Just Venting

[hoolahan, ASN, RN]

I have a problem client (I know, who doesn't?) I have worked with manipulators before, but this lady takes the cake.

40ish obese female, lives alone in high rise bldg, admitted to us s/p CHF. H/O IDDM, and L BKA. They d/c her from the hospital with +3 piting edema of the R leg. I have a referral with info re insurance Care and Caid. I saw her caid card on the table, and looked at it briefly, the numbers matched, the name and DOB and exp date were all OK. I did not notice any mention of CAP, one of those in between programs for those w low income, but not quite low enough for straight caid. Anyway, after my assessment, it is clear this woman will need more HHA hours than we can give her. I explain that under Caid, she can get a PCA for a minimum of 25 hrs of week, would she like me to arrange that for her? She says yes. It is a Thursday. I showed her a list of the agencies in our area, she asked me which one I liked, I told her one b/c they are more reliable than the others. I made the call to the agency from her phone, right there in front of her. The agency assured me they would send some one the next day.

Friday comes. Lady is stuck on the commode, and can't get off. She calls our agency, and asks where the HHA is. The sup pulls my chart, sees I documented all my calls, etc... the and asks did she call the agency re the PCA? She says I don't know what you're talking about. WHAT???!!! I left the number written for her, along with our number, on the same paper for her. OK

Another nurse went back on Friday to see her for me, since she did not have all her meds in the home, and I had rec'd a fax from the doc late in the afternoon, clarifying the meds as I requested. I stuck that in the chart, and left it to the per diem, since I was off Friday. Per diem goes in, and got totally confused by the fax and all the med bottles, there was an old rx for levoxyl 150 mcg, but they dec to 100 now, so she wasn't sure what to give. I put the fax right on top, and I had recopied the med list with the words "Updated" in big letters at the top, but I guess she missed that. She felt the pt's meds were "a mess" and told the sup she needed a saturday visit, and she called the pharm for a mediplanner, which they couldn't deliver until Saturday after noon. I would have taken her a planner and gone in the am, but I figured, this woman lied like a rig about me to my supervisor, if she wants a planner, and arrangements have been made, let her wait.

I am on Saturday, and I am anxious to speak w her b/c of the whole PCA issue. We were going to have a conversation about that. Well, 1pm, I call her, she declined a visit. She said "Honey, that pharmacy won't bring that planner until 4 or 5 o'clock. Don't bother coming today, I know how to take my meds." I won't push someone. She did know what all of her meds were for. I think she heard my voice, I have had a bad case of laryngitis, and knew I would confront her about the PCA, so she didn't want to see me.

I handed the chart to the w/e sup, and asked her to send a nurse sunday (I was off.) Apparently, someone went to the home, and there was no answer to the phone, and no answer to the door, so she left a note and left. This nurse did not know this pt, so she had no idea she would have had any problem. We don't routinely call the police or ask security guards to open doors if no one answers. I do usually call the emergency contact person, and since I opened the case, I know the info was on the chart, but some people don't do that. We have no policy about what to do if not home not found. Everyone just kind of does their own thing.

OK, Monday, I am in the office, I have her chart there to see her, and I get a VM from my manager that she was re-admitted to the hosp, she was stuck on the commode.

We have a form we have to fill out for the liaisons in the hospitals, which lists any info to be followed up on. I wrote on hers, "Client stuck on commode x 2, sn questions ct's ability to care for self at home, please suggest rehab if client unable to perform transfers" I don't know if anyone read that, or what, I did not call the liaison, b/c I don't know her well. I figured I filled out the form like I am supposed to, my number was on there if clarification was needed.

Friday 3:45, another nurse saw her today to resume her care (I opened her under care b/c she was homebound.) This nurse tells me the CAP MSW practically accused us of being neglect, leaving the pt on the commode. When there was no answer to the door, we should have followed up, etc...I was PI$$ED! I called this woman, and explained to her I spoke w the lady on saturday, and she declined a visit. OH, she says, she didn't mention that. I also told her how she totally denied any knowledge of my attempt to arrange a HHA before I found out 1 the agency never sent anyone, and 2 any caid PCA would have to come from CAP. She argued that aparently we should be able to split bill care and caid for skilled HHA, and she could give 14 hours a week under waiver, but I said to her, how are we going to schedule that? With all the call-outs of aides, subs are placed, under care there must be personal care. If our aide isn't scheduled until 1 pm, and her aide is there in the am, what will out aide have left to do? Also, my agency does not split bill, as a routine, but I don't know enough about that, or why it is that way, I am leaving that for my supervisor to hash out w this woman. We left it that we were not promising any HHA could be placed this weekend, and I restated that several times. By the time we spoke it was 4:15. I said, this should have all been arranged before her dischrge from the hospital, for crying out loud, the whole reason she went in was for being stuck on the commode? Didn't anyone THINK to ask how she could manage on her own? I said to this MSW, the bottom line is, this lady is not a dependent of our agency. She chooses to return home, living alone w/o help, so now she has to find a way to cope with that. I am thinking they probably did offer her rehab, but she refused. I will not believe anything that comes out of her mouth unfortunately. The MSW said her cousin has promised to get a 24/7 live-in and pay out of her own pocket, but her finances are tight. I said, I feel for her, but this is not my problem to solve. She acknowledged me that much. She said, you are right, but we took her back. I think my first mistake was opening her to service in the first place. But I did watch her transfer herself from w/c to couch, and she did OK slow, but steady. The amputaion was in 99, so I guess it's the edema that is making it so difficult for her to move. I don't know. I knew she would need help, and I had PT out there asap, but I truly did not think she was incapable of caring for herself upon my initial assessment. But, after being stuck on the commode x 2, I am glad she did go to the hospital. I was absolutely shocked to find out she was sent back home again so soon. I can only hope she goes back to the hospital, b/c somehow I am doubting this 24/7 assistance will materalize.

This makes me think of a couple questions

1. Do you have a policy on how to handle Not home not found (NHNF) pt's? What is it?

2. The CAP MSW asks that we notify someone if there is no answer to the door. I agreed to nursing, but them I'm thinking, what about the aides? PT? Thier subs? The care plan w that info is INSIDE the home, unless the scheduler or sup tells them about this condition. I in no way want to be responsible for every agency party going into that home not notifying someone. I feel if that is the case, the client should put a note on her door requesting that. How can I guarantee that? I put HUGE notes on outsides of charts telling nurses when to visit if they have to get in before the HHA leaves, or call a family mbr. Yet today, a per diem asked me, so what's with this call the dtr first? Well, just like it says, pt forgetful, must calll dtr and visit before the HHA leaves b/c after that the door will be locked. I am willing to bet my check that she went after that , and it means no visit will have been made this week, since they pushed her all week already. Grrrrrr!

What steps would you take to be sure everyone would know to notify someone if the pt won't answer her door? I don't think it is appropro to call the guard for this every time. I certainly don't want to be accused of entering her home w/o permission, her of all people. I do NOT trust her.

Sorry this is so long. I guess nect time I will ask to speak to her d/c planner in the hospital. But to be accused of neglect, well that just pushed my button!

[TopazStone]

Hoolahan,

Take a deep breath and let it go. It seems that many people in the system want to find somwhere to lay blame, and it is not usually on the patient. Most of our patients are sent to us for noncompliance issues. We try to call prior to the visit and let them know we are coming (and sometimes we do it as we are pulling in so they don't leave LOL). We do not usually become concerned about a NALD (no answer, locked door) for one visit. We notify the case manager and the agency, period. I do become concerned if two consecutive visits are missed on a person who does not normally leave the home. Then I call family, the mental health center, police-- whoever can best help. It sounds like she has some underlying psych disorder (probably personality disorder with her manipulation of care providers-- look for a history of self-mutilation or suicidal gestures and substance abuse). When a case like this is opened, it is best to limit the number of people in the home. Try to stick to two or three nurses who communicate well and no more than two HHAs who also communicate well. This will reduce the "splitting"; you know, the patient who tells you how awful the other nurses are and how great you are, and then does it in reverse with the others.

As for the other agency, simply do not make referrals to them. You tried their agency for their reliability and they are obviously not. I would speak with the supervisor and let them know I do not plan to use their services and that other nurses in the agency are aware of the situation (hit the pocketbook).

We don't have a policy for missed visits, it is based on nursing judgement and the patient (we have some that if a visit is missed, the admin HAS to be notified). Don't sweat it. You did what you were supposed to do and you know you did it well. It sounds as if your sup is supportive of you. That MSW works in the nice little world of hospitalization where the patient is in a controlled environment. When this "poor, sweet handicapped woman" came under her care, she jumped on the fact that someone was at fault. The patient refused her visit, and that was her legal choice. If she is not safe at home and you feel she will continue to refuse care, I would have someone come to evaluate her for probate (don't know who in your area); I would use our probate pre-screeners, PASSPORT, or adult protective services. If they evaluate her as competent, well, you have done all you can.

:kiss You are a great nurse so don't let the knee jerk reaction of oone person get you upset!

Topaz