Discussion at nurse's station

[AnonymouseRN]

I have a sticky situation that I've never seen before and I'm looking for some insight. I'll try to stick to the facts.

1. I'm a case manager for a government agency and I coordinate, oversee and perform care for vulnerable -usally geriatric- patients in the community.

2. I've had this patient for several months now with pretty grievous abuse and repeated violations of patient responsibilities I outlined with the family when the patient was admitted. They agreed to our policies in writing and have been gently reminded multiple times since admission.

3. Pt. Is cared for by a grandchild with some serious anger issues. Constantly threatening and initiating legal action (not against us), refusing to allow patient to receive pain meds resulting in violent and aggressive behavior directed at us - I'm talking drawing blood-, granddaughter constantly screaming and cursing at us.

3. Our program manager refuses to discharge anyone, Including this one, with one FNP actually quitting our program because they couldn't stand the abuse anymore.

4. Pt. Revoked hospice at family request this weekend, again, as a result of gangrene escalating to sepsis to LE complicated by PVD and 100% dependence for bed mobility.

5. As is customary, I went to the hospital to coordinate care with the hospital staff and spoke with the patient's assigned nurse at the nurse's station.

6. While nurse and I were together, speaking in lowered voices in what I was confident was incidental disclosure.......

7. ....I was unaware that one of the CNA's working on the unit had come into the nurse's station and was hovering to eavesdrop on our discussion.

8. Charge nurse was saying some pretty crappy stuff and I was agreeing with and validating her frustrations. Not bad mouthing anyone, just listening to her vent and telling her that she wasn't the only one who'd dealt with all of the above referenced behavior from the patient's family.

9. Aforementioned CNA happened to be a close friend of patient's really angry family member.

10. I received a call this evening from said family member screaming at me, repeating the conversation the nurse and I had almost verbatim. She admitted that the CNA was her "best friend" and the CNA told her everything.

I got the family member calmed down and rational somehow by the grace of God by the time the conversation was over but I'm pretty angry myself. I'm pissed that my boss allows us to be treated this way. I know it's "part of the job" especially at end of life. It is what it is but I as a former hospice administrator and an RN, I have a zero tolerance policy for yelling, threatening and otherwise abuse of staff. It's one thing to vent and work though grief. Quite another to threaten staff, scream, curse, and otherwise bully them and attempt to intimidate with fear.

This CNA violated HIPAA. I'm concerned that this could somehow be turned against me and I take HIPAA pretty seriously because that's just what we do.

Not sure how to proceed as far as telling my boss, who is very open in letting us know he doesn't care and doesn't appreciate us making waves. Lay low, be quiet and "grow the program" (increase pt. Census).

How do I handle this? What should I have done differently ?

Thanks in advance for insight.

***edit: I work in an Interdisciplinary care model very similar to hospice except that we care for patients across at every stage of disease and life, so we frequently discuss and care plan for patient and family behaviors and responses to interventions. Just to clarify that I wasn't gossiping or bad mouthing anyone. No name calling or any of that.

[Been there,done that, ASN, RN]

You engaged in a discussion at the desk... regarding a volatile patient situation. You took note that someone was eavesdropping... and continued the discussion.

In the future... make sure ALL patient care conversations are in private.

You could report the CNA for a HIPAA violation, but you and the charge nurse are guilty as well.

I would lay low and learn from this.

[AnonymouseRN]

I appreciate you taking the time to reply. I actually had no idea that the CNA was listening until I got the call later on.

I looked up once and saw her behind the nurse's station, saw her walk away and then continued talking not realizing that she was actively trying to hear us talk.

She wasn't anywhere near us when we started, otherwise no way would I have willingly let anyone hear any of that. I guess I should've made that more clear.

[Big Blondie, ASN, BSN, MSN, APRN]

The CNA breached HIPPA. The Casemanager and the nurse have to communicate information about the patient. The nurses station is a place where report is given. CNA is part of the team. She should be reprimanded and educated on HIPPA.

[JKL33]

7 hours ago, AnonymouseRN said:

This CNA violated HIPAA. I'm concerned that this could somehow be turned against me and I take HIPAA pretty seriously because that's just what we do.

Yes she did.

I wrote a book and erased it when I got to the end, because this was the end:

Lastly, I hate the idea of people like this controlling others' lives as much as anyone does, but I would very likely quit this job. I have very little risk tolerance for employers whose MO is unsupportive; there is zero way I would trust an unsupportive employer when working with extra high-risk populations. At least one member of this family is labile and volatile, and her side-kick/support clearly isn't to be trusted, either. Don't underestimate the kind of problems people can cause. If no one is going to give them boundaries, you're just a wide-open target.

[AnonymouseRN]

Thanks for all of your replies. I can't control the patient's family or anyone else but I can change me so I appreciate the insight. And I won't be giving or receiving report at a nurse's station ever again. I was in the wrong for that knowing how small this town is, incidental disclosure or not.

I work for the federal government so I can apply for a job under a different supervisor and it looks like I need to do that as this isn't the first time I've been in a dangerous situation with out of control patients or their families.

[JKL33]

I don't know the answer here, except the finding a new job ASAP part.

It would depend upon my reading of all the players, but I *think* what I would do is make sure that the actual events are recorded somewhere (incident report or other written submission to your employer with a copy kept by you). Then I would carefully decide about reporting the HIPAA violation to OCR. If I did, my report would be something along the lines of "Hospital staff member reported confidential PHI to her friend who is the family member of our [agency's] patient; said patient is receiving services for vulnerable adults living in challenging situations with sensitive family dynamics."

I will not officially advise this. Think it through. If I decided to do something, ^that is likely what I would do.

Best of luck~ ?

[caliotter3]

If I was the person with the decision-making power, I would give serious consideration to terminating the CNA without benefit of “last warning” or “benefit of the doubt”. And I would push for discharge of the client, more importantly their family. End of story. By keeping both the CNA and the problem patient family, the facility is creating and maintaining its own problems.
As I am sure most have witnessed, many CNA’s are terminated for a lot less.

[Been there,done that, ASN, RN]

8 hours ago, Big Blondie said:

The CNA breached HIPPA. The Casemanager and the nurse have to communicate information about the patient. The nurses station is a place where report is given. CNA is part of the team. She should be reprimanded and educated on HIPPA.

I stopped giving report in an open area. Too many open ears that can hear patient care details. Yes , the CNA breached HIPPA. However, OP is in a no win situation.

[El Primus]

When ethics and morality are at war with each other. The violator should at least be put on notice . Just in case something happens in the future

[CommunityRNBSN, BSN, RN]

If you can’t discuss your patients at the nurse’s station, where are you supposed to discuss them? Obviously in the patient’s room, but what about info that the patient or family shouldn’t hear? This is an honest question; I’ve never heard of viewing the nurse’s station as a public area. Obviously you speak quietly and ensure that nobody is listening in, but beyond that I’m not sure what the alternative is.

[Older Male LPN, LPN]

On 12/31/2019 at 2:04 AM, AnonymouseRN said:

I have a sticky situation that I've never seen before and I'm looking for some insight. I'll try to stick to the facts.

1. I'm a case manager for a government agency and I coordinate, oversee and perform care for vulnerable -usally geriatric- patients in the community.

2. I've had this patient for several months now with pretty grievous abuse and repeated violations of patient responsibilities I outlined with the family when the patient was admitted. They agreed to our policies in writing and have been gently reminded multiple times since admission.

3. Pt. Is cared for by a grandchild with some serious anger issues. Constantly threatening and initiating legal action (not against us), refusing to allow patient to receive pain meds resulting in violent and aggressive behavior directed at us - I'm talking drawing blood-, granddaughter constantly screaming and cursing at us.

3. Our program manager refuses to discharge anyone, Including this one, with one FNP actually quitting our program because they couldn't stand the abuse anymore.

4. Pt. Revoked hospice at family request this weekend, again, as a result of gangrene escalating to sepsis to LE complicated by PVD and 100% dependence for bed mobility.

5. As is customary, I went to the hospital to coordinate care with the hospital staff and spoke with the patient's assigned nurse at the nurse's station.

6. While nurse and I were together, speaking in lowered voices in what I was confident was incidental disclosure.......

7. ....I was unaware that one of the CNA's working on the unit had come into the nurse's station and was hovering to eavesdrop on our discussion.

8. Charge nurse was saying some pretty crappy stuff and I was agreeing with and validating her frustrations. Not bad mouthing anyone, just listening to her vent and telling her that she wasn't the only one who'd dealt with all of the above referenced behavior from the patient's family.

9. Aforementioned CNA happened to be a close friend of patient's really angry family member.

10. I received a call this evening from said family member screaming at me, repeating the conversation the nurse and I had almost verbatim. She admitted that the CNA was her "best friend" and the CNA told her everything.

I got the family member calmed down and rational somehow by the grace of God by the time the conversation was over but I'm pretty angry myself. I'm pissed that my boss allows us to be treated this way. I know it's "part of the job" especially at end of life. It is what it is but I as a former hospice administrator and an RN, I have a zero tolerance policy for yelling, threatening and otherwise abuse of staff. It's one thing to vent and work though grief. Quite another to threaten staff, scream, curse, and otherwise bully them and attempt to intimidate with fear.

This CNA violated HIPAA. I'm concerned that this could somehow be turned against me and I take HIPAA pretty seriously because that's just what we do.

Not sure how to proceed as far as telling my boss, who is very open in letting us know he doesn't care and doesn't appreciate us making waves. Lay low, be quiet and "grow the program" (increase pt. Census).

How do I handle this? What should I have done differently ?

Thanks in advance for insight.

***edit: I work in an Interdisciplinary care model very similar to hospice except that we care for patients across at every stage of disease and life, so we frequently discuss and care plan for patient and family behaviors and responses to interventions. Just to clarify that I wasn't gossiping or bad mouthing anyone. No name calling or any of that.

Honestly, I don't see any way for you to "win" the best thing you can do is do what lets you live with yourself - and let the chips fall where they may. Your program manager is a piece of Crap - if you didn't already know that, there I said it for you. I would report the HIPAA violation to a state or federal agency and let them deal with it. I would start recording your phone conversations - consider reporting elder abuse. and find another job. Your program manager is what is wrong with Health Care - praying for you! - Bless you! You know what to do, it is just a matter of if you manage to do it!