HH Advice , Difficult non-compliant pt.

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Specializes in ICU/CCU, Home Health, Case Management.

Hi all,

OK, I've never run into this before. Background, I am an RN for 15 yrs, 20 yrs prior as LPN. % yrs HH in MA., 22 yrs ICU. Well , today, a pt of mine called my agency asking for my RN license number. She said I threatened to put her in a NH. I DID NOT. She is a Non-compliant Psch pt with medical issues, calls office 6 times a day average. 3 wks ago she called office to say she had fallen, hurt her hip and knees, very unsteady from pain meds. Since she lives over 1/2 hr away I advised her to diall 911 and go to ER. She did not go. So, my agency sent LPN out to check her and found she had nl ROM. WELL, low and behold her PCP ordered MRI and XR 2 weeks ago and she broke her knee and tore ligaments in the other. She was told by him 2-3 days ago (when he got results) ???? , to go to an orthopedic surgeon. She has appt 8/10!! I asked him, is she ok to stay at home til then, he said yes! I documented all of this in Medical record. I called her yesterday to tell her and asked her to ask her husband for help in transfers, chair to bed, shower chair, etc. I said, if we can't along with her husband provide her with a safe environment to prevent further injury, WE would have to recommend her care be provided in nshg home until her knees were attended to. NO threat, I didn't tell her I would put her in NH, I can't and would never. He never appears when I visit, (has his own issues) they are both in their 50's. Anyway, my boss aid, if she refused my visit q2wks,(HHA sup), she would have to discharge her. pt said ok d/c me, then sent an em to my office, stating that if anyone from my agency came to her home she would charge them with trespassing and call police. She has a very lg guard dog!! I live in a state where firearms are permitted. Anyway, i was told the director wants to wait a few days, then call her! I do not t to care for this pt. I have never had anyone ask for my license before. I worked too hard the past 35 yrs to end up in a legal situation. TG, I have malpractice and documented all of this, plus her past slurring of speech, need to see a SW and Psychiatrist (bipolar). What would you do?? I am only RN, other than my sup who does not do visits. Please,HELP. Tyou.

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can you discuss with the social worker and perhaps file it with adult protective services?

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Specializes in COS-C, Risk Management.

She has refused services. Sounds like you're off the hook. Do your own chart audit, make sure you have all the info documented and inform the PCP that she will be discharged at her own request and that you will not accept her for care again. If you're in FL and this pt is Medicare, you have to give her 48 hours notice. Send it certified/registered mail (whichever one has to have a signature) and then write your discharge summary.

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Specializes in ICU/CCU, Home Health, Case Management.

Tyou! We have a sw, but I'm told she has kicked her out! I rec. to her PCP 1 week ago, she needed to see Psychchiatrist, but no answer from him. The director of my agency wants us to let her "cool" off for a few days! I am going to call my malpractice company today. Do I have the right to refuse to see her q2wks for sup? I think I do, considering the threats and false accusations. Plse let me know. Yes, she is a candidate for protective services. She lives in a filthy place, infested with fleas. Oh, BTW, I have another pt. who has reported me d/t his bedrm where he lives is infected with cockroaches. They are in all his dsg supply boxes, col. care boxes, etc.

I tried reboxing everything, many dead and live bugs, but that's not going to last. He is bedbound and wife w/c bound. I have suggested roach motels and even having home exterminated to no avail. "You don't see no bugs." "Just do your job. Has several open wounds!! HELP!! Yes, FL resident.

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Specializes in ICU/CCU, Home Health, Case Management.

I would love to, can you do it anonymously? Also, she, my supervisor said, "I've sent one out before and she is worse than the pts, and she'll refuse her" We need Psych nurse, MSW (who my boss is confident with) and Wound care nurse. Lots of non-healing wounds because the doctor is not a wc nurse. His orders?? I have documented MSW referral several times. Even ordered a PSYch doctor visit! For me!! LOL. no, the pt.!!!!

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One thing it has been very difficult for me to accept in HH is that patients have the right to refuse services, be noncompliant, live in filth, neglect their wounds and fall repeatedly.

Your agency has the right to drop them as a patient for any of the above.

Two weeks for a PCP to acknowledge the results, not surprising. Crappy care but not surprising. Did anyone with the agency follow up after the MRI was done? The results have a direct effect on your PoC, I'd have been on the phone every day until I got a response.

Btw, three weeks for an Ortho consult is par for the course here. Unless you're referred for casting (which doesn't require the doc see you) or are admitted to the hospital you aren't going to see one any sooner unless your PCP calls in a favor.

I called her yesterday to tell her and asked her to ask her husband for help in transfers, chair to bed, shower chair, etc. I said, if we can't along with her husband provide her with a safe environment to prevent further injury, WE would have to recommend her care be provided in nshg home until her knees were attended to.

I'd take that as a threat if I was already having issues with the person saying it.

Yes, you absolutely can refuse to provide services to this client. Whether or not your agency will accept that is another story.

What the client needs is someone she can build a rapport with, furthering the the adversarial relationship will just about guarantee she'll never accept HH services again.

Do what you feel you need to to protect your license, do an APS referral but really doubt it will have any effect at all.

One thing I've learned about myself from doing HH...If I'm ever in a position to need HH service, I'll show the door to anyone who walks in my home, criticizes my lifestyle choices and refuses to work out a PoC that we can both agree to.

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Specializes in ICU/CCU, Home Health, Case Management.

Thank you, heard you loud and clear. The pt is non-compliant with her care, which is her choice. My agency is continuing to see her, she has knee braces on and my supervisor was told she had to do Sup visits, etc. She wanted to discharge her but the "boss" said no. I did not judge her or his (insect patient) lifestyle, simply rec she was needing more help, than what we were able to provide, (qualifies only for MCare visits, not Diversion) and as for insect in bedridden pts home, it was a health concern simply due to roaches carry many bacteria. All, communication and nsg care was done with THEIR best interest in mind. I didn't want to report him as an elder at risk, nor her. Tried to avoid that, thought they both clearly were and he still is.

I am going per diem, then will be able to choose my schedule and not work 70-80 hrs week due to exempt/ salary status. I do not do any managerial duties, nor do I earn enough to equal all the time I spend working, computes to about 14.00 hr. Thank you your time. I did followup with her MD. He said he is very close to dropping her as a pt d/t her non-compliance. And the other pt. says he has an exterminator coming. Since, I have been proactive in both these cases SW is very involved. :nurse:

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Specializes in ICU/CCU, Home Health, Case Management.

Dear kids,

Well, today the patient canned my supervisor after lying about not receiving knee braces! So, put that in your hat!

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Specializes in ICU/CCU, Home Health, Case Management.

You are out of line, kids. Who's judging whom!! She canned our agency even after supervisor saw her, lied about braces for her knees not coming when they did while supervisor was there. As, for the gentleman with the insect (roach infestation), well, I guess you think it's okay for roaches to be crawling all over your supplies if you had open wounds and colostomy!

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Specializes in COS-C, Risk Management.
You are out of line, kids. Who's judging whom!! She canned our agency even after supervisor saw her, lied about braces for her knees not coming when they did while supervisor was there. As, for the gentleman with the insect (roach infestation), well, I guess you think it's okay for roaches to be crawling all over your supplies if you had open wounds and colostomy!

I don't think Kids was suggesting that it'sokay for the insect/roach problem. The point I think s/he was making is that the patient does have the right of self-determination. If he chooses to live in filth (which is really a judgment call) with bugs and whatnot, that is the patient's right. As long as he is competent to make decisions, it is his choice and while we may not like it and may cringe at the thought of entering the patient's home, that is HIS home to do with as he sees fit. It is important to meet people where they are in life and do the best you can with what you have to work with. It's not easy sometimes, but that's home health care.

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I don't think Kids was suggesting that it'sokay for the insect/roach problem. The point I think s/he was making is that the patient does have the right of self-determination. If he chooses to live in filth (which is really a judgment call) with bugs and whatnot, that is the patient's right. As long as he is competent to make decisions, it is his choice and while we may not like it and may cringe at the thought of entering the patient's home, that is HIS home to do with as he sees fit. It is important to meet people where they are in life and do the best you can with what you have to work with. It's not easy sometimes, but that's home health care.
Thank you, that is exactly my point.
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