How would you approach this situation?

[rachelgeorgina]

Let me preface this by saying that I'm not a nurse, yet. I'm a nursing student. Though, with several elderly relatives with chronic illnesses that require intense levels of care (a lot of which I've provided) I've had a lot of experience with the healthcare system (in Australia) and a bit of perspective on how frail aged people experience healthcare in the acute care setting.

I wanted to get nurse's opinions on how they see the following situation and how they might have handled it as either the nurse or as the relative or visitor:

My Grandma is 87 and probably entering the very early stages of dementia. She has COPD and is a CO2 retainer requiring continuous oxygen (3L via NP). Ideally her saturations should be between 88-92% (as assessed and recommended by her respiratory physician.)

Two weeks ago she developed pulmonary oedema which her GP failed to treat successfully at home. She was admitted to hospital, spent a few days on the respiratory ward, was transfered to ICU, stabilized after a few days, back on the ward until she was at baseline. The staff treated her very well and we were impressed with the level of care she received (after having some bad experiences with elderly relatives in hospital including one that resulted in premature death). The medical team suggested an admission to rehab once she was stable to try and get her back to where she was before the exacerbation. All well and good until we were told which rehab facility the hospital transfered to. We've had several poor experiences with this particular facility and made it particularly clear to the medical team that we'd rather care for grandma at home (which we normally do, with some assistance) than have her go to this facility. They say they understood and that they'd see what they could do... Then a week later mum gets a phone call in the middle of the day with no prior warning saying that they've just transfered grandma to said facility. At the moment we're getting services in place so that we can bring her home instead of having her stay there.

In the meantime, we're spending every minute we can with grandma at the rehab facility because a) it's pretty blood lonely. No TV, radio, windows to look out and the nurses don't seem to talk to her. It's entirely mentally un-stimulating and boring and b) we don't want anything to go wrong. We're having a hard time trusting the staff to take care of her due to prior experiences at the same facility. She's been there for three days now. I wanted to ask how you might have approached this incident:

It's twelve-pm on Saturday. She's supposed to have QID vital signs. The last set of obs were taken at nine-pm the previous day. Saturations were recorded as 82% on RA. There were no follow-up observations or interventions documented or implemented (because, you know, 82% is considered suboptimal, even critical.) When I arrived before lunch time the next day, her nasal prongs were in the bed, not in her nose --- she requires continuous oxygen. I approached the nurse's station and apologised for the trouble, said I didn't want to be one of those annoying visitors but that I had noticed that ... what I've just described above re: observations and her saturations. A nurse appeared at the bedside to take grandma's obs after I'd spoken to an RN at the desk. The nurse tut-tuted, "still 91%" and reached for the oxygen flow metre to turn it up. I almost had a heart attack on the spot! I don't know whether or not it's common knowledge in healthcare but giving a patient with COPD/CO2 retention more than 3-4L of oxygen is contraindicated!

Do you think it was appropriate of me to approach the nursing staff about this situation? Are my concerns in this situation valid? My concerns were as follows:

- QID observations not being taken/documented

- A saturation of 82% being documented and otherwise ignored/no interventions implemented

- The patient being documented as on RA when she's to be on O2 at all times (suggests that staff don't know what her needs are/what her plan of care is)

- The nurse directly caring for her attempting to turn up the flow metre (contraindicated in her condition and unwarranted considering 91% is around about ideal for her.)

& finally, where would you go from here? How can make sure that my grandma receives the best and safest care possible whilst in this facility without stepping on anyone's toes or causing a fuss? I don't want to be one of those awful visitors that hovers over the nurse and tries to control everything because hey, that's not my job. It just feels as though the staff aren't doing their jobs and that's a) putting my gran, who I love dearly, at risk and b) making her exceptionally uncomfortable, which she'd be inclined to suck up and deal with rather than speak up and say anything for fear of causing a fuss.

(It's not really relavent but these are some of the reasons why we aren't comforatble with grandma being in this facility:

- The "GP casualty" (sort of like a sub-acute emergency department) telling my grandma's sister that her chest pain and shortness of breath were simply as a result of her old age and not seeing her for two hours and then realising that she was in rapid, unstable AF with severe pulmonary oedema amongst other things

- My grandma discharging herself from said facility against medical advice and catching a cab home in her pajamas after having her hip done and going there for rehab a few years ago

- Most significantly, my grandpa/my grandma's husband died in this same facility (it's quite small.) We thought it was be upsetting/traumatizing for grandma to be there.)

[Virgo_RN, BSN, RN]

I can understand why you would be concerned. Would it be possible to meet with the Director of Nursing and review your Grandmother's care plan?

[K+MgSO4, BSN]

If she is in rehab she must of been seen by a social worker as well, esp if your family is trying to get home services organised. You could try talking him/her as well. Just a bit surprised at QID obs for a rehab pt seems a little excessive as a pt is supposed to be medically clear before transfer to rehab??

Or has she been seen by care-co or ACAS or TRAC? Try talking to the NUM on monday arrange a time in advance to see him/her and explain your concerns.

[rachelgeorgina]

^ I'm not sure what care-co or ACAS/TRAC are... We had a social worker (well, social work student - who was trying to get 15 hours/week services arranged - there's a two year waiting list) at the major hospital prior to transfer. So far I have no idea who is on the team/whether there is a team at the rehab facility. (Did I say I don't have a lot of confidence in this facility?)

I'm not sure about the rationale for QID obs. It might just be to keep an eye on her sats...? I'm only guessing. My mum gets really paranoid about whether they're okay so we have a pulse oximiter at home and at the hospital she had one at her bedside for easy access and/or to wear all the time.

[Sunflowerinsc, ADN, RN]

Since you were going to take her home anyway, can't you do it now ?

[tencat]

Hmmm....not being familiar with the Australian system, I can't really tell you what I think you should do about the facility, but is hospice available to you so you can take her home? Why does she HAVE to be in a facility? I would get her out of there ASAP and care for her at home. She deserves comfort and familiar, quality care from those who love her, if you are all up for the challenges ahead, which is a different topic altogether.

As long as she's in the facility, is it possible for a family member to stay with her? In the US sometimes that scenario is possible. That could help alleviate some of your concerns.

[rachelgeorgina]

^ We can't take her home until the private nursing agency we've chosen assesses her and checks out the house (that's happening tomorrow, Monday) and we've interviewed the nurses. (Since we've had some dodgey ones from other agencies in the past and my gran can be very stubborn we wanted to hand pick the nurses assigned to come to her home and look after her - to make sure they were suited to her needs.)

In Australia you can't stay with your relative (there isn't any space, anyway!!!) Either mum or myself is there at all times during visiting hours and ALWAYS during meals (to make sure she eats, the nursing staff don't seem to care... They weren't even filling in the 48hr food chart requested by the dietician.) We provide as much as her care as possible (so much so that yesterday a nurse just brought me a pad and told me to change her... I was like, er, isn't that what they pay you for?)

Thanks for your responses. Tomorrow I'm going to phone the unit to make an appointment to see the NUM and see if I can't discuss some of our concerns. I just don't want to be one of those awful visitors that stands on everyone's toes / that the staff hate!

[StrwbryblndRN]

Sounds like you are doing all you can until she can get home. Glad to hear that you are on top of your families care. Not many families could do the same.

Hope the transition to home quick.

I am not sure how the system works there but is there a way to report negligence regarding the facility? It may help in the long run for others not as lucky as your grandma.