Hygiene issues, behavior issues, a much older boyfriend, etc...what would you do?

Nurses General Nursing

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I've been spending a lot of time working in ER lately and we have a family of patients that is just driving the ER staff a little over the edge. There is a mother, 12 year old girl, 16 year old girl, a 23 year old daughter, and the 23 year old's husband. They have always been people that we see alot, but in the past month, I have seen one or more of them (at least daily...sometimes they will come in two or three times in one day) in the ER for things that are not really considered emergent...broken fingernails, pregnancy tests, throwing up once, etc...but that isn't the problem...just laying some groundwork here. 

Anyway, these people have the most horrible hygiene I have ever seen...they literally stink so bad that after they leave, we have to have housekeeping come in and clean the room, and even after that, the room usually smells so bad that we consider it closed for the rest of the night. They also never really "act sick." Usually all five of them come in no matter who is sick and they laugh and giggle and tell loud and crude jokes that everyone in the ER can hear. Also a bit more ground work here...
I know there are also some mental issues here...they all have a lot of trouble reading, the mother and 23 year old cannot read cursive writing, so we have to print all of their discharge instrutions. We have to be very specific, yet simple with their instructions or they will call back a dozen times trying to understand them...we have to say things like "Swallow one pill at breakfast. Swallow another pill at supper. Do this until you swallow every pill in the bottle" rather than our usual, "Take one tablet twice daily until gone." We also have to go over things very step-by-step, or again, they are calling with questions...can't just tell them to change their bandaid, clean the site, and apply neosporin twice daily, have to tell them to take the old bandage off, wash with soap and water, dry well, apply frech neosporin, and put on a new, clean bandage. 
They leave a mess in the exam rooms...food everywhere, kleenex on the floor, food on the wall, entire boxes of gloves pulled out and thrown all over the floor, supplies in cupboards and drawers gone through...
I am trying not to sound judgemental here, but it isn't working. :(
So...the problem is...I go to church with the 23 year old and her husband. A couple of weeks ago, she asked me why I am so standoffish to them when they come in to the ER. I told her that I honestly try to stay very neutral with patients in the ER and that while I will give the best nursing care that I can, I am not there to be my patient's friend...I will take care of their needs, but I am not their buddy. Not very nice of me, I know, but a lot of times I just don't have the time to be all happy and friendly with them...I also hate the idea of reiforcing to them that coming to the ER is a fun and good idea...sure I will help them with whatever they need, but I am not going to make it a good time for them....not going to make it a bad time, but I sure don't want it to be fun. Honestly, I am also not really sure if I want people I work with to know that I know these people socially...:(
Also...because of the hygiene issues, one of our doctors often talks about turning the mother in to social services for neglect. He doesn't believe the younger girls need to be removed from the home or anything, but he does think that there needs to be some sort of intervention, parenting classes, hygiene assessment, etc. I would never let anyone in the family know this is about to go down because they would probably clean up their act until they are investigated and then go back to status quo...also it is just not my place and would be inappropriate for me to do so. He also has concerns that even with very detailed instructions that often the discharge instructions are just not being carried out...they will often come in with a seven or eight days worth of antibiotics from two months ago wondering why they didn't work...the husband once left stitches in for 21 days because he didn't understand that he had to have them removed.
But...would it be wrong for me to invite the 23 year old over for lunch someday and talk to her about some of my concerns? She and her husband have the same hygiene issues and I honestly think that neither of them were ever really taught that you have to bathe, shampoo your hair, wear antipersperant, brush your teeth, etc. I think they must bathe on Sunday morning, because I really don't notice the hygiene thing at church. Would it be inappropriate to talk to her about their behavior in the ER as well? I don't want to step over any lines, but I really think that if she was told how inappropriate their behavior was, they would cool down, at least for a while.
Also, I happen to know that the 16 year old has a 23 year old boyfriend and I am about 99% sure that the mother doesn't know. I know because I have caught them making out in the hospital lobby after hours and because a friend of mine works with the boyfriend and he was asking me what I know about the girl...she looks way older than 16...and my friend acted pretty shocked when I told him that is how old she is.
So...I'm not sure if I am just venting here or being a judgemental witch or what...if I ever smelled that badly and behaved that badly, I would want someone to tell me. If I do say anything to the young lady from church, I doubt it will go over very well, but...just don't know what to do.
Also...any ideas on how the ER staff can better deal with this? I really feel like we have contributed to the making of this mess and a lot of us are really frustrated right now.
Also, please forgive me for rambling on and on...






































Dear Mom...
I am worried because your hygiene and that of your family is very poor. It concerns me that after you leave the ER, the rooms smells so bad that housekeeping has to go in and to a thorough cleaning and we cannot use the room for the rest of the night. If you need assistance with your water bill, buying hygiene supplies, etc, please call out social services director...she would be happy to help you.
BTW...I caught your 16 year old making out with a 23 year old construction worker in the hospital lobby. The hospital, while a public place, is not a good place to go on a date. The 23 year old construction worker's coworkers say he is an ass.
Hugs and Kisses
Me
Keep it simple...
Dear Mom...
Wow! You guys stink! Here's some soap.
Buh bye
















































The ER doc used to put "daily soaks in warm soapy water" on their discharge instructions regardless of what they came in for...I think it is time for bigger and badder intervention.










































Specializes in Maternal - Child Health.










I don't think that a lunch meeting would be appropriate. But you can certainly address these issues at the next ER visit, where your roles as nurse and patient(s) are crystal clear. Document your teaching on basic hygiene, then use your nurses' notes to support your request for a social services consult.
Also, it sounds like these people are either uninsured or covered by a government sponsored health plan. If they are uninsured, then it is certainly in the hospital's best interests to get social services involved in order to reduce the number of needless ER visits that go unpaid. If they are on Medicaid or Medicare don't they have a case manager your social services department could contact for guidance?










































Specializes in Critical Care, Pediatrics, Geriatrics.










I would definitely keep the relationship professional, if I were you.
I think social services should be contacted to look into the household and provide proper teaching about the relationship between good hygeine and fewer visits to the ER, plus what is and IS NOT an emergency.
If there are mental issues here, and it certainly sounds like it, perhaps they could be evauluated for those needs.
About the 16y/o... It really is not your place as a NURSE to say something to the mother, but if you go to church and are socially close then perhaps after services you could inquire about the family and bring it up casually... but I would recommend letting them work out their own issues.
















































As a former member of upper hospital management, here's what I could see happening:
The family gets a letter from someone saying they "stink up ER". The family then makes a royal fuss to the hospital administrator, who then makes a fuss to the ER Nurse Manager, who then is going to find out (to the best of his/her ability) who wrote and sent the letter.
Follow your hospital's policy for reporting such situations and let it go at that. I would hate to see you get in trouble for trying to do what you think is right, but going about it in the wrong way.
In my experience, I see nothing good resulting from sending an anonymous letter.
















































In my experience, I see nothing good resulting from sending an anonymous letter.
I was kidding when I made that comment. :)
















































If you want to have lunch with the older girl, do it because you want to have lunch with her. Don't go because you have an agenda. That just isn't honest and it's likely to backfire and shut down what little communication you currently have.
I'd suggest having a doc report the family to social services and possibly look into a psych consult for anything that is documentably untoward--frequent injuries to the same person, risk-taking, substance abuse issues. The difficulty is that psych help is usually reserved for the dangerous and not the gross and annoying. 
Social services might be able to investigate the possibility of neglect. And they might actually have a leg to stand on if the younger girls have problems with school attendance. 
At any rate, if they start getting pressure from another source, there is the possibility that the older girl might be willing to turn to you for some help. Once she's receptive, you could have an opportunity to offer some ideas that might help the family help themselves.
I think you have a good point when you say that they may never have learned what most of us consider basic. The problem is introducing the information without implying that they are substandard human beings. 
If you do decide to draw closer to this girl, be absolutely clear in your own heart about your motives. Do it for her. Offer her a top you no longer need or samples of shampoo or other small things because you care about her. If you see her as a project or a means to handling the ER problem, you will be using her instead of giving to her. 
The important thing is that you be absolutely certain about boundaries and keep your roles as nurse and friend separate.
One other thought--maybe this family comes to the ER for the same reason that troubled kids gravitate toward school health rooms. They like the attention, but even more, they hunger after a part of the world has order and sense and safety. Maybe it feels good to step out of the chaos, even if only for a short time.










































Specializes in Psych, M/S, Ortho, Float..










Hi CotJockey,
Here's the way I see it. I'm new to psych nursing (6 months) but let me share a bit of newly acquired wisdom. Stay out of the family dynamics. Keep your boudaries clean and clear. These people need professional help that may actually be hindered by your involvement. 
In church, say hello, and keep it at the level that you have. You don't have the energy to take on the whole bunch of them and all their issues by yourself, AND still have a life of your own.
Do endorse the idea that someone help these people. Get Social Services on it as quickly as possible, but stay out of the way. Let them do thier jobs. They are a team as much as nurses are. They have the staff to deal with it and they go home at the end of the day to recupperate. If you get involved, they will be at your doorstep everytime they have a "broken nail", instead of the ER. 
I would prefer to see them only at work and church, rather than setting up camp on my lawn! As wrong as it is for them to use the ER that way, in this case it is the preferable alternative until a permanent solution can be found.
It's hard because we think we know what they need to "fix" their lives, but as bad as it seems now, there is probably much worse underneath the physical that really needs a whole team to deal with. You are only seeing the tip of the iceburg. So be nice at church, be professional at work and steer clear of the fixing.
I learned this the hard way.
Good luck,
Jacquie
















































If there is a new diagnosis, new medication or treatment you could refer them to home health for skilled nursing assessment, teaching and intervention. You could also make a community mental health referral via social service or adult/child protective service. There may be develomental disability, mental illness or substance abuse issues that need to be addressed.
















































I agree to keep it separate. Let your work at the hospital be there and keep your personal life at home. I think it's admirable what you want to do, but in my opinion, I think the doc should call Social Services and let them do their "thing". The can offer classes and follow ups for this family. Maybe it's not necessarily a "neglect" issue, but more of a "teaching" issue.
Good Luck and I commend you for being so caring!










































Specializes in pedi, pedi psych,dd, school ,home health.










I have to agree that setting up a relationship in your home will end up being very taxing on you. they already abuse the ER, would you want them all in your home on the same basis?:uhoh3: 
next time they show up in the ER, i would have either social services , or one of the other staff, give them a concrete, very down to earth talking to about the hygeine issue. Maybe a "goodie bag" filled with soap. toletries. deodorant etc. Set clear boundaries about the use of the exam room...no going in drawers, no eating or drinking, etc. 
do you have a freee or reduced fee clinic locally? perhaps a referral to them with the "then you wont have to all sit and wait here" (make it sound better to them)
I have worked in home health and gotten alot of referrals for families like this, and its just basic lack of knowledge and common sense. they see the er as their primary care and the staff as "friends" 
if the daughter approaches you at church, nicely say that there is some new leadership and that is now the rules. hope this helps!
















































Julie LPN: I think the doc should call Social Services and let them do their "thing". The can offer classes and follow ups for this family. Maybe it's not necessarily a "neglect" issue, but more of a "teaching" issue.
I really agree with this. I think it's so good of you to show concern for this family, but I stongly feel that it would be a terrible situation for the family to just report them for neglect without having social services investigate what's going on or what teaching they need. Their assessment would be very important. I'm not sure what happens when a family is reported for neglect, but if their children were taken away from them without a full investigation as to what is really going on, that would throw the family into even more chaos. As a new nurse, I'm frequently told that I'm never alone in making tough decisions, and if I were in this situation I would definitely get other people involved prior to reporting them for neglect.





































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