Reporting Abuse and Facility Follow Through

[Gurlonthesun]

I have a question regarding abuse. I'm an agency nurse, and this was my experience this past weekend. Just to say - I've been a nurse for 7 years and I have NEVER witnessed any instance of abuse, so I've never had to be a part of reporting or the aftermath. I'm going to post the events that happened below, but my question is this: when someone is accused of abuse isn't it customary for a full investigation to be completed BEFORE that person returns to work - IF that person even does return??

This was my very first time in this particular facility. I was working the 3-11 shift. It is a Memory Care facility designed specifically for dementia and Alzheimer Patients.

Just before 1600 an alarm was going off in the resident common area. I went to go check for safety. There was a male resident who had been sitting in a recliner (like a normal Lazy Boy type of recliner) with the foot area in the up position. At the time I checked him, he was sitting on the foot area and not sitting back in the seat. I asked him to scoot back so he wouldn't fall. He sort of swung his arm my way - more to get me to leave him alone than to hurt me. An LNA (male) came over and told the resident to sit back in the chair. He then grabbed the resident by one leg and under one arm and attempted to move him back to sitting (which would have been a two person job). The resident starting swinging his fists at the LNA. There are MANY ways to handle a resident swinging (or biting, kicking, punching etc.). The way this LNA chose to handle it was to grab the resident by each of his wrists, cross the residents arms over his chest and physically slam (yes slam - this was NOT gentle in any way!) him into the chair so that the resident was laying on the seat part and his head was pressed against the back of the chair. He held the resident down as the resident attempted to kick him - the angle for contact was wrong and the resident couldn't actually kick him however the LNA claims he was kicked in the face (which he was not - I was standing right there). The LNA then screamed in the resident's face "I hate this ******* place", pushed off the resident's chest and let him go. At this point the resident sat up and because of his momentum and where his bottom was still on the foot portion of the chair, the entire chair started to tip forward with the resident still sitting on the foot part, practically dumping the resident on the floor. I reached out with one hand to stop the resident from falling at the same time trying to hold a recliner with my other hand while the LNA stood there. I said (probably not very nicely) "Can you help? I can't hold the chair by myself." At this point a second LNA came over, assisted me with the resident, and the first LNA walked off.

Once the resident was safe I immediately went to find the other nurse on my unit to find out what their policy was on reporting abuse as there was no supervisor on duty at the time. The other nurse had me call one of the supervisors to let her know what happened. After I told the supervisor what I witnessed her reply was "that's really not like So and So. I should talk to him." My response was that I would not stay and work with an LNA who had just physically handled a resident in that way. The other nurse then got on the phone and stated "This is abuse. He can't stay we have to send him home." The nurse continued speaking with the supervisor working out the details of sending the LNA home. Shortly after that he left and the rest of the shift progressed without issue.

At around 2015 a new schedule for the next day was delivered with the LNA's name still on the schedule but hand written in was a change from him working the unit he normally works to a different unit. To me this says they were not taking his abuse of the resident seriously. When a resident is abused by a staff member there needs to be a full investigation done before they return to work and clearly this was not going to happen here. I had already decided I was not returning to this facility based on the fact that they would allow someone who handled a resident in such a violent manner back to work.

They never asked me for a statement. They never asked me to have the second LNA who witnessed the entire incident to write a statement.

I did report the incident to my state's DHHS Elder Abuse division (obviously). But my question is - am I wrong? Should this LNA been back at work the next day?

[jadelpn, LPN, EMT-B]

The LNA was sent to a different, less acute unit. There is some sort of restraint that needs to occur so that the resident is not falling on the floor. It can also be considered a restraint if a resident is left in a lazy boy that they can not get out of themselves.

This all escalated pretty quickly. Was there a reason that the resident couldn't just get up from the chair instead of making him sit back again when obviously this was not what the resident wanted to do?

I am not saying the LNA was correct by any means, however, to assist the resident into a standing position and then see where they are wanting to go would have been a better intervention.

Another thought process is that how impaired does one need to be to go from an assisted living to a skilled nursing facility? Not sure that there's staff enough to care for this resident appropriately. And assisted living powers that be will attempt to keep someone in their facility as long as possible, and sometimes past a safe point.

So as the licensed person there, I would most definitely advocate for different interventions. In other words, you can't MAKE someone sit in the recliner. That could also be considered abusive. Reassigning a LNA to 1:1 while this resident roams around, or is given an activity to do, could be a course of action until such time as a determination is made as to the need of the resident. And that may mean skilled LTC.

As the licensed nurse, you are responsible for the actions or inactions of the LNA's. But you are also responsible to make sure that the interventions are in the resident's best interests. And in this instance, the resident was "saying" that he did not want to sit in the recliner any longer. And that is his right. If there was not enough staff, the resident is a significant fall risk, etc. then there needs to be different interventions, or you need to write up a change in function form to get this resident to an alternate level of care that can meet his needs.

As far as the LNA. Some people just can't deal with inappropriate assigned residents that act out. (and acting out due to the fact that the resident should be able to do something other than sit in a recliner when they want to do so.) So they need to be assigned elsewhere, until such time as an investigation is complete. Hate to say it could fall back on you, but it could. To get someone to sit in a chair that could be considered a restraint by restraining them is frowned upon. A person with significant dementia WILL act out to what they perceive as a threat. That the LNA in turn retaliated is not right, but apparently there needs to be some re-education and re-training on interventions.

[Gurlonthesun]

The LNA was sent to a different, less acute unit. There is some sort of restraint that needs to occur so that the resident is not falling on the floor. It can also be considered a restraint if a resident is left in a lazy boy that they can not get out of themselves.

This all escalated pretty quickly. Was there a reason that the resident couldn't just get up from the chair instead of making him sit back again when obviously this was not what the resident wanted to do?

I am not saying the LNA was correct by any means, however, to assist the resident into a standing position and then see where they are wanting to go would have been a better intervention.

Another thought process is that how impaired does one need to be to go from an assisted living to a skilled nursing facility? Not sure that there's staff enough to care for this resident appropriately. And assisted living powers that be will attempt to keep someone in their facility as long as possible, and sometimes past a safe point.

So as the licensed person there, I would most definitely advocate for different interventions. In other words, you can't MAKE someone sit in the recliner. That could also be considered abusive. Reassigning a LNA to 1:1 while this resident roams around, or is given an activity to do, could be a course of action until such time as a determination is made as to the need of the resident. And that may mean skilled LTC.

As the licensed nurse, you are responsible for the actions or inactions of the LNA's. But you are also responsible to make sure that the interventions are in the resident's best interests. And in this instance, the resident was "saying" that he did not want to sit in the recliner any longer. And that is his right. If there was not enough staff, the resident is a significant fall risk, etc. then there needs to be different interventions, or you need to write up a change in function form to get this resident to an alternate level of care that can meet his needs.

As far as the LNA. Some people just can't deal with inappropriate assigned residents that act out. (and acting out due to the fact that the resident should be able to do something other than sit in a recliner when they want to do so.) So they need to be assigned elsewhere, until such time as an investigation is complete. Hate to say it could fall back on you, but it could. To get someone to sit in a chair that could be considered a restraint by restraining them is frowned upon. A person with significant dementia WILL act out to what they perceive as a threat. That the LNA in turn retaliated is not right, but apparently there needs to be some re-education and re-training on interventions.

As I stated - I'm an agency nurse and this was my first time in this particular facility and I had only been there an hour. I have a policy that until I have met all the residents and have been to the facility a few times and know who transfers how, I do not transfer patients. Just because a resident "thinks" they can walk, doesn't mean they can. Some residents are hoyers because they absolutely can not stand/walk. I'm not looking to injure a patient or myself by attempting to walk or transfer a patient I know very little about. That was why my first interaction with this particular resident was to ask them to move back in the seat. They have a chair alarm which says to me that they are impulsive and a fall risk - so my best course of action for a resident I do not know, is to get them safe and then find an LNA who does know them and ask THEM how the patient transfers.

Secondly - this is a specialty dementia facility not an assisted living facility. All of the residents either have a Dx of Alzheimers or dementia. None of the residents are capable or competent enough to care for themselves.

As for writing up a change of function form - again - only there an hour. Don't know any of the residents. Have no basis for such an action.

Just to clear things up.

[mrsboots87]

You are correct in that a facility is legally obligated to suspend an employee accused of elder abuse. If the investigation comes back that the employee was not in the wrong, they will be paid for any missed work and be allowed to come back. If the investigation find them guilty of the abuse, they are fired, get no pay for missed work, and are reported for elder abuse which limits their ability to gain employment as a health care professional in most settings.

You our did the right thing I. Attempting to get the resident to sit back. I would never try to assist a resident I don't know out of a chair. Yes, residents have a right to fall. But, as nurses we are obligated to prevent it if possible. Also, I would never attempt to stand someone up who is sitting at the edge of the foot rest. That foot rest could buckle and then you and the resident both go down to the floor. No matter what, the man needed to be sat back in the chair before any decision could be made about whether to get him up or not.

For the PP who said the recliner could be a restraint, it is not. A restraint would be if you took away the controller to an electric recliner, or place a foot rest or something under the foot of a mechanical one that prevents it from going down. Laying a fall risk resident back in a recliner is not a restraint as long as the foot rest can be moved down. We actually careplan use of recliners for our impulsive fall risk residents as a deterrent to getting up without assistance.

Good of for you for reporting the incident yourself. If an investigation is opened, that facility could be in deep code brown over not suspending the employee during the investigation. I see absolutely no where that you can be held liable for this as you did not participate in or condone the abuse, and you reported it timely.

[Mia415]

Well it sounds like you absolutely covered yourself by reporting to supervisor, and reporting to adult abuse services. They are responsible for doing the investigation. Just like when you report abuse to child protective services, they investigate and they take appropriate action as needed. As much as I sincerely understand your concern that this person is a threat to other patients, at this point it's not your business... Unless they are assigned to help you with your patients again, in which case you could again voice your concerns to supervisor.

[LadyFree28, BSN, LPN, RN]

If the LNA returns to the unit, then you have the option of blowing past the chain of command and calling the ombudsman or the health department.