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.
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']
Correct....I didn't see anyone post about giving PRN antipsychotics; with the exception of a poster talk about giving PRN Seroquel; I thought that was an additional dose or rather an increase in dosage, since Seroquel is long acting, not short acting.
Most residents who are are antipsychotics at least where I work NEED to be on them; we have a psych team that really focuses on GDR; sometimes that is not possible.
Some residents at the facility I worked at had orders for prn ativan or haldol. When our residents had new onset agressive behavior they were also tested for uti....a uti does strange things in an elder's brain! Good luck, it sounds as if you are in a difficult situation. When working in memory care I was hit, kicked, punched, scratched, spit on, and thrown across a room. I was always very caring and kind, and was careful, but our wing turned into a geri-psych wing and I had to get out after a broken rib.
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
Being new (well, graduated in '12 but only worked 2 months in a year and a half) besides time management, my next biggest challenge, and a BIGGIE at that, is knowing what to document and all the different places to document it in. By "nurses notes," are you talking about progress notes? So for example, a resident knocks a nurse to the ground and the nurse, say, injures his/her wrist on the way down and hits his head on the floor. Do you document in the progress notes the exact injuries of the nurse just like you would a resident, or just say the resident knocked the nurse to the ground resulting in injury to the nurse? I know it may sound like a dumb question, but I'm so confused on charting sometimes.
Specializes in Gerontology, Med surg, Home Health.
Nurses' notes/progress notes are supposed to reflect the resident's condition. You would document all the behaviors and all the interventions you tried to alleviate or change the behaviors. You would document that the resident was physically abusive toward a nurse. Surely every facility has a means to document and investigate STAFF injuries. That is where you should document the nurse's injuries.
We all are aware of the CMS push to eliminate unnecessary antipsychotics in long term care. At my facility we have weekly meetings about every resident who is on an antipsychotic...the diagnosis and the behaviors. We also track any gradual dose reductions and if there haven't been any, the reason why. We are still able to use antipsychotics but we make sure we have all our documentation ready for scrutiny by any regulatory body. Personally I think they should focus on polypharmacy as opposed to zeroing in on one class of medications. Taking Zyprexa at 1.25 mg twice a day is far less hazardous than taking a total of 29 medications daily.
We had a resident who had violent behaviors. The family would not allow us to medicate the resident with any psychotropic med....no Ativan...no Trazodone and certainly no antipsychotics. We tried everything, and we are very good with behavioral residents. Finally the resident was sent out section 12 to a psych facility. The family still refused medications. We did NOT readmit him to the facility. The admissions person and I must have spent a total of 8 hours on the phone with both the family and the psych hospital explaining why we weren't taking the person back.
I'm sorry you work at a place where your safety isn't a concern of management.
Nurses' notes/progress notes are supposed to reflect the resident's condition. You would document all the behaviors and all the interventions you tried to alleviate or change the behaviors. You would document that the resident was physically abusive toward a nurse. Surely every facility has a means to document and investigate STAFF injuries. That is where you should document the nurse's injuries..
Thank you for answer my question. I appreciate it. Thats another question I now know to ask at my new job. "Where do we document emoyee injuries."
Personally I think they should focus on polypharmacy as opposed to zeroing in on one class of medications. Taking Zyprexa at 1.25 mg twice a day is far less hazardous than taking a total of 29 medications daily.
THIS ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Specializes in Leadership, Psych, HomeCare, Amb. Care.
Thank you for answer my question. I appreciate it. Thats another question I now know to ask at my new job. "Where do we document emoyee injuries."
I would not just say physically abusive, as that can mean anything from throwing their med cut at the nurse, or slapping her hand away from her to punching/kicking/biting etc. A brief description is helpful.
Specializes in LTC, assisted living, med-surg, psych.
I haven't seen too many residents with a PRN antipsychotic who weren't receiving a scheduled dose as well, and when I have, I've asked the MD to D/C the AP. They just don't do that much on a PRN basis, unless the patient is on one already and simply needs a "booster" to knock down an exacerbation of the condition for which s/he is taking the AP. Plus, they are a pain in the patoot to document, so I rarely if ever gave them if there was anything else that would settle the resident down.
But then, I'm of the opinion that we shouldn't medicate residents who are driving us crazy; we should medicate only when they're driving themselves crazy or are ramping up to a point where they're a danger to themselves, staff, or other residents. APs are hardcore drugs that shouldn't be given out willy-nilly to anyone, let alone the frail elderly, and frankly I don't think the average PCP is the person to prescribe them. Best to get a psych eval before such serious medications are considered, IMHO.
In Pennsylvania, when you send a resident out to a psych facility or even to the ER to have them 302 committed, they will not keep them if there is a dementia diagnosis. Doing so is actually illegal. We've run into this problem quite a few times at my facililty. Honestly, all you can do is keep PRN antipsych meds on hand and dole them out as you need to. I know it feels bad to do it, but when you factor in that you don't usually have time to spend 1 on 1 redirecting because you have other patients to attend to, it really seems like it becomes the only option.
*And ALWAYS, ALWAYS document as thoroughly as you can. This will make it almost impossible for an MD to deny you PRN meds!
In Pennsylvania when you send a resident out to a psych facility or even to the ER to have them 302 committed, they will not keep them if there is a dementia diagnosis. Doing so is actually illegal. We've run into this problem quite a few times at my facililty. Honestly, all you can do is keep PRN antipsych meds on hand and dole them out as you need to. I know it feels bad to do it, but when you factor in that you don't usually have time to spend 1 on 1 redirecting because you have other patients to attend to, it really seems like it becomes the only option. *And ALWAYS, ALWAYS document as thoroughly as you can. This will make it almost impossible for an MD to deny you PRN meds! Good luck![/quote']
The problem is not getting the meds unfortunately. The problem is getting the family to agree to us administering them. The family is 110% against it. The only way we are allowed to give them out is by first calling the family and requesting we be permitted to give them out to her.
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.
This must vary by state... in Indiana PRN antipsychotics can be administered, but there must be very clear/ thorough documentation to substantiate its administration (vs. the medication being administered as a chemical restraint).
At the facility I work at, we rarely administer PRN antipsychotics. We also have a written protocol in place that requires documentation of non-pharmocological interventions/ results and the notifications that must occur.
Sometimes it really is tough to deescalate a resident who is having aggressive behaviors, especially when you add dementia to the equation. Safety of everyone (the resident, other residents and staff) is the priority. It's also so hard to assess someone when they are in crisis to see if there is also a medical issue going on (low blood sugar, CVA/TIA).
To the OP- maybe after things settle down you can revisit the topic with your supervisor or DON to see what other options you have if this situation would present itself again. Maybe your policies need to be looked also, given the response of the mental health representative when dementia came up. Are there other resources available?
In Pennsylvania, when you send a resident out to a psych facility or even to the ER to have them 302 committed, they will not keep them if there is a dementia diagnosis. Doing so is actually illegal. We've run into this problem quite a few times at my facililty. Honestly, all you can do is keep PRN antipsych meds on hand and dole them out as you need to. I know it feels bad to do it, but when you factor in that you don't usually have time to spend 1 on 1 redirecting because you have other patients to attend to, it really seems like it becomes the only option.
*And ALWAYS, ALWAYS document as thoroughly as you can. This will make it almost impossible for an MD to deny you PRN meds!
Good luck!
I work on a adult psych unit that accepts geri patients. Yes we get patients from ltc with a dx of dementia on a 302 commitment all the time. If they have the dementia dx chances are they are not going to be able to sign in voluntarily, but they can be committed involuntarily.
LadyFree28, BSN, LPN, RN
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