I'm a new home health nurse and I have an end-stage heart failure, copd, renal insufficient 100 year old pt who refuses hospice, wants to avoid the hospital, and stays at home with two unlicensed caregivers.
The first time I saw him 3 weeks ago, he was alert & oriented x3, sitting in a wc. Now he's in bed, screaming, moaning, can't get up, his skin is breaking down. The md thought it was a UTI. Since pt was already on macrobid, the doc decided to have the unlicensed caregivers start giving him daily ceftriaxone IM. And the the caregiver, a bookkeeper, inserted a foley over the weekend. No one is concerned about screaming/moaning. The doc said, "oh he moaned when I just touched him, so I don't think it's pain."
Does this situation seem strange to anyone else? I don't even know why they have me doing visits. And the caregiver is so hostile to me. Can doctors give just anyone orders to give IMs and foleys?
Specializes in Vents, Telemetry, Home Care, Home infusion.
welcome to homecare!
unskilled caregivers can insert foley catheters and give injections in some states when tasks are delegated by a physician or nurse. please make sure your documentation reflects that the physician delegated this care to these caregivers. please iconference with your nursing supervisor what is ocurring and untreated pain.
with 100yo dx renal insufficiency, refusing hospitalization, change mental status highly suspect end stage renal disease (esrd) document thouroughly. do you have a palliative care/hospice team...i'd pull them in pronto. you are raising red flags that need to be lowered by explicit documentation and patient advocacy for pain relief. md needs to be approcahed again re pain mgmt, code status clarified and your supervisor should give you guidance how to work cooperatively with these companion for patients best interest.
Specializes in A little of this & a little of that.
In my state, unlicensed caregivers who work for homecare agencies (but not home HEALTH agencies) can indeed do things like insert foleys, give shots, check blood sugars, and even hang IV fluids to PICC lines. By law the task must be delegated by a registered nurse, which technically means that the unlicensed caregiver must give a return demonstration of competency before the RN signs off. I was fortunate enough to work for a homecare agency that actually followed up on all of its delegations and I felt very comfortable with the caregivers doing nursing tasks. I am guessing that somewhere within your agency there is an RN who is ultimately responsible for the outcomes of said tasks. If I were you, I would check to see if YOU are the RN whose license is on the line.
Scary? Yep. But sadly, in my state, it is also legal in homecare.
Wow, what state is that? Most places an MD or RN can only delegate tasks like these to those licensed/certified to perform them or to family members. Paid caregivers can only function to whatever level they are certified (or not certified). I have seen many many agencies or families try to get around this and even lie about it. If I lived in such a state as yours, I would be getting together with other nurses and doing some lobbying for patient safety laws. This is the whole reason nurses are licensed to begin with, so that the patients are protected by only receiving care from those who are trained to provide it. Nursing boards exist to protect the public from just this kind of thing.
Regardless of legalities, the OP should report this situation to Elderly Protection. I've seen many horrible, uncaring MD's disregard severe pain when the patient has intellectual impairments and generally mistreat such patients. In most cases, as an RN case manager, you could be held liable for care given by others. It sound like a very tricky position for you to be in. My advice, call your BON and find out what your personal responsibility is here. They will give you the best advice for your case and to protect your license as well as the patient safety.
I was a caregiver in college, and we did meds, g-tube feedings, enemas, stoma care and wafer placing, as well as restraints for sib (under the guidance of a pyschiatrist) While I look back and am surprised at all we were allowed to do i do feel that we were trained and that we provided good care for our clients.
The caregivers in this case are paid by pt, unlicensed and I have never seen them demonstrate competency. I'm new to HH, the case mgr of this pt, and I feel completely out of the loop with the Dr giving orders to caregivers and accepting their pain assessments over mine.
I don't see how this is even a question. If you are acting in the role of a case manager, not a skilled nursing provider, it is hard to see why you would have any liability for the CG actions.
The physician is free to delegate these tasks to whomever he/she chooses. There is no "only licensed caregivers or family members" rule on outpatient prescriptions to be taken at home. Regardless of how lunatic it seems to us, it's his/her license.
Now on the other hand, if you believe that there is abuse or neglect occurring with this patient, that's a whole different ballgame.
Specializes in A little of this & a little of that.
Actually "case manager" is a skilled provider role for an RN, so she may very well be liable for what she knows to be going on with the patient even though she didn't delegate it.
While it is true that it is the physician putting his license at risk, it is not true in every state that a physician may delegate to anyone he chooses when the care is in the realm of "regulated professional activities" which would include invasive procedures such as injections and foley insertions as opposed to administration of po meds which is generally allowed. All states have exceptions for family and friend caregivers but this may not apply to paid unlicensed caregivers. I actually find it incredible that any state allows paid unlicensed caregivers to do these procedures but will take others' word for it that it is legal somewhere. And, I am thankful to live in a state that has regulations to protect the public from such dangerous practices.
Actually "case manager" is a skilled provider role for an RN, so she may very well be liable for what she knows to be going on with the patient even though she didn't delegate it.
Unless the order was given to the RN, and subsequently delegated to the unlicensed personnel from her, it has nothing to do with her license.
Again though, if you argue that the situation is unsafe (RN knows that unlicensed personnel are abusive, neglectful, or performing procedure improperly), then she might be liable for failure to report the abuse/neglect to APS under mandatory reporting laws.
While it is true that it is the physician putting his license at risk, it is not true in every state that a physician may delegate to anyone he chooses when the care is in the realm of "regulated professional activities" which would include invasive procedures such as injections and foley insertions as opposed to administration of po meds which is generally allowed. All states have exceptions for family and friend caregivers but this may not apply to paid unlicensed caregivers. I actually find it incredible that any state allows paid unlicensed caregivers to do these procedures but will take others' word for it that it is legal somewhere. And, I am thankful to live in a state that has regulations to protect the public from such dangerous practices.
I just looked through the regulations governing these for a couple states (Texas, Michigan) and not only is it not illegal, it is explicitly allowed, as long as the physician takes reasonable steps to ensure that the person is trained and competent.
What state prevents physicians from delegating these procedures, or limits their performance to licensed personnel? I have never heard of such a thing.
Specializes in A little of this & a little of that.
frommassachusetts:
a) specific grounds for complaints against physicians. a complaint against a physician must allege that a licensee is practicing medicine in violation of law, regulations, or good and accepted medical practice and may be founded on any of the following:
1. fraudulent procurement of his/her certificate of registration or its renewal;
2. commitment of an offense against any provision of the laws of the commonwealth relating to the practice of medicine, or any rule or regulation adopted thereunder;
3. conduct which places into question the physician's competence to practice medicine, including but not limited to gross misconduct in the practice of medicine, or practicing medicine fraudulently, or beyond its authorized scope, or with gross incompetence, or with gross negligence on a particular occasion or negligence on repeated occasions;
4. practicing medicine while the ability to practice is impaired by alcohol, drugs, physical disability or mental instability;
5. being habitually drunk or being or having been addicted to, dependent on, or a habitual user of narcotics, barbiturates, amphetamines, hallucinogens, or other drugs having similar effects;
6. knowingly permitting, aiding or abetting an unlicensed person to perform activities requiring a license.
massachusetts states elsewhere that prescribing, dispensing and administering medications are activities requiring licensure. exceptions are made in mass and conn law for family, friends providing care for free and for domestic help who are not hired primarily as caregivers to provide assistance temporarily.
both states hold the rn responsible for planning and supervising all care that her patient receives.
it is clearly written that the unlicensed person may not give injections or perform procedures requiring assessment which would include foley placement. the texas medical board upholds the requirements of other boards on who may administer medications.
from the texas medical practice act:
sec. 157.002. general delegation of administration and provision of dangerous drugs.
(a) in this section:
(1) "administering" means the direct application of a drug to the body of a patient by injection, inhalation, ingestion, or any other means.
(2) "provision" means the supply of one or more unit doses of a drug, medicine, or dangerous drug.
(b) a physician may delegate to any qualified and properly trained person acting under the physician's supervision the act of administering or providing dangerous drugs in the physician's office, as ordered by the physician, that are used or required to meet the immediate needs of the physician's patients. the administration or provision of the dangerous drugs must be performed in compliance with laws relating to the practice of medicine and state and federal laws relating to those dangerous drugs.
NRSKarenRN, BSN, RN
10 Articles; 19,192 Posts
welcome to homecare!
unskilled caregivers can insert foley catheters and give injections in some states when tasks are delegated by a physician or nurse. please make sure your documentation reflects that the physician delegated this care to these caregivers. please iconference with your nursing supervisor what is ocurring and untreated pain.
with 100yo dx renal insufficiency, refusing hospitalization, change mental status highly suspect end stage renal disease (esrd) document thouroughly. do you have a palliative care/hospice team...i'd pull them in pronto. you are raising red flags that need to be lowered by explicit documentation and patient advocacy for pain relief. md needs to be approcahed again re pain mgmt, code status clarified and your supervisor should give you guidance how to work cooperatively with these companion for patients best interest.