duplication of services

[blondeoverboard]

i am a hospice nurse who is caring for a 56yr old woman with MS & Dementia. the pt is bedbound, malnourished, with pressure wounds to her left hip and buttock. in early september she was admitted to the hospital for replacement of a her PEG. the family revoked hospice services in order to have the PEG replaced. when the pt came home the family called to have her readmitted to hospice. 2 weeks later, when i found the other agency's folder under a pile of linen, i discovered the pt had also been admitted to home health for wound care and OT(forget for a moment that she cannot participate in therapy in any meaningful way). i notified my DON and contacted the home health agency for coordination of care. the home health nurse began making daily visits. at the time i began providing care the wounds were small to moderately sized, unstageable due to necrotic tissue and slough but responding well to santyl. i was told by my DON to defer wound care to home health. it made me very uncomfortable but i did. today i saw the wounds for the first time in several weeks. they are much worse. the hip wound is significantly larger with increased necrotic tissue. the buttock wound shows evidence of tunneling and there was purulent drainage on the bed pad. there is swelling around the wound. it appears to be infected. i discussed my concerns with the pt's daughter (she is disinterested on the best of days) and was told the home health nurse would be out this afternoon and she would tell her about it. i also reported it to my DON, her response once again was that the wounds are the home health's business and she does not want "to appear that we are looking over their shoulder."

my gut tells me this is BS. i believe that if i see a pt's condition deteriorating i am duty bound to report it. i also believe that if the family were to decide to take legal action, as a licensed person in the home i can be held responsible.

what do you say?

thanks,

debra

[ErinS, BSN, RN]

I say this is a duplication of services and I have never had a hospice pt on both home health and on hospice. How will YOU justify to medicare that her wound care was not related to her terminal condition? If you can not clearly show that, then you are involved in medicare fraud and it is time to push harder with your DON. My guess would be your DON does not want the increased cost, but this is not okay. If nothing changes I would start looking for another job. I could be wrong, but I think you are at risk of being involved in medicare fraud. Honestly, wound healing is not usually a realistic expectation for a hospice pt, so I would be less worried about being sued for her deteriorating wounds.

[nurse2033, MSN, RN]

Mandatory reporting of elder issues varies by state. Adult Protective Services would be a good place to start. Although I don't see how you could show neglect based on the information given. You don't know what they have been doing for those wounds. Perhaps they have been very attentive, following current practice, and they are still getting worse. Your concern is well placed but you would have to be in a position to observe all the care given, or not given, to know what is really going on. To cover yourself I would send an email to your boss reiterating your concern, which gives you a written record.

[#1ME]

As far as I know, if a pt cannot be under the care of both hospice and home health. Either she qualifies for the hospice or not, but not both. I would document the findings, and if your DON still does not want to do anything about it, maybe you should refuse to further keep this pt, because you are placing your license at risk. Pretty sure if legal action were taken against you, your DON/facility would not back you and try to protect themselves

[blondesareeasy]

Are the wounds "supposed" to get better if she's dying? Perhaps that's the true course of the illness. But I agree that having two agencies out there sounds a little weird.

[blondeoverboard]

Are the wounds "supposed" to get better if she's dying? Perhaps that's the true course of the illness. But I agree that having two agencies out there sounds a little weird.

the expectation for the wounds is not to heal them but to minimize progression and prevent infection. neither of which has been done in this case.