Should the following resident be in Assited living?

Antikigirl, ASN, RN · Nov 1, 2004

When I talk to my caregivers about charting I always tell them to paint a picture of what they were doing, what the resident was doing, and what they did to try to quell the situation. That is very important for folks that weren't there, and can so help in trying to quell potenially adverse environmental or social situations that can trigger behaviors that are not appropriate. To bad they don't like taking the time to write it all out like I do...but lately with all the stress the admin has put on them about liablity, they are doing it now to CYA...works for me, but wished they didn't have to deal with the fear factor in doing it...just do it because it is the right thing to chart for both patients and staff!!!

It is getting rather scary about the conditions of residents being allowed to move in! We are finding a large number of high medical need patients coming in, wonderers especially! I can't believe my admin for half of these folks they are taking..talk about liablity...but I suppose the paperwork the families must sign in order for their loved on to be admitted is half gray, and totally takes the liablity off the facility (that is the only way I can see this being done). That really harms staff and patients! Not to mention my facility is very good on blame the staff not the resident...which has us all walking on eggshells (gotten worse in the past 5 or so months...really bad infact!).

This guy is just one of the more challenging ones, I have about 6 others I am having to do all this documentation on to have them removed for their own safety and needs! But I have to challenge admin and families by doing this...very tough to do so I go very medical and document big time, and need my collegues to do the same! (but they are scared of rocking the boat so they don't do as much as I do..I do not fear the admin...they can fire me and I will go straight to the boards or a Jaycee organization and they know it, so they fear me more than I fear them!).

Blackcat99 · Nov 2, 2004

The assisted living place in my town accepts anyone who is private pay. When I worked there they had a man who was violent towards caregivers. He injured caregivers but they didn't care. After all, he was a "private pay resident" so he was allowed to do whatever he wanted. :angryfire

boulergirl, CNA · Nov 2, 2004

Oh boy, he makes our Alzheimer's residents look good!

We have TWO "Don Juans" in our unit. Why the other NA's just laugh at their behavior is beyond me.

One of them tries to get into the pants of a particular female resident every chance he gets. More than once they've been caught without clothes in his room (but never on my shift--they're asleep then!) They think they're married to each other and do THIS in front of the other residents--:blushkiss Ewwwwww.

Now we have a new resident and he wants a piece of the action. He also tried to get fresh with another female resident. He was found in her room yesterday with no clothing from the waist down, and so was she. Allegedly he was "erect" She said it was about time she got some! :eek: Oh my goodness. (BTW, this same guy had to get TWO doses of Lorazepam yesterday to calm him down because he was constantly undressing in public and other residents' family members were looking at the caregivers to do something. Oh, and did I forget to mention that he'll pee or crap anywhere he chooses? :uhoh3: He's been known to water the plants.)

On a different subject: One of our residents in Assisted Living had a PRN Haldol injection for awhile. It was to be given IM by Home Health and for excessive agitation. Only Rx for Haldol I've ever seen at our facility.

Okay, I need to go get some sleep. I'll save more real-life horror stories from the dementia wing for later. I've seen plenty, let me tell ya!

txspadequeenRN, BSN, RN · Nov 2, 2004

I am a Alzheimers nurse and He needs to be moved NOW... This family needs to come and find placement for him in a appropriate facility. I give Haldol liq, gel, inj,pill everyday at work and Seroquil by the buckets, but then I work with these type of patients exclusively. Boy o Boy this is a bad situation.... He will hurt himself before it is all over, or someone else....

Antikigirl, ASN, RN · Nov 3, 2004

You guys are great...it really helps to hear others that feel as I do about this (and other subjects). Thanks so much for taking the time to share..greatly apprecited!

So far no go...the admin and hospice are using the old "wait a while till the meds kick in"...well today he was so zonked he couldn't speak or eat! Nice huh? Now we have the opposite probelm! I want him in a facility that can provide his best interests and some dignity at least, and assisted living just CAN'T do that! This isn't assistance, this is hinderence and disrespect to me!

I am not giving up, and I heard rumor of a State Audit coming this month...this may be my way to get something heard! And my caregivers..bless them, are charting like crazy (and working as hard as they can with all ADL's and even feeding him) and so am I! All calls to hospice and communiation with admin is charted and I use quotes! Hopefully I will get some action, but it isn't going fast enough for me, if we don't move quickly...we will go from dementia and cancer to severe failure to thrive!!!!

veronurse54 · Nov 3, 2004

Yeah I know about the old haldol...but the hospice nurse said give one per MD order..then it came over on fax...grrrrrr! Okay got the order, but I gave the lowest dose possible, and then notified them in one hour about the pill rolling! It was quickly D/C'd...now we have NOTHING! Uhgggggg! (plus he started the pill rolling deal very quickly..tells me he is kinda long term psych med history, and haldol at his age was proably what was used before..since that was the drug of choice for most mental states..uhggg! They just got a Rx for Serequil (oh man I spelled that wrong...) which he has been on before, so I hope that will help, but I doubt it will help enough for his condition to keep him in assisted living! Plus, zoning him out on meds because he is too much for assisted living is simply NOT FAIR! He needs to move, pace if he wishes..have choises in care..and assisted living..well if you don't blend in with the masses, you are at a serious disadvantage....
No, when a patient must be removed their family is responsible. We try as hard as we can to get them help though various organizations, but in essence it is the families resonsiblity. Luckily my DON is a very well educated woman in our community and has so many resourses to help..she is just Awesome!!! I can't tell you how much she makes things easier for residents and family...with little time to do this...and rarely gets a thank you! She actually wants to train me for her position and was the inital thought till she got to know me and knew...I am best in acute nursing and emergencies..it is what I do well...and she realized her job would NOT be my thing! So we are both trying to find another to fill her shoes..she retires in 2 years and would like to continue on as a parish nurse (which I fully agree with! She would be so wonderful at this!!!!!). I love my DON...she is my friend, mentor, and someone I hope to know forever!
The trick will be, with this patient, is to get a Physicians order for placement...now if we can get that it will be so much easier. His family is on the East USA, (we are in Oregon)...but we will try very hard to have his move be as easy as possible, including staff volunteering their own time to help if necessary (I know about 6 or so staff that would be happy to help, including me!).
I will have to ask about the possiblity of working closely with a CCRC! I am sure my DON has that resource...now just to find out what is hindering this from being common practice when people are transfered.

Is there a Geriatric Care Management Company in your area? It is a fee for service typ[e agency but if the gentleman has the financial resources and the family is in agreement a GCM can assess and make recommendations for placement elsewhere. The only other recourse you might have is to get the department of children and families involved in this case. I know it sounds a bit drastic but this man and those around him are in danger and may need an outside agency to intervene.

anna c · Nov 4, 2004

I too am very shocked at this! However, I have had many questionable residents in ALFs too. I guess as long as you have the money, right? I understand too that sometimes or maybe most of the times, the administrator gets a nice bonus for keeping the beds full.

Anna

Antikigirl, ASN, RN · Nov 23, 2004

Well guys, my efforts failed....

Things progressed quickly into the wrong direction with my patient. Hallutionations increased dramatically, he couldn't dress himself, he was falling all the time by walking around, started walking around naked all the time (which was his choice actually...so can't tell him he couldn't!), couldn't find the dining room or even the lobby, spoke in phrases like "yesterday glue with horses in the back, tv is too loud to go pee in the country aire!". He started to become violent, and even I was too scared to go into his room alone. This is NOT an assisted living canidate, but the family and my admin insisted we could handle it! NOT! My caregivers were so overwhelmed with keeping his naked orifice in his room, doing everything for him in fear of being hit or bit, feeding him, cleaning him..and cleaning up the floor after he would urinate all over himself!

I finally got a break and he complained of chest pain...cool, I sent him off to the hospital where I knew they would find correct placement (like a psych unit in a facility with 24/7 nursing care)! But no, they sent him back on hospice! Hospice??? Oh yeah, the hospital said they couldn't tell us because of HIPAA laws (b*l*h*t!) but he had brain cancer and lung cancer! Okay that would explain it..but he was more violent and unstable than before! I begged the hospice nurse to PLEASE give the man some dignity and get him into a SNF, but she didn't. "Just give him time for the meds to kick in and he should be okay".......GRRRRR he wasn't taking his meds darn it...how many times did I have to tell her he wasn't taking his meds but spit them out!

By this time he was always naked, spoke in words you couldn't understand, was very unstable, in pain and living on the floor! He refused his bed saying that women were getting raped on it all the time, and chose to sleep on the floor (patients choice I guess, I asked for at least a matteress or futon on the floor..never happened), he refused to use the toliet saying it was unnatural and would just urinate or poop as he crawled from room to room. He needed help, and I yelled and pleaded....but it fell on deaf ears. The healthcare professionals I depended on failed me, and I was on my own with no real power begging for the dignity and respect for my patient that I am mandated to do by my license and my heart!!!!!!!

My resident died in his room in pain, on the floor naked and in his own feces! He died with no dignity, and he was a very very dignified man before this happened.

I guess at his funeral the typical thing happened. "OH he was a dignified man who passed away peacefully in his bed...we all loved him so and he will be so missed" coming off the forked tongues of his family that NEVER saw him, wouldn't listen to me and get him help...nor mentioned that he died in sh*t on the floor of his home where he spent his last days crawling on the floor! He died like an animal disguarded into a muddy corral to wallow in mud till his heart gave up! And I am so sickened...(and of course most of this happened during my days off!!!!!! When I was on duty these things didn't occur as much because the caregivers and I spent huge blocks of time working with him to the expense of other residents sadly..).

This is the worse case I have had, and not the norm...but many folks wind up dying there with hospice services when they really should be attened to by a RN 24/7 so they do not suffer with pain, fear, and alone! Hospice RN's can only visit so often..so much of the time they are alone except for a rushed caregiver that had 12-16 patients to care for..or me, in charge of 160 with no time to hold the hand of a dying patient!

These patients should NOT be allowed to return or be admitted to assisted living...because once they do, even I can't seem to get them out when they need to...

I am still finding options and seeking info on how these situations can be stopped, and feel that maybe that is why I am in Assisted Living to begin with...to help with making protocols and rules for these facilities that seem to be allowed to do things that are at least questionable! Maybe this bold 'black sheep' nurse can make a difference..time will tell. I have only been in for two years, and that is about as long as it has taken me to even get used to this assisted living concept..now onto the stage about finding out how to beat the system when my patients need it!!!!!

boulergirl, CNA · Nov 23, 2004

Wow...your patient sounds almost exactly like the new guy we've got on our Alzheimer unit! Sorry to hear your resident died the way he did, though.

This story is one reason why I tell my co-workers in the Alzheimer wing to document, document, document! If they don't, management's hands are tied. They can talk to the family until they are blue in the face, but it's our word against theirs. With no documentation, they can say "it didn't happen". And be SPECIFIC in documentation. Otherwise, the family or mgmt. can interpret a vague report any number of ways.

I'm glad to hear you're working to make a difference where you work. We're also about to go through some big changes--the residents on the dementia wing appear to have been abandoned, and we have a new aide on my shift who says thing are going to have to change or she's leaving. Wouldn't blame her, but I'm tired of losing good workers because there's no teamwork, no organization and no system--too many things have been allowed to slide by.

Antikigirl, ASN, RN · Nov 23, 2004

Thank goodness I did, and my cg's did too! I warned them this one wasn't going to be pretty...so they certainly got my CYA message and documented!!!!!!! WHEW!

I am a bit scared of being accused of not doing enough when I tried, and we have a state audit comming up soon (but the case is closed so state won't audit it). I really wish to tell them what happened but know I will loose my job, and if found to be at fault for any reason in allowing this to happen I could loose my license...so I am stuck. I did so much research at home, and that is not documented. But I did document all the calls I did to hospice, and my clinical opinions I expressed and the outcome of the calls using quotes! That should help!

The deal is..I would have to open the case up, and do I wish to do that? Kinda the pandora's box deal!!!!!! The case is closed, patient is dead...so should I focus on the future or dig up the past??? I mean, no one would help me or my patient then..why now when more potential law suits and what not can come into play.

I am thinking of just keeping this one in my mind and using it as fuel for my endevors to change things as much as I can. Always remembering in my mind and in my thoughts "I am doing this for you Mr. So in so....I haven't forgotten, nor will I!".

And, I hope by sharing these stories...we all will be open to finding ways to change things for the better. We get so caught up in the fears of loosing jobs, licenses, lawsuits we tend to let much slide...we really must take time to choose a battle to fight for from time to time...this one, it will be mine in one way or another...because it hit my heart so hard, made me sob and scream at the sky, and left me feeling I just didn't help like I wished to! I don't want to feel like that...I don't want any of you to feel like that...that really hurts too deep!

Nurse Ratched, RN · Nov 23, 2004

Oh my, I'm so sorry that this went exactly where you feared it would.

Here's how I might try to avoid this in the future:

Everyone upon admission designates someone as their legal health care rep in the event of a future disabling condition, with paperwork on file at the facility and every possible way to contact that person updated quarterly. Said person will also sign a form along with resident confirming receipt of admission criteria and discharge criteria. Discharge policy will also be included with initialed receipt. When pt is found to be approaching discharge criteria, pt and HC rep if applicable will be advised and assistance given in planning for further placement if needed. This is the time to bring in the Agency on Aging or whomever in your area is responsible for determining eligibility status for placement in an ECF. "Approaching discharge criteria" can be whatever you designate it as - perhaps a list of ADL's pt is having difficulty with that you don't cover in your services - checking off a certain # triggers the investigation of other options. Perhaps they could stil live there with a private caregiver checking in on them, but the resident and family understand that the person is declining in ability to self-care and decisions should be made.

Finally, if a resident is beyond your ability to care for, and no one is willing/able to advocate, then APS is contacted.

Again, my condolences on your ordeal, and that of your resident. If nothing else, as you said, you can make sure this doesn't happen again.

You need to scream at the top of your lungs to the powers that be in your facility/corporation that the current unclear discharge situation is unacceptable and needs to be remedied. As I said before, this is a financial issue as much as a patient's rights/dignity issue - if common decency doesn't make them listen, then perhaps a threat to the pocketbook will.

http://nsweb.nursingspectrum.com/ce/ce125.htm

While not exactly applicable, here is an article on issues facing home care agencies in regards to legal concerns. The below is of most interest.

A reasonable time frame for notice of termination can be viewed on a continuum. For example, on one end of the spectrum are patients or their caregivers who are violent or prone to violence. The home care provider is justified in discontinuing services immediately if the staff feels threatened or is in danger. On the other end of the spectrum are patients with mental illness or poor judgment; few economic resources; and no able, available, and willing caregiver. In these cases, where the agency is unable to meet care needs, but the patient may suffer injury without the service, hold a conference with all involved disciplines to develop a discharge plan. Submit a referral to community resources, such as Adult Protective Services, as soon as a potential for patient injury is identified. A discharge date two to three weeks in advance can be set with the patient. Once the date arrives, the nurse needs to terminate care as discussed with the patient. If a potential for injury if the agency discontinues care exists, the agency should arrange for an ambulance to transport the patient to a hospital. If the patient refuses, he or she has terminated the relationship. Document discharge planning and the patient's response, including refusal of transportation to the hospital, in the patient's record.

lovingtheunloved, ASN, RN · Nov 23, 2004

TriageRN, your compassionate and gracious heart astounds me. You're in my prayers.