DCFS opinions?

[Rasberry_RN_]

I work as an ER nurse. I encountered a parent who brought a child in to be evaluated because the child suddenly developed heart palpitations. The child was complaining of a racing heart. After evaluation it turned out their heart was beating well above the normal range. The child was awake, and responding appropriately, the other vitals were good.

I informed the doctor immediately and was later given verbal orders. I then let the parent know that we needed labs, I was informed by the parent that the child admitted to taking a piece of an Edible brownie laced with marijuana.

The parent states that they themselves had consumed the brownie but wasn't aware that the child had come in contact with it. I told the doctor that I needed to contact DCFS due to the fact that a minor ingested a drug laced brownie. The doctor didn't think it was necessary and wanted to immediately discharge. Drug test was positive for THC. I contacted DCFS.

What could have been done differently?

Staff note.... This has been edited and may not reflect in the initial replies

[Rasberry_RN_, BSN]

3 minutes ago, LovingPeds said:

This discussion is going no where. You did what you thought was right and what your conscience dictated.
We’ll have to agree to disagree.

Absolutely!

[morte, LPN, LVN]

7 hours ago, LovingPeds said:

You have posed a lot of 'what ifs' that you then say are probably not applicable to your case. You admit the parent was reasonable. Did the child seem fearful or anxious around the parent at all for you to think that was the case?

Again, drug use in adolescents is considered a behavior of concern and not a reportable event by the Department of Health and Human Services at a national level. Furthermore, adolescents if they are drug users themselves, are patients who have a right to confidentiality by law. Even if the parent gave this 13 year old the brownie, the 13 year could have very well chosen on their own to eat it knowing what it was. I'm not saying that is right. I'm just saying that is a case that will be opened and closed.

An investigative case can go into this child's home and do full evaluation and not be able to predict this outcome. You work ED. How many children come in with overdoses intentionally self-inflicted even after hours upon hours spent with psychiatrists and counselors? How many toddlers come in because their parents or grandparents accidentally dropped one of their medications on the floor which they could not find but the toddler did? How many come in because the pills were within reach and the parent turned their back for a moment to find the bottle opened? Do you report all of these cases? You reasonably make judgements based on who is at risk based on the information you have at the time. No one can fault you for not predicting the future based a reasonable assessment that a child is not in a situation that causes recurrent potential danger. Otherwise, you might as well report every parent who walks through your ED because these things can and do happen.

I live with myself because I have learned to not question my judgment for things outside of my control. I have diagnosed children with a simple AOM with an attentive mother in office to later receive a phone call from an ED because her boyfriend got angry at the crying and shook the baby to the point of subdural hematoma. You can't predict everything.

I am a PNP. I work closely with DFS. I do the examinations when children come into their custody or to document when there are allegations of physical or sexual abuse. I often have to report cases that they are not aware of when they come to the office with trusted adults to report the abuse for the first time. And as I mentioned earlier, some times those new cases take weeks to be investigated because there are so many reports for DFS to sift through. So for every child who ate a pot brownie that is reported to DFS there is another whose family member or family friend is physically or sexually abusing them. All of these cases are treated by law the same until the investigation evaluates the full extent of danger.

For every DFS working chasing after the case of a child with a reasonable parent seen in the ED after the ingestion of a single known pot brownie, there is a child waiting in a documented nightmare for someone with the power to take them out of it. I don't have that power. Like you, all I can do is report and make recommendations to keep the child away from the abuser. If the abuser is the legal guardian, all I can do is report. I can't kidnap a child. How do I live with that?

I asked three of the pediatricians in my office about this case. All three agreed with your ED physician that it is not a reportable incident. One went so far as to say it is a waste of resources and a breech of this child's confidentiality. These are pediatricians who see patients in the ED, the hospital, and the primary care office and all who have over 25 years experience in Peds. We live with ourselves because we have learned to trust our judgement and to make judicious decisions based on the information available to us so that children in situation where they are actually in potential danger get the help they need.

You did what you thought was right. I'm not arguing that. I am just asking that not report things to just report them so that you don't get in trouble in some unforeseen future if you have a reasonable belief the child is not in potential danger. I am asking you for the sake of the kids that are. If your only reason to report someone is "what if" or to cover your ***, you don't have a reason to report. Point blank.

This is the most common sense post here. OP is coming across as more than a little self righteous.

[hppygr8ful, ASN, RN, EMT-I]

On 5/3/2020 at 8:48 AM, LovingPeds said:

Also, the Administration for Children and Families with the Department of Health and Human Services does not define teen drug use as a reportable event but rather a 'behavior of concern' per their Mandatory Reporting and Keeping Youth Safe (2013) webinar and I cannot find evidence where this has changed since. This can vary by state. The only concern with this particular case is if the parent left the brownie out in the reach of children for the teen to unknowingly consume, then it which would meet the basic definition of neglect for leaving a substance within reach of a child, but I doubt many social workers would truly pursue that. It depends heavily on context. If the teen ate the brownie knowingly, they absolutely would dismiss it and you will have wasted time and resources.

Marijuana is rampant in society even in states where it is illegal. I have families come into the office all the time for care reeking of skunk weed and denying anyone in the family smokes anything. Should I report all of them? All that does is make these families hesitate to seek care out of fear of being reported.

You asked what could have been done better. Did you have a conversation about whether or not this was a child knowingly eating the brownie?

I'm glad you mentioned that. Yes, we are mandated reporters, but we have to be judicious in what we report. People keep mentioning all cases of children dying from child abuse and neglect. How many of those kids were already known by the system? Gabriel Fernandez (8 years old, died 2013)? LeBrawn Rankin (8 years old, died 2018)? Noah Cuatro (4 years old, died 2019)? All of them with open cases because multiple people reported signs of actual abuse. Every time you report a case just to cover your ***, a case worker has to stop and decide if it's worth investigating or to investigate it. In some places, by law, they have to investigate it in order to close it. Every single child listed above who died had the case workers involved sued for neglect of duty. Every single case worker listed the case load and the number of cases as a causative factor in their failure to protect those kids.

It is DFS's job to investigate suspected abuse and ours to reasonably report it. You mentioned the mother seemed reasonable. They admitted what happened without hiding information. Yes, you had the minimal grounds to report for neglect if the child did not knowingly eat the brownie, but at what potential outcome? Was the child in immediate or potential danger with a reasonable parent who sought care and told the truth as to the facts leading up to it?

You did what you thought was right and no one can fault you for that, but I caution you that reporting every single incidence of questionable behavior just because it's questionable contributes to the case loads which results in severe cases being missed. Don't mistake that. I have called cases of severe physical or sexual abuse in myself only to have it be weeks before they contact me for additional information. Why? The number of cases they have to investigate and they have to treat each one the same. You have to develop judgement on these cases.

Interesting - In California when the case is severe we usually get a DCFS worker out within two business days.

[LovingPeds, MSN, APRN, NP]

3 hours ago, hppygr8ful said:

Interesting - In California when the case is severe we usually get a DCFS worker out within two business days.

The problem is that DCFS visits aren't the end of the situation. They have to investigate and that often takes days, if not, weeks before they can remove the child from the home or sever the parental guardianship if the evidence isn't abundantly clear. Case workers don't just have one case. They have multiple cases they have to investigate at once so there are delays related to that just as a busy nurse may have a delay in patient care related to the number or acuity of patients they may have on a busy floor.

Gabriel Fernandez died in Palmdale, California in 2013. The case made national headlines. I remember his little picture plastered everywhere. There is even a Netflix documentary about it now. Sad, sad case. It brought national attention to the plight of children in abusive situations. He was visited by DCFS multiple times over a long period of time. He died in his home at the hands of his mother and her boyfriend. Beaten to death at 8 years old. Noah Cuatro died in 2018 in Los Angeles. He was four and in a similar situation. He was also visited by DCFS multiple times. These are just two cases I know of in California. I can name a few in my own state. These kids were all under DCFS investigation and the case workers short-cut the investigations despite multiple complaints from several sources citing (after the fact) the number of cases they had to investigate as overwhelming.

The problem isn't a DCFS worker showing up. The problem is the completion of the investigation and the removal of the child from the home. A lot of case workers do the best they can to help as many kids as they can.

I've reported cases of sexual abuse that have occurred in the home by a parent's significant other and had it take up to three weeks for the child to be removed because the parent will deny the significant other is around, etc. that delays the investigation because you have to prove that there is the potential for harm before even DCFS can remove a child. And this is cases where siblings agree with the facts as presented to have happened. It would be one thing if the case worker could concentrate on only one case, but when you have multiple cases in this situation and then added to that the ones where you have concern with reasonable parents... not to mention finding placements once the child can be removed... it's a nightmare for all involved with the system.

[hppygr8ful, ASN, RN, EMT-I]

1 hour ago, LovingPeds said:

The problem is that DCFS visits aren't the end of the situation. They have to investigate and that often takes days, if not, weeks before they can remove the child from the home or sever the parental guardianship if the evidence isn't abundantly clear. Case workers don't just have one case. They have multiple cases they have to investigate at once so there are delays related to that just as a busy nurse may have a delay in patient care related to the number or acuity of patients they may have on a busy floor.

Gabriel Fernandez died in Palmdale, California in 2013. The case made national headlines. I remember his little picture plastered everywhere. There is even a Netflix documentary about it now. Sad, sad case. It brought national attention to the plight of children in abusive situations. He was visited by DCFS multiple times over a long period of time. He died in his home at the hands of his mother and her boyfriend. Beaten to death at 8 years old. Noah Cuatro died in 2018 in Los Angeles. He was four and in a similar situation. He was also visited by DCFS multiple times. These are just two cases I know of in California. I can name a few in my own state. These kids were all under DCFS investigation and the case workers short-cut the investigations despite multiple complaints from several sources citing (after the fact) the number of cases they had to investigate as overwhelming.

The problem isn't a DCFS worker showing up. The problem is the completion of the investigation and the removal of the child from the home. A lot of case workers do the best they can to help as many kids as they can.

I've reported cases of sexual abuse that have occurred in the home by a parent's significant other and had it take up to three weeks for the child to be removed because the parent will deny the significant other is around, etc. that delays the investigation because you have to prove that there is the potential for harm before even DCFS can remove a child. And this is cases where siblings agree with the facts as presented to have happened. It would be one thing if the case worker could concentrate on only one case, but when you have multiple cases in this situation and then added to that the ones where you have concern with reasonable parents... not to mention finding placements once the child can be removed... it's a nightmare for all involved with the system.

I guess my experience is different and we will have to agree to disagree on this. For the record I'm not saying you are a bad nurse because of your practice nor do I believe my practice is wrong. We simply differ on our interpretation of mandated reporter laws. Maybe because I work in in-patient psych and it's not uncommon for DCFS workers to visit our kids while they are in-patient, issue a detainment order and keep the child/adolescent in the hospital until a safe and temporary placement can be found. I don't doubt that DCFS workers are overloaded and some less scrupulous ones cut corners . I my opinion those DFS workers should be prosecuted when the worst happens.

Under California law adolescents 13 and older have privacy rights and in the psych hospital we cannot even give lab results to parents without the minor's permission. I can't tell you how many times a parent has demanded an STD profile and I have to tell them we need the minor's permission and the results are confidential to the minor.

In the original case cited by the OP I was less concerned about the patient eating the brownie and more concerned that the parent appeared to be altered and had apparently driven in that condition to get their child to the hospital. Perhaps I did not make that clear. I am stepping out of this debate for now.

Hppy

[TriciaJ, RN]

On 4/29/2020 at 9:53 AM, Rasberry_RN_ said:

No I wasn’t angry I was just trying to make my point loud and clear and also yes I was defending myself. I didn’t need reassurance, I know I did the right thing. I wanted other people’s opinion because I got a lot of push back from the doctor. Also a little bothered by the fact that a lot of people didn’t see why this was reportable. It worries me that there are kids are out there who may be in danger and this kind of situation would be overlooked by the majority of people. A little sad to say the least. If you ask any lawyer they would tell you to report something like this.

Over the years I've read several items in the paper about children coming to a bad end for lack of a timely intervention. I once read of a 15 year old girl who starved to death, despite her teacher making several calls to CPS. Apparently the younger children had been removed from the home due to abuse, but it was thought the 15 year old could better fend for herself. She couldn't. And the neighbours who had been concerned about her were all regretting that they hadn't created a bigger ruckus.

I would much rather report a false alarm than second-guess the situation and find out later that I should have called.

[Rasberry_RN_, BSN]

Update: this case was actually founded for neglect. 
thanks for all of your feedback even though this thread is two years old.