Body: RULAC Type: Agenda Meeting: Committee Date: 2015 Collection: Council Agendas Municipality: Frontenac County
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APPENDIX “A” Changes in Long Term Care: Fairmount Home
August 21, 2015
The Residents complex and multifaceted care needs have increased greatly over the last five years and does not match our funding and staffing levels. The sustainability of quality and safe care for our Residents is at risk.
-see attached graph with outcome scales. Five years ago -There was a mix of Residents with low to very high care needs. -Some Resident’s came in doing their own laundry, playing high end card games and driving their own cars. Residents had a higher cognitive status. -Residents admitted had manageable responsible behaviours with Geriatric Psychiatry that visited once weekly. -Several Residents could provide own care independently.
- Residents had one chronic disease
Today -A significant increase in the number of Residents who need help with activities of daily living such as toileting, personal hygiene and dressing -One-third of our Residents with Dementia and Alzheimer’s have severe cognitive impairment. On our 32 bed secure unit there are 18 Residents who require assistance with feeding. -79% of Residents exhibit some level of aggressive behavior. There is a significant increase in moderately aggressive behavior. There were three form 1 made this quarter and the Residents did not return. A form 1 is an involuntary admission of a Patient into the hospital for psychiatric assessment. Psychogeriatric team visits decreased to bimonthly. -1 in 2 Residents has a psychiatric diagnosis such as anxiety, depression, bipolar disorder or schizophrenia, and dual diagnosis (e.g., Dementia coupled with a psychiatric diagnosis)
-Over 90% of Residents have two or more chronic diseases, with notable increases in the proportion of residents with common conditions such as arthritis and heart disease -More specialized and complex care needs. ie IV therapy and PICC line care.
- A generation of Residents and Families with higher care expectations (toileting 6-7 times daily).
Case 1 This gentleman is a 92 year old Diabetic man with multiple comorbidities and compromised circulation. This gentleman had a Diabetic infected foot wound, with green infectious slush tissue that put him at risk of further complications. He was at high risk for developing gangrene shortly in the next few days. An urgent consult to vascular surgery was done and a transfer to Emergency department was necessary. The Emergency Physician assessed him and ordered IV antibiotics and sent him back immediately. This entailed IV therapy every day performed by our Registered Nurses. We now can order these supplies and receive them in 12 hours. This also entails that all of the Registered Nurses are certified and trained in IV site maintenance, IV bag and line changing. This gentleman was sent back to hospital within two weeks for a necessary below the knee amputation. -Five years ago this gentleman would have been kept in hospital as Long Term Care did not provide IV therapy.
Case 2 This woman is 94 years old with multiple comorbidities and complex care needs. Her diagnosis of Multiple Sclerosis results in total dependence for all care. Although her continence record showed that she had only 30 percent bladder control she requested to be toileted six to seven times a day for dignity and skin care protection purposes. Due to her complete lack of trunk control a staff member had to stay with her for the entire toileting time. Including the transfer by a lift and sling this can require two staff for up to 20-30 minutes each time. -Five years ago 13.2% of the Residents admitted were independent with care vs. 0.8% being admitted today. Most of the admissions today are extensive and total dependent of care requiring more nursing care and time.
Case 3 This 85 years old with man with Dementia has severe responsive behaviours. Responsive behaviours is a term used with Dementia Residents to describe actions, words and gestures as a response, often intentional, to something important to them. This includes agitation, yelling out and aggressive behaviour. He also has multiple comorbidities and was bed bound. He was previously at Baycreast for specialized geriatric and psychiatric evaluation? When admitted he was taking Seroquel for his aggressive behaviours. He had several aspiration pneumonias at our Home that was attributed to the side effect of Seroquel causing a decrease in his swallowing abilities. His daughter is a Doctor and requested Seroquel be titrated back and ultimately stopped although resistive to care for months at the Home. He became very resistive to care and hit multiple staff during care. Another Psychotropic was trailed as per the suggestions of our Geriatric Psychiatry team and aggressive behaviours continued causing continued physical injuries to staff. Several care conferences and outside resources were used until he was ultimately sent to hospital by physician on a form 1 due to his aggressive behaviours towards staff. -Five years ago there was more mental health beds in our Region available for this complex case. Case 4 This 68 year old woman has several comorbidities and allergies. Her care is very complex due to various medical confounding variables. Advanced assessment skills are necessary to successfully monitor her condition. She has had multiple abdominal surgeries and has an ileus conduit. She is followed by a specialist for ongoing right sided kidney pain and chronic history of Urinary Tract Infections/ Pyelonephritis. She requires IV antibiotics regularly. She has a peripherally inserted central catheter (PICC or PIC line) which is a form of intravenous access that can be used for a prolonged period of time. The PICC line requires regular dressing changes, blood draws, flushes, cap changes and site maintenance by our Registered Nurses. It was necessary for our RN’s to be certified and trained to use PICC lines. -Five years ago we did not have PICC lines in Long Term Care. Case 5 This 59 year old man was admitted from the new BTSU in Bellville with Dementia and aggressive responsive behaviours. He requires a secure unit. This unit has Resident’s that will enter into your space and touch you unprovoked. He is a tall and fast man that does not tolerate others in his space. He requires a very detailed plan of care for social interaction, feeding and care. It was requested that he be admitted to our Home on a
temporary bed hold from the BTSU yet this was not an option from the BTSU. He has had the Mobile Response Team providing transitional care for six weeks now. He is unable to settle into Long Term Care. He recently has been running after staff and showing increased signs of aggression around others. A form 1 was considered. There was no mental health beds or BTSU beds available. His wife was so opposed to a transfer to hospital that she considered taking him home despite a history of violence with his entire family. Psychotropic medication has been increased. Staff are frightened by his behaviours and are concerned for other cognitively impaired Residents that enter his room or space. We have used our 1:1 HIN staffing and MRT support. We have required multiple care conferences with the family and interdisiniplinary team. -Five years ago there was more mental health beds in our region available for this complex case
There has been a paradigm shift in Long term Care facilities. We are no longer dealing with just the elderly frail population. The lack of community and psychiatric beds and nursing care resources has also played a significant role in the changes to Long Term Care. The Residents are entering our facilities much younger with the diagnosis of neuromuscular disease, Acute Brain Injury and unstable Dementia with aggressive responsive behaviors.
Report provided by Emily Shoniker Director of Resident Care Fairmount Home
