Why not admit this patient?

[tokmom, BSN, RN]

My neighbor with a history of bladder CA, severe COPD, and possibly some sort of osteoporosis, and s/p ball replacement to his right hip 1 yr ago, and most likely ETOH abuse fell the other day at home. His wife called us to come and help. It was 11 pm at night, and I had to work the next day, so my husband who is also a nurse went over to see if he could help. This man, who is 74, tripped with his walker in his nasty, dirty home. My husband found him on the floor and he could not touch the right leg/hip without this man screaming. My husband told the wife to call 911 and the wife did not want to. Their house is a living pig sty. Garbage bags piled in the kitchen, cig butts strewn on the floor and cat crap piled a foot high in the corner with piles of it everywhere else. It's all hubby could do to not gag. These people live this way and think nothing of it.

Anyway, he convinced her to call 911. The ambulance came and carted him off to the hospital and later sent him home! I guess the xray did not show a hip fx, however the pain was so severe they couldn't even get decent films. The wife came home and had my husband get this man in the house. It took two of them almost carrying him and he was screaming in pain. The wife put him in bed.

She once again tried to get him admitted by once again calling 911, the next day. This time they did find a fx femur that is inoperable. They have offered no hospital stay yet again, only some percocet. They supposedly told neighbor woman that her neighbors, as in my husband and myself, can help her at home.

Seriously, why would they not admit this man?? Am I missing something? He's been in bed for 4 days now. He will not turn or get OOB. They said she could put him in a nursing home, but they have money, except for beer and cigs. Medicaid won't pay because he wasn't admitted.

She can be a lose cannon (and a smelly one at that) when he's been in the hospital. Do you think she's been so bad in the past, they have banned her and she's not fessing up?

Sorry this is long, but I want some feedback.

[gtoko]

I would report this to Adult Protective Services. This man needs medical attention.

[sara_ky]

It sounds like you are both concerned for, but frustrated by, your neighbors. Do they have children or other family members with whom you could share your concerns? They may no longer be physically or mentally able to keep up with the necessary ADLs to maintain a safe and clean home. Although one would hope that children/grandchildren/siblings, etc. would be aware if someone in their family lived in such deplorable conditions, if they're not in the immediate vicinity and don't visit often, they may not be -- and they might be willing to take a more active role in the couple's care if they are made aware.

Perhaps the couple is on a fixed income, which could contribute to the wife's reluctance to call an ambulance. They may not have any insurance, and their Medicare may not cover all of the expenses. It may have been the wife who refused to have her husband admitted and said that you and your husband would take care of them -- again because of money. She probably feels very fortunate to have you and your husband living right next door, because if there's an emergency, she feels she can count on one or both of you to help. She may not realize she's being an imposition.

There are a number of church-based and volunteer-run organizations in my community that offer free meals-on-wheels services for home-bound seniors, as well as light cleaning, errand-running or companion servies at little to no charge. Perhaps your neighbors would be interested in something like this, or benefit from it?

As far as their living conditions, have you considered calling your local health department or adult protective services? If the couple is incapable of maintaining a safe, clean home on their own and their family is unable/unwilling to help them, maybe there's some legal recourse that can, at least, protect them. Call Animal Control and report the unsanitary cat feces condition - that may be sufficient enough grounds to have any pets remanded from their custody and care. If they can't take care of themselves, they surely can't take care of dependent animals. (And if you don't feel comfortable calling adult protective services or the health department, at least by alerting Animal Control, you've got one civic agency involved in the matter -- and based on their intervention, they may go on to call in additional resources to help.)

It sounds like an unpleasant and unenviable position to be in. Good luck finding a solution!

[brownbook]

As crazy as it sounds sometimes it is easier to get animal protective services into a house than adult protective services. If the cats or any animals they have seem to not be well cared for, dirty environment, filthy living conditions for animals, etc., animal protective services can enter the house and sometimes that gets the ball rolling for adult protective services getting involved.

[tokmom, BSN, RN]

What family is left has alienated them. She pulled some dirty work with the homeowners books and is going to trial for embezzlement in June. She might end up going to jail. She does not know we know this is the case, and if she does, she ignores that fact.

The cats look really good, dh said. Fat and clean. The house is just their little box. When the wife was served papers the cop that came out reported her to animal services, but nobody came out.

They both have lived like this for years, by the looks of it and are happy. I guess that is why I have issues reporting him.

Dh just went over to see if he could help get this man OOB and he told DH to leave and was very foul about it. The wife is worried sick and crying.

Would APS be able to get this man admitted for pain control or at least get some sort of hospice lined up? The wife wants help at home, but nobody would dare to step foot in that house.

[tokmom, BSN, RN]

And yes, they are on a very fixed income. That is why she embezzled a lot of money from the association.

[sara_ky]

I believe you can register a complaint anonymously with APS. If I were you, I would. I don't know what kind of action they can take, but at least you will have done all you're able.

This sounds harsh, but you may also consider putting your foot down and refusing to help them. If they know they can count on you to come over in the middle of the night in the event of an emergency, or even to check on them, as you've described, they have no incentive to seek help elsewhere.

I would be polite but firm about it. If they call in the middle of the night, explain that you and your husband have to get up for work in the morning, but you would be glad to call an ambulance and then, when it is en route, you could wait with them. (Or omit that last part, even.) If they ask you to come and help get the husband out of bed, etc., you can explain there are home health services and volunteer organizations who can assist them on a regular basis; for liability reasons, you cannot do more than act in a good samaritan role in the event of an emergency. (Even if that's not true, it sounds good, LOL)

Someone with more experience than me probably has better advice to offer. (I'm a student nurse.) But I do know that no one can take advantage of you without your permission - so don't let them any longer! :) I know it's hard to say no, but if the man is in no immediate physical danger or harm, then laying down some boundaries as far as the care you and your husband are willing and able to perform for these folks sounds pretty fair to me.

Good luck!

[dscrn]

big time intervention seems necessary. Consider this..God forbid, it the house caught on fire. one or both of them might be hurt or killed, if reswcue teams can not reach them. I would say APS, your local board of social service-even board of health-living in a house strewn with cat feces just can't be good for your health..Good luck!!

[JBudd, MSN]

As said above, he may well have refused admission, especially if he was foul mouthed at your husband's offer of help. We've had people adamantly refuse admission before, and in leaving AMA no insurance will pay for the visit (don't know about Medicaid though).

APS, to be sure. Call as often as needed.

[Triage24]

Worked Utilization Review and Case Management for a several years. What you are describing is a social issue much more than a medical issue. Adult protective services is the correct route. What seems to have happened here is the first time the ER did not see a broken hip on X-Ray. This would justify not be admitted as it does not meet the severity of illness/injury criteria. The second time the break would have met and he could have been admitted. Sometimes, right or wrong Dr's do social admits. In this case they did not. The wife is using you guys as a makeshift home health nurse. I suggest Adult Protective Services involvement. They can take custody of the patient if warranted. If they do they will have the responsibility to see that he is taken care of. Would also suggest that you do not enable this situation further. There is always the potential for liability even if you are acting in good faith. The law sees you as Nurses with a duty to report and accountable for anything you do.

[tokmom, BSN, RN]

Yeah our licences our my first concern. I feel like a rat turning them in,as they seem happy living in filth. Maybe APS can help them.

Thanks for the input. I will call tomorrow.

[Nascar nurse, ASN, RN]

I would report this to Adult Protective Services. This man needs medical attention.

Without reading the rest of the replies.. this is the correct answer - 100%

You may also want to watch the assist you provide. If she is that sly, she may try to find any reason at all just to sue you.