The Remark Mid-Dressing
Mrs. R, 78, is on day 6 of a skilled nursing stay after ORIF of a right distal femur. She lives alone in a two-story home; her daughter lives three hours away. Yesterday she scored 3/7 on lower-body dressing, needing setup and verbal cues. Today, midway through the task, she pushes the clothes away and says, "Why bother? I'll just be dead weight to everyone. Maybe it'd be better if I didn't wake up." She then jokes, asks to go back to bed, and rates pain 4/10. No psychiatric history is documented. The supervising OT is off-site at another building until tomorrow. The COTA has 35 minutes left in the session and four patients still scheduled.
1. What should the COTA do in the next ten minutes, and what should she not do?
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Do not treat this as a scheduling inconvenience or as attention-seeking. A statement of not wanting to wake up is a red flag for suicidal ideation and must be acted on the same day, regardless of the OT's absence.
Immediate steps:
- Stay with her and do not leave her alone until nursing has been handed off in person. If she expresses a plan, means, or intent, that is an emergency - activate facility protocol and keep continuous observation.
- Ask directly and neutrally: "When you say it might be better not to wake up, are you having thoughts of hurting yourself?" Asking does not plant the idea.
- Notify the charge nurse/supervisor immediately per facility policy, and page or call the supervising OT the same day. Off-site is not the same as unavailable.
- Do not perform a formal suicide risk assessment, diagnose depression, or write a counseling goal - those exceed the COTA's role and this setting's purpose.
The four remaining patients get rescheduled or covered; a same-day safety handoff outranks the productivity number.
2. How should this encounter be documented and communicated to the OT?
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Document objective, verbatim data with times:
- Exact quoted statement and context (mid-dressing, task abandoned).
- Behavioral observations: affect, tearfulness, joking that followed, whether she made eye contact, any plan or means mentioned.
- Actions taken: who was notified, by what method, at what time, and their response.
- Patient's response to being asked directly.
- That the session was terminated and remaining treatment was rescheduled.
Avoid interpretive labels such as "manipulative," "seeking attention," "depressed," or "noncompliant." Those phrases follow the patient for the rest of the chart and can bias everyone downstream.
Communication to the OT should be a live call, not a note in a mailbox: state the finding, the actions taken, and ask explicitly whether the OT wants the patient seen by OT tomorrow, whether a cognitive/affective screen should be added, and whether social work should be looped in. Follow with a written summary. This is a screen-and-refer duty, not a diagnostic one.