The Coat at 2:15 p.m.
Mr. Alvarez, 78, lives on a locked dementia unit. He has moderate Alzheimer's disease and has exited into the courtyard twice in the past month. At 2:15 p.m. he puts on his coat and tells you, "I have to pick up my wife from work - she's waiting." His wife died four years ago. He is calm, smiling, and has no history of aggression. The courtyard door is alarmed, leads to an unfenced parking lot, and facility policy requires a check every 15 minutes for residents with exit-seeking behavior plus documentation of every episode. The chart contains a family note: "Do not let him outside under any circumstances - he wandered off last month." Your shift partner is on break for 10 more minutes, and there are 11 other residents on the hall.
1. What do you do and say in the next 60 seconds?
Read the worked answer
Do not correct him about his wife. Telling a man with moderate dementia that his wife is dead will not change his plan - he cannot hold that fact - and it produces grief and agitation you then have to manage. The goal is the behavior, not the belief.
What reasoning looks like:
- Join the feeling, not the fact. "You don't want to keep her waiting. That's a long day for her." He is oriented to a duty, not to a door.
- Redirect toward something with the same shape. "Let's get you sorted out - I need a hand folding these towels first, then we'll see about the car." Give him a role, not a command.
- Move with him, don't block him. Walk alongside and turn the walk. Standing chest-to-chest in front of the door escalates and looks like restraint.
- Offer a legitimate substitute. A supervised walk in the enclosed courtyard satisfies his right to fresh air and movement.
- Get eyes on the door. If he turns toward it, call for your partner or the nurse; never leave him alone near the exit.
Then report to the nurse and document time, exact words, intervention, and outcome.
2. He stops, folds his arms, and says, "You're not my boss. I'll go when I want." How do you keep him safe without a struggle?
Read the worked answer
Privately, this is the moment the situation can become a restraint. Physical force on an unsteady 78-year-old risks a fall, a fracture, or an injury to you - and it damages trust you will need at 2:15 p.m. tomorrow.
- Drop the head-on conflict. Offer two acceptable choices: "The courtyard or the sunroom - which one?" Both are safe; he keeps control.
- Give space and silence. Step back half a pace and let him think. Filling the silence with reasons backfires.
- Use empathy as a broken record. "I hear you. I can't let you go to the lot alone, and I'm not going anywhere."
- Bring in a second person if he moves toward the door - a different face often resets the moment.
- Physical contact only to prevent imminent harm (he is stepping into the lot). Stand in front, arms down, calm voice, call loudly for help; do not grab or hold unless he is falling.
- Document the refusal and the behavior and report it - an escalating pattern is a care-plan problem, not a discipline problem.
3. How should the family's chart note shape your actions?
Read the worked answer
The note is a family's fear written down, not a physician's order and not a rule you personally enforce. Three things are true at once:
- He has a right to the least restrictive setting and to go outdoors. An unlocked, unmonitored exit is not safe for him, but a blanket "never outside" is a restriction that should be justified, time-limited, and reviewed - that is the nurse's and social worker's call, not yours.
- The locked unit and alarm are the facility's safety measures. Your job is to work inside them, not invent new ones.
- You advocate; you don't decide. Report the note to the nurse and ask whether supervised courtyard walks can be added to the care plan so the family's worry is answered with a plan instead of a prohibition.
Also keep the note confidential. Don't quote it to coworkers who don't need it, and never discuss it in front of Mr. Alvarez or other residents.