seen is psychiatrists "trolling" for patients in nursing homes -- they make monthly visits and encourage the staff to share any concerns they are having about any residents, and then suggest that an acute psych admission (by them, to the unit they have privileges on, of course) might help. Even if residents are being aggressive and/or disruptive in the NH, that doesn't necessarily mean there is anything acutely psychiatrically wrong with them (believe me -- if we (the psych community) could fix dementia, we would!) The person is admitted to the psych unit, and spends a week or two there, during which time the doc tinkers a little with her/his medications; it's never really clear exatly why the person was admitted to the unit and it's certainly not clear how s/he is improved at discharge, or how the decision was made that s/he is "ready" for discharge; the doc makes lots of money off each of these admissions (Medicare -- our tax dollars at work :rolleyes: ); so does the hospital; and nothing has really been done for the person that couldn't have been done at the NH (a little med titration). IMHO, it's borderline Medicare fraud ...

I'm not criticizing any individual LTC staff for this problem -- I understand v. well that they have their own set of problems and pressures. But, honestly, nearly all the psych admits from LTCs that I've seen over the course of my career have been inappropriate/unnecessary (psychiatrically) ... There's got to be a better way; acute psych units are not appropriate or therapeutic places to dump DLOPs (the acronym we came up with at one place I worked for "demented little old people") or other varieties of "problem" residents.

boulergirl, CNA · Aug 17, 2005

A while back my boss had one of our residents admitted to the ER at a local hospital in order to get her a psych evaluation. She had been very disruptive on the Alzheimer's wing (and my boss had recently been attacked by a male resident), so she panicked and had her sent out. I was given orders not to allow the hospital to send her back to us until she had been thoroughly evaluated. That night I got a call from the hospital saying that the resident was not observed to be a threat to herself or others and was talking with the staff, so she was coming back. I called my boss, who said she wanted them to keep her until she'd been through a complete psych evalution. (There is a hospital in the area that does the type of evaluation--7 to 10 days--that she was looking for. Why didn't she send her there?) So I ended up talking to the charge nurse and then the doctor, who threatened us with a COBRA violation if we didn't take her back. (I'm a nurse's aide and don't know what that means. MY boss is an LPN.) I called my boss about this and she said, "NO!! They can't do that!" So I let her hash it out with the hospital, her boss, corporate office, whoever--this was her decision, her battle, and I didn't want to be caught in the middle of it. That night, the resident went to her daughter's house (and I think there was a court order prohibiting this). Believe me, it was no fun being threatened over the phone by a doctor and not knowing what to say to them. I hope I'm never forced into a similar situation again.

BTW, she's back with us now and is doing fine.

Town & Country · Aug 17, 2005

I've been a psych nurse for a v. long time, and must say that I've seen plenty of "dumping" by LTC facilities. With some facilities, it seemed like anytime a resident raised her/his voice they would ship the person off to the local psych unit, and pop a new person in the bed immediately (often even before the person actually arrived on our unit) and it would then be our job to find a new placement when it turned out there was nothing psychiatrically wrong with the person and no reason for her/him to be on an acute psych unit. This often appeared to be just a way of getting rid of an unpopular resident (someone who complained a lot, or whose family complained).

This is what happened ~ we got a little old lady from a NH; she wasn't even demented. She was sharp as a tack.

Evidently, she had been upset about her family's lack of attention at the NH.

Seems like these old people "fall thru the cracks" ~ NH can't/won't handle their "behaviors" and the psyche unit isn't the place for them.

It's a need waiting to be filled. Inservices to NH on how to better deal with "high-maintenance" residents? Something like that.........

noclpn · Aug 18, 2005

I remember one woman in particular, who was admitted to us with dire accounts from the NH about how she had abruptly and dramatically declined, the main, specific symptom being that she had suddenly stopped eating ... When she arrived on the unit, she was A&O, v. pleasant and cooperative with us (although I gathered that she had not been so at the NH), and was able to explain to me coherently in the admission assessment that the reason she had quit eating was that she didn't like the food at the NH -- they deep-fried nearly everything, which she didn't care for, and refused to serve her anything else, so she was just eating what appealed to her on the trays (which wasn't much) and leaving the rest. This is a reason for an acute psych admission?? She ate fine for us, and our psychiatrist couldn't find anything else wrong with her, but when we called the NH the next day (needless to say, the admission took place after hours -- otherwise, we might have headed it off in the first place ... ), they admitted that was she told us was basically the truth but they had already put someone else in her bed, so it was now up to us to find her another placement. I have seen more situations like this than I could possibly count, and have worked on psych units where they finally made it a policy that we wouldn't take clients from NHs unless the facility promised to hold the bed and take the person back at discharge -- but the facilities would say whatever we wanted them to in order to get someone admitted, and then turn around and give away the bed ...
In most states, beds (by law) can not be filled for at least 24 hours after a transfer to another facility for evaluation. At our facility, it is 72 hours by law. Also, residents act one way at LTC and then do a 180 for ER or other facility. I have never heard of a LTC facility that deep fried everything. LTC facilities are under strict regulations regarding nutrition. In my LTC, we offer alternatives to every meal (state mandated) and offer snacks throughout the day (state also checks and verifies that this is done). I have had a 1:40 patient ratio at an acute skilled care facility, so you can imagine how hectic and busy we are. Even there, simple questions like UTI? or Nutrition? would be assessed for mental status change. It also worries me that other psych nurses may feel the way that you do and are downplaying s/s reported from the nursing home. Psych is a big problem in LTC, docs want to give meds to easily without even attempting to find the real cause of the problem. Some LTC nurses fight for the res to get screened by psych. Although they might be A&O for you, they might have been a different person 24 hours ago. Just remember that!!! :) Also, I would be more worried about sending the pt back to the NH that was not providing proper nutrition than being put out by finding them a new placement.

elkpark · Aug 18, 2005

It's a need waiting to be filled. Inservices to NH on how to better deal with "high-maintenance" residents? Something like that.........

They know how to "better deal with 'high-maintenance' residents" -- better staffing, better programming, etc. -- but that would cost money and eat into their profits (can't have that, now, can we? :uhoh21: )

(Again, I'm not criticizing the individual, direct care staff, but the administrative people who are making the big financial decisions.)

In most states, beds (by law) can not be filled for at least 24 hours after a transfer to another facility for evaluation. At our facility, it is 72 hours by law. Also, residents act one way at LTC and then do a 180 for ER or other facility. I have never heard of a LTC facility that deep fried everything. LTC facilities are under strict regulations regarding nutrition. In my LTC, we offer alternatives to every meal (state mandated) and offer snacks throughout the day (state also checks and verifies that this is done). I have had a 1:40 patient ratio at an acute skilled care facility, so you can imagine how hectic and busy we are. Even there, simple questions like UTI? or Nutrition? would be assessed for mental status change. It also worries me that other psych nurses may feel the way that you do and are downplaying s/s reported from the nursing home. Psych is a big problem in LTC, docs want to give meds to easily without even attempting to find the real cause of the problem. Some LTC nurses fight for the res to get screened by psych. Although they might be A&O for you, they might have been a different person 24 hours ago. Just remember that!!! Also, I would be more worried about sending the pt back to the NH that was not providing proper nutrition than being put out by finding them a new placement.

That particular example is quite old, so I would hope that the NH rules regarding nutrition and dumping have been improved since then (because of examples like that). It was in a very rural part of Appalachia, and, heck, the hospital kitchen deep-fried nearly everything (although they did always have alternative choices), so I don't doubt the NH kitchen did. When we confronted them the next day, they basically conceded that the entire episode was because this woman was giving them a hard time about the food.

I agree that psych is a big issue in LTC, and, probably, the residents who might most benefit from a psych eval don't get them. However, there is no reason a psych eval can't be done at the NH -- in fact, the results of the eval would be more valid if done in the resident's "natural habitat" instead of in a new, unfamiliar environment. That's no real reason to admit someone to an acute psychiatric unit, and it's certainly no excuse for dumping residents.

And I don't "downplay" s/s -- I'm merely commenting on how often it was the case, in my own experience, that the NH would report symptoms and we would be unable to find any evidence of the symptoms ourselves. You cannot keep people on a psych unit because someone else (even NH staff) said they were exhibiting symptoms when you can't find any evidence of an acute problem ...

dutchgirl · Aug 18, 2005

looks like geriatric psyche care units will be necessary - hope they get some before I need it... :crying2:

Nascar nurse, ASN, RN · Aug 18, 2005

Wow - this LTC nurse feels beat up on in here. OK - put the shoe on the other foot for a moment. You have a parent in LTC facility. How do you feel about your Mom/Dad being in the same facility where another resident just down the hall is hitting, swearing, sexually abusing, etc.. etc, other residents. You would be screaming "Lawsuit" so dang fast it wouldn't be funny if it was your parent that got hurt. No we can't just restrain them - that is highly against our regulations and we can't just chemically restrain them (ie: snow them) either - Also against regulations. Other LTC nurses posts are correct, we do try to eliminate other possiblilties, ie UTI, Resp, infect and the like. We also try to adjust psych meds at a slow pace, but this all takes time and in the mean time - IT'S YOUR MOM THAT MAY GET HURT. We have an obligation to provide the best care to all residents not just one. One of the first posts indicated that we didn't WANT to provide 1:1 care to problem residents. Have your ever been in LTC - please!!! If I provide 1:1 for even 1 hour - thay may be AT LEAST 20 residents not getting any attention for one full hour - AGAIN THIS COULD BE YOUR MOTHER UNATTENDED WHILE I HANDLE THE OTHER PROBLEM. As for education - in my state we are required to have an annual inservice (plus upon hire) regarding the care of specialized/dementia residents. We preach over and over about the correct way to approach a confused person, etc, etc. But we are not the only ones they come in contact with - ie: lots of times another resident purposely or inadvertently gets them wound up, heck I've even heard residents go balistic when the church group was singing X-Mas songs in the hall. And last but not least - we have received plenty of admissions from the hospital that told us what a "sweet LOL" so and so, only to find out from family later that the hospital had had a bunch of problems with them too. Sorry for the long rant, but it is very unkind to just blame the LTC industry for this problem. I understand your feelings too. I think the system is just broke and these poor folks fall through the cracks. I hear in ILL. they are thinking of passing a bill regarding criminal background checks on all pre-admit LTC residents to prevent convicted sex offenders from being admitted. Just goes to show, this whole dilemma will not end any time soon.

laurakoko · Aug 18, 2005

Happened to us last week.

The 'granny' said she was going to kill the doctor... they dumped her off at the ER. Louisiana has some law that states nursing homes cannot dump for psych reasons unless acute (harming themselves/others) without fore-warning of 30 days..

Since she wasn't going to see the MD she "wanted to kill", until next week, we sent her back, and had time to find a place for I/P psych treatment. (Found a small loop hole THAT time)

(oh, she just said that, and didn't mean it...., she states)

After an investigation, the NH couldn't deal with her controlling personality, and telling what the staff to do anymore.

I hate dumping... it is wrong.

Bird2 · Aug 18, 2005

Wow - this LTC nurse feels beat up on in here. OK - put the shoe on the other foot for a moment. You have a parent in LTC facility. How do you feel about your Mom/Dad being in the same facility where another resident just down the hall is hitting, swearing, sexually abusing, etc.. etc, other residents. You would be screaming "Lawsuit" so dang fast it wouldn't be funny if it was your parent that got hurt. No we can't just restrain them - that is highly against our regulations and we can't just chemically restrain them (ie: snow them) either - Also against regulations. Other LTC nurses posts are correct, we do try to eliminate other possiblilties, ie UTI, Resp, infect and the like. We also try to adjust psych meds at a slow pace, but this all takes time and in the mean time - IT'S YOUR MOM THAT MAY GET HURT. We have an obligation to provide the best care to all residents not just one. One of the first posts indicated that we didn't WANT to provide 1:1 care to problem residents. Have your ever been in LTC - please!!! If I provide 1:1 for even 1 hour - thay may be AT LEAST 20 residents not getting any attention for one full hour - AGAIN THIS COULD BE YOUR MOTHER UNATTENDED WHILE I HANDLE THE OTHER PROBLEM. As for education - in my state we are required to have an annual inservice (plus upon hire) regarding the care of specialized/dementia residents. We preach over and over about the correct way to approach a confused person, etc, etc. But we are not the only ones they come in contact with - ie: lots of times another resident purposely or inadvertently gets them wound up, heck I've even heard residents go balistic when the church group was singing X-Mas songs in the hall. And last but not least - we have received plenty of admissions from the hospital that told us what a "sweet LOL" so and so, only to find out from family later that the hospital had had a bunch of problems with them too. Sorry for the long rant, but it is very unkind to just blame the LTC industry for this problem. I understand your feelings too. I think the system is just broke and these poor folks fall through the cracks. I hear in ILL. they are thinking of passing a bill regarding criminal background checks on all pre-admit LTC residents to prevent convicted sex offenders from being admitted. Just goes to show, this whole dilemma will not end any time soon.

Thanks SriggRN320. I find it very offensive that the rants are often directed at LTC's. We are the most regulated in all of healthcare. I love working in Geriatrics and fortunately there are some of us willing to do it. When I did the LPN to RN transition I heard over and over from the other students to not work in a LTC because the real nurses work in hospitals. People can not get past the preconceived ideas about LTC's. Our local nursing programs are now making the students do leadship clinicals at the LTC's to try to get past the negativity. We have to protect our pts and get them the best possible care. BTW we already are doing background checks on all residents to check for sex crimes.

ClaireMacl · Aug 18, 2005

We get the family based "granny dumping" particularly around holidays, sooo many at Christmas. I remember one year, an old man was found sitting outside the hospital in a wheelchair in freezing temperatures by security, when questioned, the man said his family threw him out of the car and left him there. No contact numbers, the poor old man couldn't remember where he lived, nothing! Makes me mad.

Now, for the US long term care nurses, please don't take offense. In the UK, many nursing homes are staffed by unqualified nurses as it is not deemed acute care. Every day, we get ambulances dropping off patients from local nursing homes, either because they can't cope with them or because they called the on-call doc who didn't bother to do a thorough investigation (by phone) and instructed to call 999. The most frustrating thing for us is that patients from home should be directly referred to the medical team, which speeds things up by 50%, better for the patient and us... but 9 times out of 10, they arent!

Our confused, violent and abusive elderly patients aren't sent to the psych ward as it doesn't include elderly care at present, so they are sent to acute take wards... surely worse for the patient, staff and most of all, to the patients suffering from actual acute conditions and not exacerbations of chronic conditions such as dementia.

I just wish we could find a solution.

11 to 7 · Jun 22, 2006

I'm in LTC also -- just posted about this problem. I had a resident the other night who chased me around the unit for an hour, if I had to pull her off of someone else, she would try to tear my hair out and scratch at my face and arms with feces under her nails. She grabbed my name pin and stabbed me wit it. As I've said, the nurse would not intervene. I understand that these kinds of incidents will occur on a locked unit, but something needs to happen before it goes on this long. That's why they get sent out -- Doc doesn't want to order a restraint, chemical or physical, because family gets upset. Nurse can't restrain without an order, so they CNA is left to defend herself. Once she gets seriously hurt (there's blood), they send them to the ER, where they are, of course, sedated, which could have been done at the LTC center if there had been a little more cooperation.