HELP!

[spejsa]

so, I am new to home health. I started with the agency that I am with in February, 2010. Right after I started a nurse quit, so I was "handed" her patients... But, I didn't know what I was doing and people were saying things like "these patietns needs to be seen", etc... so I started taking them and by my 2nd week (after 2 days of orientation in the field) I was on my own with my own patients... I am an RN and there was an LPN that was working with the nurse that left in seeing some of the patients. So, as I knew nothing about what I was doing, I just let the LPN continue what she was doing. By the time I did a supervisory visit on one of the patients, I found out (while at the home) that the patient had a "hole" in the bottom of one of her feet. She is a Diabetic and has been having Unnas boots put on twice a week for some time. Apparently, the LPN didn't notice the wound on the bottom of her foot... The patient went to the hospital in December and the nurses in the hospital found the wound... Ut oh... So, then we were putting silver dressing in the wound and then covering legs with Unnas boots. In February, when I made my first visit to the home I saw the wound and saw what I thought was tendon in the wound.. I charted the wound and sent a report to the doctor that day... I asked the MD if there was anything else we should do for the wound. The patient, all the while, cannot do anything for herself. She will not lift her legs when we apply the Unnas boots, which is why the LPN never saw the wound in the first place... She is overweight and cannot see the bottom of her feet. She is poorly managed with the Diabetes, with blood sugars being over 200 almost every day. So, last week I spoke with the doctor again and they said they wanted her to go to the wound clinic. We sent her over there last week and the doctor there stated "why is this nurse still coming to yoru home?" (per patient). The patient then tells me that she doesn't know why the nurse is coming out... Blah, blah, blah... Then, I came out this weekend to do the dressing changes (which are clean wound and pack with packing strips & Dakin's solution... cover with gauze and wrap with ACE bandage)... I did dressing changes on Saturday & Sunday last weekend and then asked LPN to do wound care this week each day. The patient told me today, after she went to wound care, that the LPN was not doing the dressings right. Per the patient, LPN was not wringing out the packing strip with the Dakin's and supposedly her whole top of her foot has been "burned" by the Dakin's? She went back to wound care today and per the patient she was told that she had Osteomyelitis (which I already figured) and she needed to be in the hospital to get IV antibiotics. She was told she could lose her leg... I asked why he didn't admit her today and she said she had to go to an LTAC and it would not happen until next week... I then called wound center and they stated the same and that we are to keep doing the dressings... This is a very manipulative patient who does not take any responsibility for herself. She has blamed the LPN and probably now blames me... I just try to document as much as possible... But, it is so hard for me. I cannot go to every person with a daily dressing change everyday. The LPN can help with visits and I need her to. A lot of time I have 6 visits plus admissions. I have 4 people with daily dressing changes right now and feel like I need to have the LPN do a lot of visits to help out... But, what do I do??????

[caliotter3]

I would go to your boss and plead for the addition of an experienced, effective RN or LPN or two of them. It is up to them to do the recruiting and hiring. Do you personally know any good nurses who could be coached into signing on for part time or even full time work to help you out? Otherwise, I see you going down the road like the last nurse went.

[KateRN1]

The first issue I see is that daily dressing changes are rarely indicated. It disturbs the wound bed too much and is likely to do more harm than healing to the wound. And Dakins is so caustic to the wound bed, I can't imagine that anyone would still be using it. Scary. Whoever prescribed this particular wound care set you up for failure. Do some research on current wound care theory so that you have the knowledge to question outdated treatment modalities.

Then there's the issue of your staffing. Although the LPN is a licensed nurse, you are still responsible for the overall care of the patient and any bad outcomes are yours to own. You can't say that you knew the LPN was not doing a good job but there was nothing you could do about it. If you already knew that she was not visualizing the bottoms of a diabetic pt's feet (!) then she shouldn't have been back out there for that pt, IMHO. Do you have other staff or is it just the two of you?

If the patient is capable of going to the wound clinic, she may no longer qualify for Medicare Home Health care, depending on the overall situation. If it's a once-a-week thing and truly a taxing effort and can't get there more often, then keep going. But if she can easily make it to the clinic and back without hardship, consider discharging her to the care of the wound clinic.

Sadly, your agency is going to own this infection in terms of outcomes. There was a documented diabetic foot ulcer, out of control blood sugars which don't seem to be addressed, poor compliance on the part of the patient--all of this should be part of your coordination of care with the physician and LPN. The LPN should be calling you report daily (or at least weekly and when there are changes) and calling her findings to the doctor as well. The doctor cannot address medication treatment issues without input from the home care nurses.

My advice is to take this case and learn from it--learn what not to do. Have a sit-down with the LPN and find out what's going on with her. Is she a new grad? Experienced? What does she know about home care and the home care nurse's role? How does she see her own role? Is she overworked as well? Does she know what things to report? How would she have handled this situation in hindsight? And then ask for a meeting with your Director of Nursing and the LPN and discuss how care can be better coordinated for your patients.