Anyone Ever Drop A Client?

  1. I had a pt. that was noncompliant; had wound care that was frightening (but not beyond me) and was argumentative, noncompliant, AND complained about every other Home Health Company in town (and mentioned names of nurses).

    Not only was the pt. difficult, to me, it was scary. Particularly the noncompliant part. I have never, in the Home Health arena, tried to unload a client. My manager ambivalent about my concerns to him, I lost sleep over worrying (more then the client it appears) about his wounds healing.

    Without support of my office, I decided to draft a letter to unload the pt. to "someone else" thinking another Agency with a Certified Wound Care Specialist and a Psych. Nurse would be a better option for this client. Up until the time I drafted the letter, I was pretty much ignored. I felt very concerned about my own feelings of frustration, being left out to dry if this guy sues ME because his wounds (3 - 1 a stage IV) on the ischial and he REFUSED to off of his wheelchair to stop working.

    Without whining, and I am so trying to get past the semi-guilt, I will stop there. It has been a couple of weeks, the dust has settled, but my manager, who took over this pt. and is giving it to the "new nurse" stated that if we dumped him we would be out of favor with DHS.

    Has anyone experienced this? What did you do? I feel pretty isolated at times with some of these hard decisions like ethics versus protecting my license and my sanity. I did serve notice and gave adequate time to have other support set up for this client etc. I ended up having to force my Directors hand and served notice of unloading the pt. off of my caseload.

    Last edit by nightingale on Mar 27, '04
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    About nightingale

    Joined: Apr '01; Posts: 6,312; Likes: 106
    RN, CLNC, Entrepreneur


  3. by   nightingale
    Anyone care to comment?
  4. by   renerian
    I have transferred patients to other agencies based on staffing issues, specialty issues that a new agency might have that could only benefit the client.

  5. by   nightingale
    Thanks Ren, you have such a varied and long history in Home Health. I appreciate your feedback.

    I guess I feel a little guilty (but I will get over it) because the other nurse who took this client is now having to contend with this difficult and concerning client.
  6. by   renerian
    I have always rotated the difficult folks around. Don't feel bad about it at all.

  7. by   Traveler
    I believe that if you have a patient who has non-compliance, severe wounds and no reliable caregiver they would best be served in a skilled care unit of a nursing home. I had a patient recently in this category. It scared me to death because I knew his wound would not get any better and my limited time with him wouldn't help as he wasn't compliant when I was not there.

    I ended up talking him into skilled care which he left ama after several weeks. The doctor called us wanting us to pick him up again. Luckily people are very supportive where I work and they knew the whole situation. They informed the doctor that we could not help this patient. I do not know what happened to him.

  8. by   nightingale
    Thank you Ann and Ren for your feedback. It is a no win situation.

    He is now being cared for by the "other two nurses" who have agreed to take turns with him so they will not burn out. I will likely see him occasionally on the weekends as his care is rotated by the other two nurses; it was a lot different this past weekend for me when I talked with him about his care and his ongoing decisions to say "well ok, *&%, I will let your caseworder help you decide".
  9. by   hoolahan
    It is hard to watch someone do harm to themselves. That is one of the things about homecare, you really cannot control what a pt will and wont do. This is what I have found are the best things you can do...

    1. Document document document. Document that you have discussed the pt's noncompliance to the POC, the possible consequences of not following the poc and list them, put the pt's comments in quotes. This even better if you take a witness, like a supervisor or MSW on a joint visit. Have them witness your notes.

    2. You can attemt to have the pt sign a behavioral contract. This way they sign that they will change the drsg daily or will have someone else do so, and what will happen if they don't.

    3. Send a letter to the doctor and copies of the documentation. If the pt files a complaint with DHS, then you have covered yourselves well. Pt's can be discharged from HH services for noncompliance. I believe Medicare requires an in-person 48 hour notice, then the pt has 24 hours to file an appeal. But, it behooves you to give him 2 weeks notice, at least. Unless of course personnel are in danger.

    4. If your agency dumps him, offer assistance with placement. Why would your agency lose favor with DHS?? If every other agency has dumped him, it is clear your agency is not the problem, the pt is the problem. Your agency must have a few little secrets, like other complaints or a bad review from the state or something to be so paranoid.

    5. Request an ethics meeting and have the agency keep minutes of the meeting. One agency I worked for required documentation of an ethics commitee meeting before they would give notice to someone. The letter of notice was then hand-delivered by 2 people from the agency, for witnessing purposes and safety.

    6. Write a letter if he gets admitted to recommend they do NOT acept him back on services.

    We had a very difficult pt, we never should have even accepted the referral. She was a KNOWN problem. The agency sent me out because "I am a strong nurse..." I get sick of that BS!! I opened the case in spite of them, I then wrote a 3 page letter, attaching the note from the supervisor which never clearly laid out the problems, it said "If this pt does not have a CG, do not open the case." I asked the pt if she did, she told me her father. He didn't seem very interested when I got there, but wouldn't it have been utterly helpful to me if the a-hole supervisor had informed me that the pt's father broke a behavioral contract prior to her hospitalisation??? I didn't know her, so what was I to do, call her a liar?? She was pitiful, and I felt we were better than nothing. In fact, I felt very strongly we had let her down MORE by allowing the hospital to think she would be admitted to services, when in fact, if we had refused her, she would have been in a much safer situation, placed in a LTC or remained in the hospital. I gave the letter to the director, and I recieved several apologies for even being put into that position. NRS Karen then gave me policies of her intake dept, explaining the tier system they use for determining if they would refuse a re-referral. Very objective, and she even told me our director could call her if she had questions. They thought it was wonderful!!! So wonderful, they never implemented a single change!! Grrrrrrr!!!

    Bottom line, good for you. Patients in desperate situations can also be very manipulative. You are human, of course you feel badly, you have a warm heart, they KNOW this too. Should I have left this woman laying in her own menses and stool, unable to get up to her wheelchair to get food and water, and not opened that case?? How could I do that?? I am not heartless! I got her washed, dressed, hoyered into her WC, fed, admitted, and went home to write my letter.

    When you advocate for yourself, you are usually also advocating for a patient's welfare most of the time, don't forget that. We are here for you!! Sorry, I haven't been around much lately, for support.
    Last edit by nightingale on Apr 24, '04
  10. by   Stitchie
    Nurses should never have to work in situations where they feel that their personal safety is in danger.

    We all make choices in life. If your patient chooses to allow his wounds to become infected and horrible, then that's his choice. You are not able to influence his behavior, and having your license in jeopardy will only prevent you from helping people who want and need our attention.

    It's good of you to feel for this man, but he's made his choice, and you must protect yourself, whether physically, emotionally, legally.
  11. by   elkpark
    I am a psych CS, not a home health nurse, but have encountered similar situations in my career in roles as an outpatient psychotherapist and psych consultation-liaison nurse at a big teaching medical center. As others have noted, document, document, document!!! You are not obligated to provide care to people that they don't want (assuming the patient is competent to make that decision), and you can discharge them if they are consistently refusing to comply with treatment.

    The ethics committee review is an extremely good idea. Another idea is a competency eval for possible guardianship ... If the patient is determined to be competent to make those kinds of choices and chooses to forgo treatment, so be it. If incompetent, then it will be out of his hands and he can be placed where his needs will be best served (and signing out AMA won't be an option).

    Best wishes for a difficult and painful (for you) situation --