Violent/combative residents?

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Specializes in Critical Care, Neuro-trauma.

How do you handle them? As in, what is your company protocol? Recently, we had a 96 year old (dementia with no noted behavioral issues) become extremely aggressive and violent. They had wandered into another area of the facility thinking it was their home and when an attempt at being redirected was made, resident began swing at staff, causing legitimate injuries to myself and another coworker (bloodied lip, bruises, and a nice gash to my left leg where it became the victim of being hit with a walker) our facilities protocol is to call our mobile mental health unit in such circumstances. We followed protocol and when they arrived, they asked us the residents age, if she had any known mental issues, and what they were. When their age and dementia came out of our mouths the social worker looked at me and goes "what the hell did you call me for? I'm not even making a report. She's over 90 with a known issue." And they left. Not long after they left, they began swinging at another resident. At that point, I called 911 from which they were transported to a Geri psych unit as an impatient. Today I got slapped with a nice little reaming out from my DON and Administrator for "not following protocol" despite having tried and our mental health unit dismissed it. She said that that should have "told me something" I feel like it was a lose/lose situation. Not only were they a harm to themselves and staff but they were a danger to my other residents who I have a duty to protect as well. What could I have done differently? I feel like I can't do right by this place.

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How do you handle them? As in what is your company protocol? Recently, we had a 96 year old (dementia with no noted behavioral issues) become extremely aggressive and violent. They had wandered into another area of the facility thinking it was their home and when an attempt at being redirected was made, resident began swing at staff, causing legitimate injuries to myself and another coworker (bloodied lip, bruises, and a nice gash to my left leg where it became the victim of being hit with a walker) our facilities protocol is to call our mobile mental health unit in such circumstances. We followed protocol and when they arrived, they asked us the residents age, if she had any known mental issues, and what they were. When their age and dementia came out of our mouths the social worker looked at me and goes "what the hell did you call me for? I'm not even making a report. She's over 90 with a known issue." And they left. Not long after they left, they began swinging at another resident. At that point, I called 911 from which they were transported to a Geri psych unit as an impatient. Today I got slapped with a nice little reaming out from my DON and Administrator for "not following protocol" despite having tried and our mental health unit dismissed it. She said that that should have "told me something" I feel like it was a lose/lose situation. Not only were they a harm to themselves and staff but they were a danger to my other residents who I have a duty to protect as well. What could I have done differently? I feel like I can't do right by this place.[/quote']

In my place we call the doctor on call and he will sometimes order a stat haldol or Ativan shot to calm them down and get a follow up with in house psych who will most likely order daily antipsychotic for new onset agitation. But at that moment you did what was in the best interest of the staff the patient and the other residents you made a judgement call that you had every reason to make. Too many facilities are overly concerned with census and get upset about a bed they aren't getting paid for.

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Specializes in retired LTC.

I am just praying to the Powers that Be that you and your co-worker made out necessary incident reports for your employee injuries.

Always, always, always do so for these kind of injuries. How management will really address it may yet be to determined. But you need to do the emp incident report, entry into nurses notes, and I suggest, your 24 hour desk report sheet/notebook (whatever you call it).

Nurses notes need to document it so there is explanation when psychoactive meds may be ordered for pt-to-staff contact. (It's permanent documentation that shouldn't conveniently make it to the 'round file' or be misplaced. as some emp incident reports 'accidently' do).

And always be super cautious for any pt-to-pt contact. This is a big biggie.

As for the original situation, sounds like you were damned when you did; and would be damned if you didn't. And you were right - you fell into a lose-lose. If it feels any better, just know some of us experienced ones have very similar experiences in these kinds of situations. It's very difficult with the demented AND aggressive pts - nobody else wants them and your place won't get paid for an empty bed. To be honest, this type is at the top of my most disliked pt situations. Your options are limited. When emotions settle down, review with others what else you could of/should of done.

And good luck for future situations..

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In my place we call the doctor on call and he will sometimes order a stat haldol or Ativan shot to calm them down and get a follow up with in house psych who will most likely order daily antipsychotic for new onset agitation. But at that moment you did what was in the best interest of the staff the patient and the other residents you made a judgement call that you had every reason to make. Too many facilities are overly concerned with census and get upset about a bed they aren't getting paid for.

I absolutely agree. I recall a similar situation in which I simply called the doctor and he ordered Seroquel PRN. That did the trick nicely. I think you did the right think. You acted as an advocate after following protocol did not help. Unfortunately we get in "trouble" even when we do what is best for our patients/residents. If I were in your shoes, after being reprimanded, I would think to myself "Yep, and I'd do it again." Hold your head high.

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Specializes in critical care, ER,ICU, CVSURG, CCU.

i only have a limitted 41years experience, and have been DON in several facilities......... I would have done the exact same as you did.

& with the right documentation, and other requirements, possibly some skilled rug $s on resident return for a short while :eek:

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Specializes in Critical Care, Neuro-trauma.

Resident returned to our facility today. And all

We got out of it was a PRN order for Ativan, through which daughter and son will not allow

Us to administer unless first contacted. What kind of BS is that? States that if we had "just let her go" that she wouldn't have became agitated and this wouldn't have ensued. DON agrees. I think I'm looking for a new place of employment. This place is a joke.

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Specializes in Pediatrics, Emergency, Trauma.
I am just praying to the Powers that Be that you and your co-worker made out necessary incident reports for your employee injuries. Always always, always do so for these kind of injuries. How management will really address it may yet be to determined. But you need to do the emp incident report, entry into nurses notes, and I suggest, your 24 hour desk report sheet/notebook (whatever you call it). Nurses notes need to document it so there is explanation when psychoactive meds may be ordered for pt-to-staff contact. (It's permanent documentation that shouldn't conveniently make it to the 'round file' or be misplaced. as some emp incident reports 'accidently' do). And always be super cautious for any pt-to-pt contact. This is a big biggie. As for the original situation, sounds like you were damned when you did; and would be damned if you didn't. And you were right - you fell into a lose-lose. If it feels any better, just know some of us experienced ones have very similar experiences in these kinds of situations. It's very difficult with the demented AND aggressive pts - nobody else wants them and your place won't get paid for an empty bed. To be honest, this type is at the top of my most disliked pt situations. Your options are limited. When emotions settle down, review with others what else you could of/should of done. And good luck for future situations..[/quote']

Agree. :yes:

I would've documented and done the same thing...

Any redirection or appropriate intervention during chalking behaviors doesn't always work, and not always applicable during situations where safety is at risk. :no:

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Specializes in Gerontology, Med surg, Home Health.

In long term care, you can NOT give a PRN antipsychotic unless there is already a scheduled dose. I don't know where all y'all practice, but we don't do that here. Ativan sure...trazodone great...but not a PRN antipsychotic.

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Specializes in Geriatrics.

When I deal with a combative resident, as a CNA, I try my best to calm them down but if it doesn't work I take a step back and watch them from a distance to make sure they don't hurt themselves or others, wait a little while and try to approach them again. If I seem to be the person irritating them I ask a coworker to try (if you are a female try a male and visa versa also). Usually a different face works and most of the time just allowing the patient space for a while does the trick. Trying to calm a dementia patient down and seeing your efforts are not working yet you continue to try only irritates them more and the situation gets worse real fast.

Patience and tone of voice is a very important factor. Some coworkers I work with don't have patience and as a result their voice becomes gruff and demeaning.

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Specializes in Critical Care, Neuro-trauma.
In long term care you can NOT give a PRN antipsychotic unless there is already a scheduled dose. I don't know where all y'all practice, but we don't do that here. Ativan sure...trazodone great...but not a PRN antipsychotic.[/quote']

Same here. We aren't allowed PRN antipsychotics. I hadn't even heard of that being done before honestly.

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Specializes in Critical Care, Neuro-trauma.
When I deal with a combative resident as a CNA, I try my best to calm them down but if it doesn't work I take a step back and watch them from a distance to make sure they don't hurt themselves or others, wait a little while and try to approach them again. If I seem to be the person irritating them I ask a coworker to try (if you are a female try a male and visa versa also). Usually a different face works and most of the time just allowing the patient space for a while does the trick. Trying to calm a dementia patient down and seeing your efforts are not working yet you continue to try only irritates them more and the situation gets worse real fast. Patience and tone of voice is a very important factor. Some coworkers I work with don't have patience and as a result their voice becomes gruff and demeaning.[/quote']

Right. I have worked in our secured unit the whole time until we closed it down, unfortunately if those residents weren't our wanderers, they were put back on to our other units. I'm excellent with those types of residents, except this one lol. I couldn't just sit back and watch this when she was barging into another residents room late at night, disturbing them, going through their things and getting in their face due to them being in "her house." It just turned into a big huge disaster.

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Specializes in Geriatrics.
Right. I have worked in our secured unit the whole time until we closed it down unfortunately if those residents weren't our wanderers, they were put back on to our other units. I'm excellent with those types of residents, except this one lol. I couldn't just sit back and watch this when she was barging into another residents room late at night, disturbing them, going through their things and getting in their face due to them being in "her house." It just turned into a big huge disaster.[/quote']

Yeah sometimes it doesn't work at all. I haven't personally ran into that issue but a couple times. The ones that have not been calmable (is that even a word?) were the elopers. We had to resort to calling a family member in once at 3am to calm them down for us. I just haven't seen a resident who can't be calmed very often. Maybe I'm lucky? *knocks on wood*

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