I believe this was neglect, ADON disagrees...what should I do?

  1. I am a CNA in a continuing care facility. We have both long-term and rehab residents. Recently, one of our long term residents had a nasty roll off her bed from near-chest height while with another aide...a second aide had been in the room, but had left to get some supplies. This resident was sent to the ED and was kept at the hospital for several days and came back to our facility with over 20 stitches in her face and a fractured leg, receiving hospice care. Myself and another aide that care for her on my shift (7p-7a) had told the charge nurse that her "good" leg was bending the wrong way at the knee. She did everything she could do to resolve the problem, but it was 2 more days before this resident even got an xray. It was found that her other leg was broken as well(obviously!) This is my first issue..being fully aware that legs arent supposed to bend that way, not one other nurse bothered to look at this resident, or even follow up with the MD for several days. Neither did administration. The family is threatening legal action regarding this incident, and I believe it should have been taken care of on monday at the latest (it was first discovered at 3am sunday) On to the next...I was listening to report to another aide about this resident, and when asked about her condition, the aide getting report was told, "I really have no idea how she is, Im not allowed in there." So we asked the other girls on shift who had been caring for her..everyone answered, "not me", myself included. Apparently, the 2 aides involved with her fall were banned from her room by the residents family, and the aide responsible for her that evening didnt tell anyone. So I went with another girl to check on her and we found her in bad shape...1130pm and she was still dressed in her day shirt, saturated with urine from the middle of her calves to the middle of her back(keep in mind that both legs are in stabilizers which are also saturated and cannot be removed long enough to clean and dry) due to a leaking foley. She had not been turned, changed or cared for since around 8pm. It took over an hour to clean her up, put new sheets on the bed, and assist the nurses with inserting a new catheter. The ADON called me back into work the following am to discuss it, and she says it was not neglect because it had only been 3 hours since someone had been in there. To me, that is assuming the previous aide had given care before she left at 7pm, which is assuming too much. Also, this resident had orders to be turned and checked every hour due to her condition...3 hrs minimum is way more than 1. I am disgusted by this, and it made me ashamed to be associated in any way with 90% of the people I work with..CNA's, nurses, and admin. alike. I am considering reporting this to the state, but Im not sure if it really constitutes neglect. Advice anyone?
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    About littleone25

    Joined: Apr '12; Posts: 6; Likes: 9


  3. by   littleone25
    I really just am not sure what to do here...
  4. by   NurseCard
    Well... you've let the ADON know your concerns...

    I work in a facility in which state inspectors frequent.
    I don't think it changes a thing to have state go into a
    facility, other than it makes life tougher on the nurses
    who really are trying to do a good job but cannot due to
    poor staffing. Besides having to deal with the daily nightmare
    of not having enough help, now they have to worry about
    state inspectors looking over their shoulders, and supervisors
    freaking out over ever last thing... IMPORTANT things, like
    medicine carts being dusty.. you know.

    I mean, if you feel that strongly about the situation and
    feel like more needs to be done, than report it.

    After working in this particular facility, I've just become
    cynical about the whole, calling state thing. I don't
    feel like it changes anything.

    It's 3AM. I may feel differently when I'm not so tired.
  5. by   littleone25
    Its unfortunate, but Ive seen that also. them coming really doesnt do much to change things for the long term, and I dont want to have a state inspector over my shoulder either. But ive seen this type of thing happen in the facility I work in many times, and Im tired of it..and Im wondering if its because nobody ever has the fortitude to actually report until something ugly happens like this. I didnt come the the ADON...she called me back in at 730am while I was driving home after a 12hr shift, and then proceeded to tell me that.."This could be massive, or this could be minimized," and basically tried talking me into believing it was not as bad as it was. in not so many words, she expected me to sweep it under the rug. The urine on this resident wasnt even wet anymore where she wasnt actually laying on it...it was a huge dry orange ring, which speaks to how long she was really left unattended. I dont know..the whole dang facility is backwards and after this I dont know if I even want to be a part of healthcare anymore.
  6. by   ncook7
    Honestly, I would contact the inspector, that's uncalled for. I am an RN and have worked as a CNA, I know it sucks to be spread thin, but someone should have at least checked this woman at least by seeing if she was wet.
  7. by   leslie :-D
    personally, i am sickened to read your post about this pt on hospice!!
    it is atrocious that this could happen to any pt at all...but one that is supposedly at end of life???
    i want to vomit.

    yes, it *sounds* like blatant neglect, blatant delay of treatment.
    you can and should report this...anonymously if you desire.
    or, you can contact the ombudsman of this facility - their name and number should be posted on a public wall.

    it's too darned easy for each and every one of us to wonder, "what's the use?"
    and so, we trudge forward in our daily lives and pretend it didn't or isn't happening.
    meanwhile, we have a helpless pt that is being ignored/avoided...
    and could easily die contorted, in pain, alone, soaked in urine, and smelling of urine, etc.
    sounds dignified to me (NOT!).

    most of us are overworked - that is NO excuse in ignoring a human being's most basic needs in life...and death.
    if i can make excuses up the wazoo, as to desensitizing myself to inhumane situations...
    then why the hell did i ever become a nurse???

    whatever (not at you op - i appreciate that you're upset.).
    i've had upper mgmt try and talk me out of substandard txs.
    you need to stay true to yourself, otherwise your whole life is a lie. (stated generically)

    good luck to you, littleone.
    you'll go far in life....for doing what is just and truth.:redpinkhe

    Last edit by leslie :-D on Jun 27, '12 : Reason: typo
  8. by   nurseprnRN
    report it. chapter and verse to the state and to the state board of nursing...because a nurse had oversight over this patient and did nothing. and then go work somewhere else.
  9. by   -jnicole
    You really should report it. I mean, you pretty well followed chain of command and reported to you ADON who didn't really seem to follow through with the matter. Try talking to your DON or Administrator, maybe they could be of some help. There isn't any reason for the nurse, or aides to be acting so nonchalantly about this. What if it was their family member? Their in this field to help those who need it. You shouldn't leave healthcare because there are a few bad apples. Keep standing up for what's right, littleone!
    Last edit by -jnicole on Jun 27, '12 : Reason: misspelling
  10. by   sharpeimom
    you went up the proper chain of command first, which shows professionalism.
    a good yardstick on whether or not to go higher and report an incident is to ask
    yourself how you would feel if it had happened to your grandma or an elderly aunt
    instead. you'd sure as heck want someone to advocate for her then! report it!
  11. by   Scarlette Wings
    Leave, Get out, and Run! Do not pass Go and do not collect 200 dollars!
  12. by   CathRN
    You are obligated to report this to state. NOW!. Also as a previous poster stated, also report it to your state board of nursing. Call your state reporting hotline. ASAP, if not sooner.
    I am a "state investigator", my mantra is "it is better to report it to be safe, than not to report it and regret it."
  13. by   FORTHELOVEOF!!!!
    If you feel it needs to be reported, then do it! Your DON clearly has other motives, you can anonymously report them and would do so for the personnel who didn't go in to check on her as well. I'm sure there was someone there that was allowed in the room and she should've been cared for! You do what you know is right, never let admin lead you by the nose, those patients are why you are there, not the admin! Good for you for being this patients voice!
  14. by   littleone25
    Thanks everyone...I thought about this all night and called to report first thing today. There were 3 CNAs that day allowed in her room, and I am one of them, so I suppose Im partly responsible, even though none of us were aware that 'her' aide couldnt care for her. Im not okay with taking the fall for this, but I would prefer that to the alternative...seeing it happen, and doing nothing, and potentially allowing something like this to ever happen again. your input is much appreciated!