Did I Do The Right Thing?

[Anon1423]

Hello, everyone. I had a situation yesterday that I'm struggling to come to terms with. I've been an LVN for about a year and half now but my new job is in Home Health nursing. I have a patient who lives in an apartment with his elderly wife who is unable to provide care. He is completely bed-bound and has advanced dementia. He is non-verbal and requires around the clock care. Unfortunately, he only has a caregiver at night and his daughter comes by as much as she can to help care for him. He currently has a foley catheter that has been giving him issues from the start but I'm currently awaiting orders from his nephrologist on what she'd like to do. This is where the problem comes into play... I walked into the apartment yesterday for my weekly visit and found that the daughter had tied both of his wrists to each side of his hospital bed with two bandanas. I asked about the restraints and she said he had been trying to pull his catheter out for the past few days. His catheter had been leaking and she was unable to keep a brief on him which in the past had deterred him from pulling on it. I felt very uncomfortable about the situation and told her she needed to release him but she said that she couldn't keep an eye on him 24/7.  I then noticed a large bruise on his right wrist that was new and the daughter couldn't explain how it happened. I released him from his restraint to check his vitals and blood sugar but she quickly tied him back up as I was leaving. I immediately called my manager and reported what I had found. My manager was horrified and notified APS right away. Due to him being tied up when I left, the police had to get involved and went to visit the patient right away. My manager said I did the right thing but I got an email this morning saying that the family was extremely upset and unhappy with what happened. I understand they're upset but I just hope I did the right thing and didn't overreact. I'm sure I'll feel better once my supervisor says everything is okay but I just need reassurance. 

[amoLucia]

FWIW - I believe you acted in the pt's best interest under a very difficult situation. His being inapprop restrained was not acceptable. The right wrist bruise was prob a result of his fighting the restraint. You called your upper mgt (just like you should have) and the call to APS & the police was then approp made.

It is sad the family is so upset. His home situation needed better case management (esp if he was just in the hosp?). His home needs are just too great for what was in place. I also feel so sorry for the wife - what a terrible burden for her to try & manage. I don't know his status when his case was opened, but I'll venture the home arrangements made were bare minimum, as best as poss. There's much more to this family's dynamic than that are known to you (& us).

Hopefully, better arrangements will now be made.

I feel you did the best & correct interventions as poss. You did NOT overact.

Welcome to AN, even under this difficult situation.

[Anon1423]

Thank you for your response. I should also mention that this man had been tied like that for the past 3 days. The family was unable to turn him every two hours so who knows how long he'd been lying flat on his back. I had tried to educate previously about turning him but the daughter just said it wasn't possible. He has a history of pressure sores and it was just a terrible situation overall. 

[amoLucia]

And how has he been being fed???

He most def needed more care than can be given under the present circumstances. I have my suspicions re this case - influenced by my years & years of LTC experience. Your agency would prob be better off if declining this case in the future. Looking into my crystal ball I foresee a lot of conflict for caring staff.

This is also my opp'ty to recommend that you are hopefully carrying your own malpractice insurance. Sadly, these kinds of sorry cases do occur in Home Care.

[Jade Nicole, LPN]

You definitely did the right thing. Thank God you were there to see it!

[kbrn2002, ADN, RN]

Holy smokes did you ever do the right thing!  I hope he was removed from that unsafe and frankly abusive environment immediately. I don't usually advocate for the arrest of a likely overwhelmed family member but my God how could this man's own child be willing to just tie him down instead of reaching out to somebody/anybody for help?? 

For that matter if he had been tied down like that for three days why didn't the overnight caregiver do anything if they were were aware of the situation? I assume that person is covered under the umbrella of a mandated reporter and this situation certainly was reportable well before you became aware of it.

A simple phone call by his daughter, his wife or even the overnight caregiver to 911 would have at least sent the poor gentleman to the hospital where his issues could have been addressed.  Not blaming you or your agency at all here but it sure doesn't sound like he's appropriate for remaining at home with only intermittent nursing care. 

By your own statement he's bedbound and nonverbal requiring round the clock care. Plus he has an elderly wife who likely needs some measure of care herself as she is unable to provide any assistance for her husband. I understand the desire to keep a person in the home as long as possible but this gentleman obviously requires more care during the hours that a caregiver isn't staffed than the family can provide.  

Even with some less than ideal family dynamics going on, heck maybe even more so with a difficult family this man should never have been discharged to home if he was hospitalized. If he wasn't in a hospital setting and all his care has been on an outpatient basis where was the case manager that let this situation progress to this point?  I guess my point is what darn care team decided he was OK at home with only an overnight caregiver in the first place?  Somebody seriously dropped the ball there.

[Thunderbunsmom]

You absolutely did the right thing APS family as well as your nurse manager needed to be aware of the situation the family requires additional education and if it's not able to care for the patient 24/7 or as the patient needs then the patient is not safe in that home it can be very frustrating taking care of a dementia patient very difficult to care for an aging parent however if the family does not have resources available for 24/7 care then the next best option his to find suitable care and a long-term convalescent facility. Your instincts are right I'm sure you were fine home health nurse and your manager has sound judgment. Restraints are only to be used as an absolute Last Resort by a trained professional not by a family member not with the bandana and especially this should not cause bruising to the patient hopefully you'll continue to work and home health as it is a very gratifying field. It does have its own unique challenges which those who have never worked it will never understand you are triage nurse you are supposed to be knowledgeable of all areas of nursing which is nearly impossible you come across things you've never done before and you may never do again it is definitely a very challenging and rewarding experience when in doubt call a senior nurse. Seasoned nurses who have been in the field for a while are wonderful and underutilized resource good luck to you.

[CommunityRNBSN, BSN, RN]

I feel so badly for this family, and I understand why they were upset. But you did the right thing in an impossible situation. The point at which someone thinks “We can’t handle this— the only solution is to tie him to the bed” is the point at which the situation has to change. Taking him to a hospital, as another poster mentioned, would have at least allowed a different plan to be made. 

[JerzeeMike]

Hell yes, of course you did the right thing for your patient. What if he was in a SNF and the family came in to find him restrained and with new bruising? The state would be called in a heartbeat. As nurses, it’s our duty to advocate for our patients, NOT the families.  What you witnessed was concerning and has the potential for harm/abuse. Rest easy knowing you did your duty for your patient.

[Robmoo, ADN, BSN, RN]

You did the right thing.

Many of you act like you've never at your wits end with a patient has many tube and lines and is trying to pull them out.  What that daughter did was wrong, but was not trained for that situation and was in over her head.  Clearly the family is trying to keep papa out of a nursing home, but has reached the end of what a family can reasonably do.

This is just a sad situation.  

[renatanada]

It is a sad situation. But hospitals are for acutely ill patients, not people whose families are at their wits end... Too many times hospitals are dumping grounds when families would rather spend their time and money on things (cigarettes, tattoos, pizzas, etc.) other than taking care of their loved one. 

[Mintezia]

I won't repeat what has been already said. It seems he needs more care than the agency and family can provide. LTC centers are not the best of places but being in a facility there's less of a chance he will be neglected at least in the way his family neglected him. Restraints will not be given unless they are ordered for and in the plan of care. 

The family is not being reasonable and sometimes with home health there are situations where your license is put into jeopardy. It isn't worth it. 

Good luck!