Get me the alligator gun …

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I’m in need of a bigger alligator gun. I am up to my ass in them, and they think they’re winning.

I’m providing nursing care for 42 residents in a two-building, 60-bed facility. They are all here because they failed placements at other facilities for behavioural reasons. Lots of LTC facilities have “memory units,” and take demented old Granny as long as she can pay. But as soon as she starts screaming at the wallpaper, eating off of everyone’s plate but hers, delivering poop presents to staff, peeing in the fireplace, and getting naked before arts and crafts, they send her packing.

That’s where a facility like this comes in. It’s set up to safely house and care for the soon-to-be-homeless schizo seniors, the demented dodderers, the hitters, the kickers, the spitters, and the screamers. The youngest residents are in their 40s, the oldest in their 90s. Some have as many as 12 failed placements before they end up in a facility like this.

I spent the day wheedling med orders out of distant docs. I was polite when I told one doc that her wound care order was [barbaric] and 50 years behind the times. I shoveled one resident into a cab three times, only to have her exit out the other side three times. I finally had to send for a cab with lockable doors. My staff is uneducated, and although some have potential, some need to find other jobs. I have conversations that involve invisible refrigerators (it was in her stomach), “purple sixteens,” the people in the television [off] who tell them to not take their pills, poisoned food (the “twelve-inch people” do it), and missing hair. One resident called the police on me today when I wouldn’t get her a pregnancy test (“Polly, you’re 81 and you yell ‘whoop! whoop!’ every time you poop. I’m not thinking the guys around here are lining up outside your door at night to do the granny-hop with you”).

My first week in the new job as DON – 60+ hours – I spent defending the facility against a Statement of Deficiency from the state that ran 76 pages (it arrived Monday afternoon, my first day). Six IJs (immediate jeopardy tags), and 21 other nursing citations – the state closed one of their  buildings to new admissions. I had no idea that on my first day as DON I would go from the frying pan into the fire. I had to write a policy manual for the facility from scratch, and provide the nursing care for 42 psychiatric and advanced dementia patients (four of whom I discovered had pressure ulcers; there would be more).

At the end of two weeks, I was fried. The weekend came, and I tried to crawl inside a scotch bottle and hide. It didn’t work, Monday still found me.

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Not all it’s cracked up to be …

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Being the Director of Nursing for a psych facility is not the cush job it first appears to be.

  • 0625. Arrived at the facility. Met at the door by two NOC staff with their updates, complaints, and emergencies.
  • Five eloping patients tried to leave over 100 times during the day shift.
  • Four resident assistants reprimanded for leaving door alarms unarmed.
  • One computer meltdown finally fixed after four days with no connection.
  • One dying patient in pain and with sinking O2 sats assessed and comforted. Hospice notified but tells me “We’re pretty busy today, can you handle it?”
  • Two crisis family meetings.
  • Four missing syringes of morphine.
  • Nine calls to the VA and hospice to order more morphine.
  • One meeting with a parole officer, one meeting with an angry parolee.
  • Five calls to MDs to adjust meds.
  • One resident transported emergently to the ER for chest pain.
  • One solid beating of the DON (me) by an angry bipolar who wanted to leave the back yard. One pair of broken glasses.
  • One new exterior gate latch purchased and installed by the DON to prevent further back yard escapes.
  • One trip to Shopko for toilet paper, butt wipes, and gloves.
  • One extremely unsavoury coccyx wound repacking on a screaming resident.
  • One hemorrhoid tucking for a resident who’s spitting on me.
  • One call from and collaboration with an ER doc.
  • Nearly 400 meds found in a closet from 2010 logged in and destroyed.
  • Over 110 HIPAA act label violations found in a mailbox and remedied.
  • Two missing psychotropic med scrips tracked down and original orders refaxed to pharmacies.
  • Two wound care packages ordered.
  • Two staff fights refereed, the staff’s July schedule approved, and three more staff schedule disagreements handled.
  • Another 150 pages of protected patient information shredded.
  • 26 residents rounded on twice.
  • Multiple hugs administered.
  • Office chairs cleaned of resident urine twice.
  • Cellphone located in resident’s shoe.

1855 heading for home. Day 19 in a row without a day off. My cellphone rings before I even leave the driveway.

Drive by …

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I take the people who have nowhere else to go. My patients are those who exhibit what is known as BPSD – behavioral and psychological symptoms of dementia. They aren’t the “pleasantly confused” folks whom everyone loves. They’re the hitters, the spitters, the kickers, and the screamers. They’re the wanderers, the accusers, the punchers, and the shoppers. They throw food, smear excrement, and pee in the fireplace. They’re all mine – they literally have nowhere else to go. Some of my patients have failed a dozen or more placements at other facilities.

This week’s best intake – a 70-yo, hard-of-hearing, schizophrenic, alcoholic woman in stage 3 alcohol withdrawal. She was basically an after-hours drive-by-drop-off from the ER. The hospital’s Discharge Planner still hasn’t faxed me her orders. Her kids said they would be by the next morning to handle the paperwork.

“THOSE AREN’T BUGS, THEY’RE DEVIL BIRDS!”

“Berty, there aren’t any bugs or birds in your room.”

“I SAID THEY’RE ALL OVER MY WALLS! WHACK ‘EM! WHACK ‘EM!”

“Berty, there isn’t anything here that is going to hurt you. I’m here to keep you safe.”

“I’M NOT TALKING TO YOU! SHUT UP! I CAN’T HEAR THE NURSE WHEN YOU’RE YELLING LIKE THAT!”

She was having a very loud argument with the voices in her head about what was or wasn’t climbing the walls of her room. It was a lot like listening to Gilbert Gottfried on acid – for three. Fscking. Hours. Not a single one of my Resident Assistants would even come into her room until she exhausted herself (and until I had enough PRNs in her to quiet the voices).

It’s lonely at the top.

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