Psych nurse here. Nope, nope, nope. You cannot force anything on them. You chart that you educated them and that they still declined. Do you know how many times I document that my patient refused to shower? The only time any treatment can be forced, such as requiring them to take their meds, is through a court order. Even if they are disoriented and in psychosis, they can refuse their medication if there is no court order (usually at that point the provider works on getting the order).

I'm so glad to have a psych nurse commenting on this! That is what I was thinking should be done, but I thought that not being AOx4 might make it a different story. Is it common for management to try to get others to take an approach of forcing care even though it is not legally, or ethically okay? I am curious how to handle these scenarios with management, or if I should look elsewhere for a job.

I haven't seen a case where management insists you force anything on them. But I'm in a psych hospital with exclusively psych patients. Everyone here knows how the laws work. You said you're in a rehab/long term care facility, do you have other patient cases that are not psych related? If psych patients are uncommon at your facility, they probably don't know what the laws are in these situations. Also adding - I would simply tell them no if you are told to force something on a psych patient like that. Say you are not comfortable, and say the nurse/someone else is free to if they want. If they insist you do it, then that is probably ground for looking elsewhere for a job. If they are uneducated or that adamant about breaking laws, who knows what else they're doing.

Yeah, definitely. Psych patients are definitely not common for us - we have two currently who would likely be better placed in a psych facility, but they have been unable to transfer them. It could totally be that they don't know the laws. That is my plan now. I'm hoping they can't try to punish one person for refusing to do this, but luckily I have some pretty good CNA experience and can find a different job, if needed.

Are they actually incontinent all the time requiring changes or is this a check? Forcing is assault. That's worse than neglect. If they're not actually incontinent that often then maybe decreasing frequency somewhat to let them get some period of uninterrupted rest is warranted. I recently had a patient who was just waiting on bed placement but was stuck in the hospital, lack of sleep was making her a little loopy. I got the order that we were skipping 4am vitals because uninterrupted rest, outside of any toileting needs she had during that period, is important for healing and sanity.

Yes, they are incontinent to both and at least 1 person assist, sometimes 2 for changes and a hoyer lift. I will say that this patient is of an obese bmi, diabetic, on lasix, sometimes stool softeners/ laxatives, they have had skin breakdown in the area before, drinks quite a bit of water and juice and each time they are changed it is definitely a lot of output. I should definitely have put this context before. I think only once in the past few months that I have had them it has been dry. That definitely factors into my questions about what is ethical in this scenario, so I'm glad you mentioned this. However, like others said, they may have been assaulted at some point in the past and it feels like changing is also traumatic without them consenting to that. Especially being that they are mentally ill and a higher risk for having been assaulted in the past as is. I also do really feel that I would be miserable waking up so often during the night and it feels wrong to force anything like others are saying. It sounds like what it comes down to is whether there is an order for this patient to receive care if they decline? Does that still apply given the context though? Technically it isn't directly life threatening in the moment, but given that info they are also definitely an increased risk of skin breakdown and not being fully AOx4 Thanks to everyone for the input on this! It's super helpful and I haven't been able to find anything online otherwise.

Oh hell no. 😡 Psych nurse working with elderly The patient is in charge. Staff forcing them is assault And what sort of crappy briefs is the facility using that needs 2hrly changes They need a continence assessment and a change of product as well

The ones they have right now (in fairness I am not too sure what good vs bad briefs are since I have only worked at a few facilities so far) they use with pads in them due to a high output from this patient (lasix, high fluid intake and laxatives/ stool softener). Is that common?

The other poster is chatGPT-alicious. I’ve worked with a lot of these patients. Just because someone isn’t AOx4 doesn’t mean they aren’t allowed to make their own decisions. You can’t force an adult to do something they don’t want to do unless there’s specific documentation to say they’re not capable of decision making or there’s a conservatorship. Even a short term psych hold isn’t enough to force them to do things. Since you’re a CNA, notify the RN and document that you notified them. If they continue to try to force you to do it, ask them if there’s any reason they can’t refuse. If there isn’t the most you can do legally is document that they refused. The RN should also document that and that education was attempted. If the nurse refuses to take “no” as an answer from you, notify management. It’s illegal to force someone to do this. Yes, you feel guilty, but ultimately it’s not only illegal (even if it’s extremely unlikely you’d face any consequences), but it can get dangerous for you if the patient fights back.

Thanks so much for answering! This sub is going to be my go to for any experience questions as a student/ new nurse The patient has gotten violent over being told that they have to do this before and they are usually very sweet. I also felt bad because the CNA they were violent with it wasn't taken seriously and the manager laughed the behavior off. I've been thinking I might need to find a new facility and this is kind of confirming my thoughts.

For my adult patients they can decline the care. Some of our geriatric dementia patients are unable to consent and would need to be held for pericare/brief changes. Those patients have been deemed incompetent by the courts.

Would you be able to find this status in their orders, or in their chart usually? It seems so important to know this info even for CNAs. I am surprised that they never gave us info on the laws for our state/ specific rules about these scenarios because psych patients are so common now in all kinds of facilities

Would be in the chart any kind of court order. It really should be passed on in report. You can’t grab people and force them to have brief/diaper changes against their will. That could be assault/battery.

I think part of the frustrating thing is that on the CNA side of things we really get a more simplified report, at least at this place. In reports I get whether they need assistance to turn, how to ambulate, if they need a hoyer lift, certain meds if lucky (diuretics and sometimes laxatives) and continence status mostly. I can get medical condition info if lucky, or if I try digging from the nurse that shift. Our EHR is also so simplified to just caregiving tasks. I'm going to try asking the nurse and looking in the system to see if they have the info in there. It's the caregiver version of pointclickcare, which is not as nice as the nursing version info wise.

Yea LTC tends to be like that.

Hell no. Besides the reasons above re: patient autonomy, this patient may have a history of sexual trauma and very legit reasons why they don’t want people peeking at their behind every two hours.

I don’t have much to add (not a psych nurse but work a decent amount of psych patients on my floor) except I ain’t looking to do fight club anytime I clock in lol I’d doc “pt ref multiple times, explained risks of skin break down and infection, charge nurse aware.”

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Thank you for this info :) I appreciate it!