Need help quick

  1. Hi pals,

    I have a new HH client, new to me, 6 years on service. I have been informed that this pt and his father have been very abusive to our home health aides, esp when it comes to this MS pt's daily ROM routine. This aide there now is the last one who has been able to tolerate this pt. Of course no one told me any of this helpful info when I took this case, and the pt and his father have been nothing but nice to me.

    Anyway, I have the dubious honor of "having to talk" to this man and his father about a more resonable exercise program. As it is now, the dad stands over the aide while she does ROM and counts out the reps she does, and gives her a hard time if she does 14 instead of 15. This program is one I presume they designed. He had PT available a few years back, but that was stopped when goals were met, the family was very angry, and an offer was made to continue as private pay, but the family declined.

    OK, beside the fact that this blows that I come on the scene and now have to police something my agency has allowed for the last 6 years, I need your help.

    What exactly is the standard number of rep[s for a routine ROM program that an aide w.ould be responsible for Of course we have no policy on this (Surely you jest!) I did a search and the only site of any value suggested 5-10 reps per activity. This still sounds like a lot to me. Frankly when I have done ROM in the hospital, I only ever did 3 reps per movement. Maybe I am a cheapskate (?)

    Anyone know the gold standard here? I should have posted this sooner, the visit is tomorrow. I told my sup's I would "do my best?, but frankly, they created this monster, and I think a supervisory visit is in order here. Whenever I have sup'd the HHA, I have never seen this in action. Patients generally do not want the nurses there taking away from the HHA's time with them, or having an extra set of eyes on them while they are being bathed, so I usually visit at the start or the end of a HHA visit.

    Any bright ideas?? How many reps?
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  2. 12 Comments

  3. by   Huganurse
    ..
    Last edit by Huganurse on Jun 30, '02
  4. by   Ekaye
    I have to agree with huganurse. 6 years is along time. How has the company been able to bill this. I know this isn't the problem you asked about but if your name is on the papers, this is something important to know. It could be fraud. As for your question, no one has to take abuse. In your roll as the CNA's supervisor you can let the client know that verbel abuse is not tolerated. If you can't find any other way to tell them, you can always fall back on the old "this is our company policy and I always tell all my new clients" It could give you space while you look into the situation. Even client getting care thru state aid are not allow to abuse caregivers. Good luck and keep us posted
  5. by   mario_ragucci
    In some cases, verbal abuse has to be "tolerated" in order to get things done, and move on. I am even coming to the mature level that emotional abuse can be tolerated as well (from patients). Not everyone feels this way, and each day brings a brand new big rubber ball.

    This sounds like a "deep grey area." Dignity is an issue. A restorative aid has to use judgement, yet insure dignity. I talked to some, and contractures, once contracted, don't come loose. RA's I have spoken with tell me the trend is toward moreROM to prevent contractures.

    I wish I had more to offer hotlips; You really helped me tonight :-)
  6. by   NRSKarenRN
    Hoolahan:
    Several ideas (as usual):

    1. Pull the chart and check for last PT note (don't know if chart available if services sev years ago). that way yould have the "offical" PT POT to guide you. 10-15 reps is what I would do.

    2. Think of the parent " Fifteen reps is keeping my son's muscles from atrophying, and I want him to get better, if they do less than that he might get worse". HOWEVER, abusive langage to staff NOT permissable.

    3. Look at situation with fresh eyes. When was last PT eval?? Observe the patient during the ROM---is he becoming fatigued, grimicing, spasms....a lot can change in several years. Is a RE-eval indicated( one time visits for MS patients are ok) to re-eval TOLERANCE to a program or maybe needs NEW program.

    4. Idea in Northeast is to keep patients out of nursing homes. Have cared for many with indwelling foley's, Gtubes requiring change, complicated conditions for years at home under Medicare and medicaid and insurance payments. HOME CARE IS CHEEPER!

    5. Evaluate how PARENT is doing ROM---he's part of ''Treatment plan" too!

    6. If all else fails, sicum with THE SUPERVISOR...so many times familes changed tunes when I came trotting out to interceed. PROTECTION of staff is imperative. "A change to a new agency with fresh ideas" has been known to happen,,,share the "wealth" in Philly is praticed.
  7. by   hoolahan
    There is definitely no fraud here guys, he has a foley, so there is a skilled nursing need, covered under Medicare. We have had MSW out to eval for other programs he would be eligible for. And yes Karen, you are right on target with what the father's ideas are. I don't blame him one bit, it is his behavior that is the problem while doing the routine.

    I know what you mean by share the wealth. :chuckle
    I am quite certain no other agency would accept him, since he is a high utilizer. My agency has already made it clear they are not doing any more PT, he was just seen in the last 6 months, and they are firm about it.

    The thing that just sucks is that they have decided I will have to be the heavy. I am supposed to erase 6 years of allowing this fathers' behavior?? Poof! I'll have to pack my magic wand in my bag today!

    I was going to ask PT for a rpint out of ROM, and yes, I'll have to check the chart for the last recommendations.

    The sups are all worried over what they will do when this aide refuses to go any more. I asked, well this has all been documented hasn't it? I mean the aides refusal to go and why? If you can't find an aide willing to go, the family will have to try another agency, and "problem" solved. I just really don't like the agencies attitude on this one. How is it that home health aides are allowed to refuse assignments, but we never are?? Another interesting piint to ponder. I mean ROM IS in their job description.
    They may not like it, but disimpaction is something I have to do and I don't particularly enjoy that very much either. I would feel much more comfortable with this whole thing if I had seen the behavior myself. I don't even punish my kids for things I don't see, why should I punish this family who is struggling with stress that I hope I never have to imagine!??
  8. by   semstr
    Sorry Hoolahan,

    No idea, how to help you here!
    Just thinking of you, ok?
    Take care, Renee
  9. by   hoolahan
    Thanks Renee!! :kiss

    Well, be careful what you wish for I guess. Got to see everyone in full action today. I was prepping avonex inj and heard HHA and pt going at it in his room. went in and took vitals, gave inj, and said, well, what's going on today?

    They both strated yelling at the same time. Each had valid complaints and points. I basically did not intervene too much, b/c then dad walked in and then the $hit really hit the fan. All three people screaming at the aide. I still didn't say much, just letting the verbal diarrhea run. The aide I have to say, was wonderful, she told the family exactly what she did and why. She did c/o the room being "unGodly hot." And I did tell the family well, I am standing here sweating and I didn't even do ROM like the aide did. The father screamed at me, well you aren't naked are you??!! It went on and on. I allowed all parties to vent until exhausted. Told them I would do what I could, but not sure there was anything left to do, they admitted they knew that already.

    I suggested that if family feels all the HHA have conspired against them and have preconceived ideas, etc, it sounds like they have lost trust in our agency, and perhaps the best thing for all involved is to try a different agency. They seem to feel that our agency is responsible for this pt entirely. Even the aide said NO, he is not a dependent of our agency!

    Tomorrow I am off, but now I will be on the phone to my sup first thing in the am, since the aide walked out of the house saying, "That's it, I'm not coming back here." I was trying to leave to speak to the aide outside, the mother was holding me back from exiting the house. The aide says "I want to talk to the nurse!" They said well we want to talk to her too! I told them I would come right back in. I told the aide, I hope you understand why I let them go on like that, she said, I thought you did the right thing, you needed to see how they are.

    Problem now is, they will have no aide. Father threatened to call Medicare, TV reporters and newpapers and say how our agency "abused" his son. I said, if you feel that is something you need to do, then it is certainly your right to do so. I do hope that you understand, if that happens, it will be very uncomfortable for anyone to come out here after that. They also claim to have tape-recorded HHA's w/o thier knowledge, and after they said that I was glad I did play it low key, Lord only knows if they were taping me. I have to say, we have some really outstanding aides in my job, and I do find it disturbing, on many levels, that this family felt it was necessary to tape-record the aides.

    It is definitely time to share the wealth. I am going to tell my sup, if they want to D?C him from the agency, they need to make a visits themselves. I refuse. Hope I still have a job!
  10. by   4XNURSE
    Originally posted by hoolahan
    Thanks Renee!! :kiss

    Well, be careful what you wish for I guess. Got to see everyone in full action today....

    .... They also claim to have tape-recorded HHA's w/o thier knowledge, and after they said that I was glad I did play it low key, Lord only knows if they were taping me. ....

    I refuse. Hope I still have a job!

    Well now, in California, I believe it's illegal to record a conversation without someones knowledge and permission. I suspect that it is in New Jersey as well. Someone correct me if I'm wrong.

    Why wouldn't you have a job? I suspect your admin would have a hard time justifying a termination, based on you not forcing a HHA to go to a place they are uncomfortable, or you not returning to a place where you are uncomfortable. You and the HHAs have rights too. You don't have to accept an assignment if you don't feel safe in taking it. I'm big, bad, and ugly, but I wouldn't feel safe there either. Not just for personal physical safety, but career safety.

    just my $ .02

    ken
  11. by   Jenny P
    {{{{{{Hoolahan}}}}}}

    How can the agency hide this info from the nurse they have assigned to the case? Are you being set up here? Or is your reputation for problem solving so good they think you are a miracle worker?


    What a mess!!!! I will tell you that the WORST thing you can do for someone with M.S. is have the room too hot! Heat makes the symtoms much worse. That's why M.S. pts. get worse when they are ill (and have fevers).

    The other thing is that I'd encourage the family to go to the media and Medicare. And I'd line up EVERY HHA and nurse that they had abused along the way. Oh, yeah, and get a neurologist to tell what M.S. is etc. It might be very educational to the general public what nursing and M.S. are all about.
  12. by   outbackannie
    Shouldn't one of the focuses of Home Health be education? I should think that after 6 yrs of training the family certainly knows how to do ROM. Is the family unwilling to assist in the care of their son? Our usual guideline is 10 reps each with the patient increasing the number themselves as tolerated.

    Under OASIS, foley cath changes are usually just once a month. A HHA is not necessary for that.
  13. by   MHN
    hoolahan,apart from the reps question has anything been done for the family with respect to greiving problems they may have the fathers attitude reminds of some clients families and their misplaced aggression .If you can get that dealt with the stuation with the family may be more tolerable.MHN
  14. by   hoolahan
    MHN, you are seeing the very root of the problem! We have had the MSW out there sevearl times, the most recent being in early January, before I became the CM at the end of January. From my limited attempts to reason with the family, it is clear that they still have not accepted that this man will not be cured. I can only say I have been assured that every nurse who has had this man has tried to educate the family on the progression of the disease, but they cannot accept that.

    Outback annie, Hi! Anyone under Medicare for a monthly foley change is eligible for personal care assistance by a HHA with supervision q 2 weeks. We also give a weekly avonex injection. NRSKaren and I were discussing this same thing tonight on the phone, and we have both worked for agencies who were more and some less generous with the interpretation of this hcfa regulation. Maybe your agency does not encourage a HHA be placed when a pt has a foley, but the pt is legally entitled to that as a benefit of Medicare. That is why I am worried about this man, our agency is one of the more generous with this situation in my area, and if they dropped us or we drpped them, I am not sure he would find another agency willing to do what we have done. This particular man has too much money to be eligible for any kind of PCA services program (which is what he really needs), and the family does not want to spend down as the parents are elderly, and want that money saved for this man for when they are gone. Frankly, I do not see how he could possible remain in this home unless he had 24/7 paid live-in, and they know that, that is why they want to save the money for that purpose for when that time comes.

    Jenny, I wouldn't give mysef that much credit! LOL! No, I simply inherited this case when the former nurse left. I was unaware of the problems until 2 weeks ago when I reported the aide for leaving early, per the family. After I did, they HHA supervisor/educator, my supervisor, and our director called me in to discuss all the things that had been going on. Needless to say I was shocked, as the family has never been anything but kind to me when I was there. Iwas unable to follow up last week, b/c I had to give the assignment for the inj to a LPN, but the other day, it was again time for the HHA sup, so I was told to address the exercise routine issue.

    Hi Ken, I did not listen to the tape, like I said to my sup, how do I know the pt's remarks were not altered? I think it is illegal to tape someone w/o thier consent here too. I was never really afraid I would be fired for that. I just wondered if they would try to force me to inform this family of discharge, if it comes to that. I suggested we have an ethics conference over this one. I did tell my boss that if there were any more problems, I was going to insist she make a joint visit, and she agreed to that.

    There is no easy way to solve this problem. I am glad that I have several people working with me toward a resolution. Now that I have seen the true situation, I need some time to think about it. Frankly, I am hoping they can find another agency asap!

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