Short-term Care Readmission with Medication and Programming Issues
Ms. A. was a 44-year old who had been diagnosed with Severe MR and had several medical issues including; a history of seizures, atopic dermatitis, history of UTIs, diarrhea-laxative induced and obesity. She had lived at Southern Center since November of 1964 and was discharged to a Community Based Residential Facility (CBRF) in 1995. At the time of discharge, she was on no psychotropic medications. A Behavior Intervention Program (BIP) and an Active Treatment Program controlled her behavior. She was taking Phenytoin for seizure control. She was readmitted to SWC in May of 2000. The reason for readmission was that she became a danger to her smaller and more vulnerable peers at the CBRF. She was described as aggressive and destructive. She returned to SWC on Seroquel, Inderal, Depakote, Clonazepam, Paxil, and Imipramine. All psychotropics as they were used. Depakote severed a dual purpose to control seizures as well.
Once Ms. A. settled in on our short-term care unit, she was given a full medical evaluation and integrated into a daily program. Over the next few weeks, her behaviors began improving and her medications began to be reduced. She was also given an extensive GI work up and it was found that she had gastritis. A medication for the gastritis was added. Her diet was adjusted and daily fluid intake monitored. Her laxatives were greatly reduced. All her psychotropic medications were discontinued except for the Depakote. Her behavior was manageable again with active programming and a BIP. She was discharged to another agency in January 2001. She is apparently doing well.
Short-term Care Admission Discovers Medical Condition
Ms. L. was a 20-year old who had been diagnosed since childhood as having autism and had been in her local school special education program since elementary school. Although she had been diagnosed as hyperactive since she was five years old, her parents and the school had learned how to keep things pretty much under control until a year or so ago. Ms. L. became more hyperactive and started constantly demanding one thing after another, especially food. When her mother was not able to meet her requests, she would become physically aggressive, pushing her mother around and screaming. Similar demanding and aggressive behavior was occurring more and more often at school. A community psychiatrist proposed a diagnosis of bi-polar disorder. In addition Ms. L. was frequently up at night roaming the home and getting her mother up to get her things. Ms. L. also developed certain peculiar demands, such as insisting she wear the same outfit of clothes. Her mother would have to wash them when she slept or she would refuse to get dressed the next day. After Ms. L. choked, her mother and three people were needed to remove her. A short-term care admission was requested at SWC. Ms. L. arrived with her parents and a big bag of chocolate chip cookies to keep her happy (and quiet) for the ride to SWC.
Her admission physical found her glucose level so elevated that she was briefly admitted to a community hospital! Ms. L. had out of control diabetes which had not been recognized until now. Although she had to start out on insulin injections, a diabetic diet soon resulted in her blood sugar being controlled just by diet. Her weight had also decreased during that year from 210 to 152 pounds; a loss of 58 pounds. Gee, those diabetic diets sure work wonders!
As her diabetes was addressed, Ms. L. became much less agitated, had a longer attention span, less compulsive or ritualistic behaviors, and in general, became a much more pleasant person. She still demands of a lot of attention, but her parents and those working with her all say she is now fun to be with.
Consultation of Client with Successful Behavioral Intervention
A consultation was requested for Mr. W. who was refusing to follow his diabetic diet. He was increasingly stealing food at home and at his day program site. He started engaging in more frequent testing and uncooperative behavior when supervision was increased. For example, he would turn the burners on in the kitchen and smile when caught. The provider and treating physician were convinced it was obsessive/compulsive behavior and had started him on Zoloft.
Some in home observation convinced the team that Mr. W. was very aware of the reaction his behavior was generating, and the attention was driving the behavior, not an inner compulsion. They suggested minimizing the reaction to food "stealing" while increasing other opportunities for Mr. W. to get positive and appropriate attention. The residential provider thought this suggestion was way off the mark, but said they would give it a chance.
A couple of months later we heard that things had made a dramatic turnaround! Mr. W. was being praised when he ate good food or did other nice things. When he turned a burner on or tried to eat something else, it was ignored. Pretty quickly those activities disappeared and Mr. W. was happy doing "good" things.
Consultation of Client with Undiagnosed Medical Problems
Mr. C. was not sleeping well. He had started throwing things at people as well as hitting the walls. It was believed he was hallucinating since he was spending a lot of time seeming to be talking to the walls. He also engaged in strange behavior such as a session of ripping each page from a hundred magazines, one at a time. The initial solution proposed was a large increase in psychotropic medications.
Although Mr. C. had a possible diagnosis of schizophrenia already, it was found that he had other medical conditions that were probably driving his disturbed behavior. Medical follow-ups and testing found severe arthritis in his knees and also Gastro-Esophageal Reflux Disease (GERD) . Mr. C. was upset because he was in pain nearly all the time. When these medical conditions were addressed, his behavior returned to normal.
ADDITIONAL SUCCESS STORIES
Short Term Care Admission And Readmission
Mr. W. was a 33-year old white male admitted from a crisis house. Upon his admission, he was having periods of sleeplessness, aggression, disruptive behavior, non-compliance, confusion, and elopement. He carried diagnoses Axis 1: of PDD and Psychosis Not Otherwise Specified (NOS); Axis 2: Moderate Mental Retardation; Axis 3: History of Grand Mal Seizure - 1 isolated incident, seasonal allergies, and history of fracture trauma to face at 4-5 years old. He had been living with his parents up until he was placed in the crisis house. He was unable to return to his home or his day program until he was evaluated medically. He was admitted to SWC for this medical evaluation.
During Mr. W.'s admission, his behavior was monitored as well as observations made concerning his allergies and mental status. He was also seen by specialists in Psychiatry, Neurology, and ENT. Staff noticed his behavior and mental status deteriorating around the beginning of February. He exhibited an increase in episodes of non-compliance, confusion, and inappropriate behaviors. It was observed and reported he had a sinus condition beginning. On February 5, 2006, he had a major clonic tonic seizure episode. Medical staff had begun to taper some of his medications by this time. He continued to deteriorate with more disorientation, aggression, and generalized agitation. Psychiatry and Neurology, working together, had increased his seizure medications and added another. ENT and his primary physician found him to have several environmental allergies. There was aggressive treatment for the allergies and his symptoms subsided. His diagnoses were re-evaluated and he was given; Axis 1: Bi-polar Affective Disorder NOS; Axis 3 added with Seizure Disorder and Allergies - ragweed, mold, grass, dust mites, and cats. Mr. W. remained stable until his discharge back into the community to an adult family home in April of 2006 with a structured day program. A 30-day follow up found him stable, cooperative, and symptom free. It seems that with a proper set of diagnoses and treatments to follow, Mr. W. is today, a changed man.
Ms. G. was admitted from an acute psychiatric unit in a community hospital. She had reportedly been aggressive toward her grandmother/primary caretaker as well as verbalized some suicidal intent. She was sent to the hospital and then to SWC for protective placement as she appeared a danger to herself and others. At the age of 8 years old, Ms. G sustained a severe cranial injury when she was hit by a car. She developed a convulsive disorder after that and was also diagnosed with an impulse control disorder. There was some question of exposure to sexually explicit material during this developmental time and her impulse control includes hypersexual inappropriate behaviors. After her accident, her mother could not take care of her and her grandmother became the primary caretaker. Ms. G. had several admissions to other facilities; schools for the developmentally disabled, psychiatric facilities, and group homes. Before this last episode of aggression/suicidal ideation, she had been with her grandmother for about a year following a group home. At SWC, she was placed on a unit with female clients. Her day was structured and she was kept busy. A Behavior Intervention Program was implemented addressing her aggression, hypersexuality, and self-injurious behavior/thoughts, which included a positive reinforcement system for low incidence of target behaviors. Her seizures were addressed by SWC's neurologist and medications were adjusted. Our psychiatrist removed her Lithium and her appetite improved. Her diagnoses were adjusted to Axis 1- Mood Disorder due to traumatic brain injury; Axis 2 - Mild MR; Axis 3 - Seizure Disorder, post traumatic probable focal motor type, left side weakness/unsteady gait secondary to closed head injury. A structured day, close staff supervision, and positive reinforcement has worked well with Ms. G. SWC has seen no hypersexuality or suicidal ideations and very little aggressiveness. The SWC team's thought is, it would be best if Ms. G was placed with an agency capable of duplicating the structure, supervision, and implementation of behavior treatment plans that paralleled those of SWC Ms. G. was admitted August of 2005 and contrary to recommendations, discharged back to the community with her grandmother that October. She was readmitted to SWC July of 2006 with essentially the same problems reoccurring during her placement with her grandmother. The county is now working with the SWC team to find a placement with an agency that will provide an active, well-structured day of appropriate things to do, attentive and well-trained staff, and proper medical assessment as this should continue to aid her in maintaining some control over her life.
Mr. M was admitted to SWC from a psychiatric facility he ended up in when he became aggressive in a hospital emergency room. At that time, he had toxic levels of Dilantin. He was stabilized medically at the psychiatric facility for 3 days in April 2005 before transfer to SWC. Prior to his admission, he had lived in an adult family home with an elderly caretaker. Allegedly, the caretaker could not remember very accurately how often the medications were to be given or if they had been given at all. While at SWC, he was seen by Psychiatry, Neurology, Gastroenterology, Dermatology, and Urology. The psychiatrist found no psychiatric pathophysiology and recommended no psychiatric medications. Neurology adjusted and monitored his three seizure medications and established that a 0-5 per month frequency range should be the goal in controlling the seizures. The neurologist added a fourth seizure medication to help control his seizure frequency and intensity. After the detoxification of extremely high Dilantin levels, Mr. M. was much more compliant and behavioral issues no longer were a problem. GI Clinic performed an EGD and found he had a hiatal hernia. In addition to his Prilosec which was increased, a stool softener was added and Lactinex to optimize his intestinal health by adjusting the bacteria. Incontinence of bowel and bladder remains a developmental issue and good perianal care by staff has kept Mr. M. free of skin breakdown. SWC worked with Mr. M.'s county and eventually found him an adult family home with the ability to duplicate the services provided at SWC. He was discharged to his new home in July of 2005 and has been doing well.
Mr. K. was admitted to SWC in January of 2005. During 2004, Mr. K. had become more paranoid, aggressive, and non-compliant. He was picking fights with his support staff and several had quit because of these behaviors. He would not let staff leave the apartment if certain things were not exactly in their right place, position, or in the right numbers. He had also had some verbal and physical confrontations with random people in his environment. He had attacked a bicyclist who was riding on the sidewalk and according to Mr. K. he shouldn't have been on the sidewalk. Confusion also resulted in aggressive behavior. He came to SWC with Seizure Disorder secondary to brain trauma, Diabetes Mellitus 2, bilateral hearing loss, and bilateral shoulder adhesive capsulitis. He was initially placed on an SWC cottage with clients who have the most challenging behaviors. After a few months of assimilation to the Center, he was moved to another cottage with a less restrictive environment. His seizure medications and his psychotropic medications were adjusted several times. After finding some medications caused more confusion and diminished cognition, he was placed on Abilify 10mgs and three seizure medications at therapeutic doses. His seizures were reduced significantly. Because of the adjustments in medications, his mood was more stable and his compliance improved. The team at SWC derived that much of his negative behavior was to escape from people or situations that made him feel uncomfortable or threatened (real or perceived), and relieve anxiety or frustration when over stimulated. These behaviors seemed primarily connected to his brain injury, but are also influenced by his personality traits which include paranoia, obsession, and narcissism, as well as life experiences and learned habits. Staff was trained to approach Mr. K. in a non-confrontational manner, with simple and straight forward instructions. Mr. K. was not asked to do anything he felt uncomfortable doing and prompt staff interventions seemed to curb some of the situational antecedents that preceded the target behaviors. The frequency and severity of his challenging behaviors were reduced overall. Staff at SWC emphasized that due to his brain damage, his behaviors would likely continue to surface at times related to stressors and perceived threats. Mr. K. was discharged to the community in April 2006. So far, he seems to be doing satisfactory.
Mr. C. was admitted to SWC for the first time in January 1992 after several placements in other ICF/MRs, group homes, and State institutions. This was primarily due to depression brought on by the loss of his mother, and primary caretaker in November 1979. He was living at SWC until April of 1995 when he was placed into the community after his mood was stabilized and an intervention program was used successfully. When the AFH he was living in closed in 2001, he spent 3 years living in CBRF's with some intermittent times spent in hospitals and an ICF/MR recuperating. In July 2004, Mr. C. was admitted back to SWC's medical unit to address medical needs (specifically pressure ulcers and urinary tract infections related to catheter use). While at SWC, there was a treatment regimen implemented to address the pressure ulcers. Healing was slow and the medical team decided to surgically repair the site. Treatment continued until Mr. C.'s ulcers were healed completely. Urology intervention and eventually dilatation of the urethra allowed unrestricted flow and elimination of further catheter use. Mr. C. was discharged to a community CBRF in June 2005 and is doing great. SWC's team recommended some good health and behavior interventions and with well-trained staff and good nursing intervention, he should continue to do well.
Ms. B. was admitted to SWC in November 2005 from Mendota Mental Health Institute. She had lived with her parents until 2002 and was then placed in a CBRF due to unmanageable behaviors at home (i.e., property destruction, aggression, and non-compliance). She was incapable of following a diabetic diet or administering her insulin properly. She was subsequently sexually assaulted at her residential placement. After moving to another CBRF, she trashed an office when a favorite staff left for vacation and when the police were called she tried to take the policeman's gun and threatened to shoot a replacement staff member. While she was living at SWC, her diabetes, hypertension and seizures were well maintained . She was provided with Neurology, Dermatology, Cardiology, Endocrinology, and Podiatry services with improvements in all these areas. Ms. B. had only one act of aggression (a slap), and 3 incidents of disturbed behavior, (yelling out) during her stay at SWC. There were no reports of hallucinations during the last 2.5 months of her stay. Hallucinations may have been related to situational stress coupled with PTSD from an assault history. Ms. B. was stable and socially appropriate for most of her stay, with improvements after medical, behavioral, and psychiatric interventions were modified. Ms. B. was placed in the community in February 2006 into a CBRF with well-trained staff who monitor her diabetes and other medical problems and continue to provide a safe and structured environment for her.
Ms. L. was admitted to SWC in June 2005 after numerous incidents of property destruction, aggression, self-injurious behavior, elopement, and suicide gestures. She had several medical problems besides her emotional and psychiatric issues. She had a history of alcohol and other substance abuse, obesity, diabetes mellitus, hypertension, sleep apnea. She also had PTSD related to verbal, physical, and sexual abuse, mixed personality disorder, and mood disorder. While at SWC, she followed a diet to control her diabetes and improve her weight. She did her own blood glucose monitoring after receiving training and her diabetes improved somewhat during her stay at SWC. She had one episode of self abuse every two weeks or so, consisting of superficial cuts/gouges to her arms and occasional head banging, one elopement attempt the first week, property damage once per week, aggression once every two weeks, and disruptive behavior several times per week. While at SWC, she saw a psychologist who helped her to use more appropriate problem-solving skills. She began to improve somewhat from her baseline behaviors. The treatment team suggested that she continue to see a therapist in the community to address her mixed personality disorder and PTSD. With the help of the SWC team, she was placed in an adult family home where the staff has been trained to care for clients with personality disorders and PTSD. She was successfully placed in the community in August of 2005.
Robert Eisenbart, Nurse Specialist
James Henkes, Director
Last Revised: January 22, 2013