my father hit another resident

CarolynATL

Reading some of the other recent posts has given me some good advice how to understand this, so thank you all!

The MC facility called me yesterday - my dad had punched a resident in the back.  She seemed physically ok - didn't need immediate care. The staff didn't see it happen, so they don't know what led up to it.  The aide said that earlier this week he was getting very impatient with others while playing games, also yelled at a staff member.  These are completely out of character, so the PA came in to evaluate and do labs a few days ago.  They don't have the follow-up from that yet (why??).  The only other change I am aware of is that the Activity Coordinator retired, so possibly his fitness and activity schedule is off?  I went over and spent the afternoon with dad.  He seemed calm, no anxiousness or anger.  

I'll be talking with the RN and Director tomorrow.  What are some things I need to ask/talk about with them?  I'm thinking - what are the lab results and why wasn't I called?  Any other ideas?

Thank you!

dayn2nite2

Labs were done, but no urinalysis?  I would suspect a UTI first.

Jo C.

So hope UA with C&S was done; that is important but some seem to not do that with males as much as with females and they should.  Sometimes physicality can happen out of the blue.  Too bad it was not witnessed or that there were no cameras.  Could have been something leading up to that as a trigger that someone said or did.  Maybe.

Has he had any changes in medications lately?  Not getting them, or new ones added, or change in strength of med?  Or perhaps giving him PRN "as needed" meds that he usually does not take; even sleeping meds?

Is he in pain?  Constipated?  Hungry?  Etc., etc.  Has to be a stimulus and need to rule out any triggers, and since this is happening only upon occasion, there may well be triggers.  Would hope staff would observe for that, but that may be easier said than done.

If you do not hear by tomorrow a.m. what the labs are, I would get the number for the PA and call and ask for the results. Also find out if the PA ordered a UA with C&S; if not, ask for one to be done.   It will take three days to get the culture back, but it is important.  Just doing a "dipstick" test of the urine is not sufficient as the dipstick error rate is very high; C&S needs to be done.

Since this is so out of character for him, something must be happening. 

Next time you visit, it is totally okay for you to ask to read his Medical Record; you will want to read the nursing notes and the aides notes.  Check what they say, check his activity, his sleep, food, check to see when his last BM was; see if he has been incontinent of urine or has complained about hurting or not being comfortable.

Then . . . ask to see the Medication Chart; it will be separate from the medical record.  Check each day to see what he is being given and when and check to see what PRN (as needed) meds are given if any and what he is being given for sleep if anything. If any meds are new or if he is taking sleeping meds or as needed meds he usually does not take, this may possibly be contributing to the problem.

Do not worry about doing anything wrong; it is the law that the family member can indeed see the medical record and the medication record.  If you have a DPOA that even lends more power to the request. When I did this with my mother, the first time I was looked at a bit sideways, but I stayed smiling  and kindly.  They were fine with it and soon got used to it as I did it at intervals and I was able to see that some of the PRN meds were causing a bit of an issue from time to time and they were able to be adjusted. I was also able to see that she was not getting bathed when she should, so that got kindly corrected too.

Let us know what you find out, we will be thinking of you and so hope the labs find any issues if there are any. 

J. 

MN Chickadee

I know the health care industry is stretched to the max nationally right now. Hospitals down through all types of clinics, clinicians, and staff are stressed and maxed out and most entities are short staffed. Perhaps this combined with it being a weekend has delayed the results. I would definitely want to see the lab and urinalysis results before making any other plans for him. Does the clinic or hospital system that his PA comes from have an online portal? My mother has always used the PCP who does rounds in her facility and though that person has changed I have always been able to use the online patient portal to access lab results. Often the results appear on there before the physician has even had a chance to receive them/look at them let alone call me or the facility. 

If the med list and  labs turns up nothing I would inquire if the facility works with a geriatric behavior health psychiatrist and/or inpatient facility. This may be the only route to keeping him there, as they have a duty to protect their other residents.

I would also inquire about the circumstances which led to him getting worked up on each occasion. Was it evening sundowning? Is there a particular resident who rubs him the wrong way? What was the staff member doing when he yelled at them, was it bathing or toileting (a hot button issue for many PWD) or totally out of the blue? Could a different staff person, time of day, or approach work? These things will help point you to whether there are things that could be tweaked in his day to alleviate the issue or if more extensive pharmaceutical interventions are needed. 

jfkoc

What are the results of the UTI test (UA)?

CarolynATL

Thank you so much everyone.  These are great points to consider.  I'm meeting with the director and nurse in a couple of hours.  Ideally they'll have his test results and we can go from there.  I'm also sharing how disappointed I am that I didn't find out there was an issue until he hit someone days after the onset.  I feel for the staff - they're all stretched so thin, so I know there aren't any easy solutions.  I do know that I'll need to spend more time there to be supportive and helpful in managing his stressors.

Jo C.

Good to have a meeting. Try to get them to put together a multidisciplinary team meeting to discuss putting together a Plan of Care for his needs, etc.

This should be unit licensed nurse, PT, activities director, social worker, dietary, DON if interested, his most usual aide, and anyone else involved.  Doctor's do not attend these.

At that time, there is input from everyone, a Plan of Care is put together with new approaahes for any challenges as well as routine care needs.  Plan is communicated to staff so all are on the same page and it becomes a permanent part of his record.

Wishing you well,

J.

CarolynATL

We all met today and had a great conversation.  The impatience and yelling at a staff member, they agree, *may* have been triggered by situations that could have been approached differently.  They're not sure what led to hitting the woman.  They still don't have the UTI results because of lab back-log, so I asked why they didn't simply start an antibiotic treatment, and they agreed.  That should happen today.

My big concern was that the doctor recommended zyprexa.  I've read through these boards, side effects research, FDA...I'm thinking this is an extreme approach for what we know so far.  Prior to this week, he's had no history of aggression or yelling.  So for now I've shut that down until  we get blood and urine results back.

Jo C.

Good meeting and good for you!   You are right on spot re starting such a heavy new medication when labs and all are up in the air.

Best to modify approaches with full care team in locked step; med should be last resort. It takes 72 hours to get a urine C/S back from lab.  As for lab "back log" I do not think I would believe that; heavily busy labs turn those things around quickly.  Perhaps they did not get the urine right away.  Don't know

If he does have a UTI, check the "sensitivity" part of the report to ensure he is on an appropriate antibiotic.

Also, while it does not happen with everyone, abx can cause a patient to become confused or seeming to have delusions, hallucinations or other changes.  Just kind of watch for that. My mother had this happen with Levoquin and it was very dramatic.  Other abx can have that effect too.  As said, not with everyoone, but good to remember for a "just in case."

So hope all works out well. 

J.

aod326

Hi Carolyn. I know you've had the meeting already, so my comment may be too late. I would want to know how they know he punched someone if none of them saw it? Maybe the resident he "punched" was over-reacting due to surprise. Maybe your father clapped the other resident on their back and it was a bit harder than expected.

Of course it could be that he punched someone, and all the things you're doing are perfectly appropriate, regardless. But I remember getting a call from DH's first MC telling me he'd thrown a can of soda at a resident; as he was a fit 60 year old, and the other residents were mostly ladies in their 80s, I was horrified! When I spoke to another member of staff they told me he'd got frustrated and thrown a soda, but not at anyone - it just so happened another resident was sitting a few feet from where it landed. (Not good, but entirely different.) Another time I had a call that he had scared a resident because he went to her chair and picked her up. In conversation some different day, a member of staff told me how he had seen the woman struggling to stand up and had gone over to her to help - not that he'd randomly walked over and scooped someone up!  

So, worth making sure you get the full picture before coming to upsetting conclusions. Good luck.

kmasenact

I would also ask what time of day the incident occurred and what the environment was like. This type of behavior is common with sundowning, which happens later in the day (usually around 3 or 4PM, but it can happen all day long). It's also common for residents with Alzheimer's to act out if the environment is too overstimulating. With so many distractions, they may be feeling overwhelmed or tired (especially if it's later in the day), which can contribute to aggressive behavior.

jfkoc

Good for you Carolyn...sad but true that we have to be on top of things...always. Please continue to keep us in the loop.

JJAz

Ask to see the written incident report.  This is how we found out that another resident was taking father-in-law's stuff and it caused a fight.  Another time, someone "came into is house (read:  his room) without permission."  Sometimes there is provocation . . . still a problem, but more understandable.

May flowers

I hope you get some answers soon. I posted a similar situation with my FIL but it’s dropped off the board. He hit 2 people, 2 weeks apart, but had not been uncooperative or showing any issues leading up to it or after. Both events were witnessed - there was nothing leading up to it. His caregivers told us they were shocked because he is the most compliant easygoing resident they have. At the same time. At the same time the hitting started, he also has been feeling cold and having problems walking. He normally walks 1/2 - 1 mile/day at a brisk pace so this is also new.

After he hit the second time, they sent him to the ER who checked his bloodwork and urinalysis, all normal.

He is now at a mentally health facility with a dementia wing for evaluation. One of the docs there sees residents at the facility so he knows my FIL, which is helpful (he knows his baseline)

He had an episode there, calm one minute, and then spiraled out of control. They started him on risperdone. But yesterday he started coughing and they did a chest x-ray. He has pneumonia. So he is coming off the risperdone and started on an antibiotic.

CarolynATL

Thank you all for your perspectives.  I'm still working with staff to understand his triggers.  Not all staff are on the same page and it seems like some of his agitation stems from situations that can be avoided. The RN tells me he's doing fine, the med tech tells me he's increasingly agitated.  I'm meeting with the PA and staff tomorrow because clearly there's a disconnect. I'm getting everyone in the same room at the same time.

I'm also trying to wrap my head around the idea that he may prefer to spend more time alone than I think he should.  I suppose I want him to be engaged and social in a hope that he is not as advanced as he is.  I now see how uncomfortable he is and that I am part of the problem.  Ugh...this disease is such a moving target.