Alright, so I need to vent (I seem to need to do this a lot, maybe I shouldn't work every day). EMS brings me a 93 year old man from a nursing home who fell from his chair and hit his head. Non-urgent, head lac, no biggie. Until, of course, I get him undressed.
This poor old guy was totally AAO and coherent. He had been moved to the nursing home because his wife couldn't take care of him alone any longer and they have no family. He's just old and fragile. I get his pants off just to assess his skin to see how well he's being taken care of and... he has cellulitis all up his right leg and he's red in his groin and backside. The doc is with me when I do this. He semi freaks out because there was no mention of the leg in his NH papers and the pt himself didn't really know he had cellulitis.
The patient starts to tell us how he's neglected at the NH. He is put in his room early he says, around 7 or 8, alone and without being checked on. He says he can't get anyone to help him get up to go to the bathroom or bring a urinal and is consistently wetting himself and laying in it until morning because no one checks in on him.
I call the NH and they tell me he's being treated for a wart on the bottom of his foot and they soak it in warm water. And he's not on any medications. Despite his being on medications per his paperwork. So at this point, I'm ******. I call his wife who was the POA and was very knowledgable when I spoke with her. She explained to me how he had been complaining to her about the care at the NH. When I asked her about the cellulitis, she said every day when she came to see him, they had socks and shoes on him so she never saw his leg. So, I hotlined the NH for neglect.
Throughout his entire stay in the ED, he just went on and on about how grateful he was for us just being there for him, taking care of him, paying attention to him. Even when I was bandaging his head, he went on about how gentle I was and that I never need to become like the people at the NH. I teared up when I had to go tell him we were sending him back to the NH. He just had the saddest look I've ever seen when I said that. All he wanted, he said, was to go back home, where he could be with his wife and not have people neglect him every day.
I just do NOT understand how anyone, whether it's a nurse, an aide, or a clerk could even witness neglect and let it go. When do people lose their ability to care about another human being? They might be old, but they are still humans with very real emotions and not all of them have dementia. The only thing this poor little old man wanted in the world was to be cared about. He wasn't needy or mean or anything less than kind. It's a tragic thing how far some people deviate from the line of caring.
Let's face it, there are 3 shifts and why didn't any progress notes that are sent with most/all ER pt's that come from NH indicate the current problem with the pt. ....remember not all NH take care of their pt's as they should and also, not all family members are as involved as they should be. So, actually its number one, the caregivers at these NH'S that are responsible and not all pt's are aggressive/non-compliant be it for whatever reason. Remember, there are great NH's and less than sub-standard NH's!!!!!
Its all about money. Nursing homes either won't or can't pay for adequate staff. Makes me sick. I hope the powers that be that are in charge of this horrendous nursing home situation never find themselves in the condition that poor old fellow was.
Simply heartbreaking and infuriating all at the same time.
I worked in a nursing home for 5 months as a new nurse. The poor nursing assistants were worked to the bone and I could barely help them because I had such a large assignment.
The system is definitely broken. How can we fix it?
Exactly. The people who make the "business decisions" should be nurses, Mds, or nurses aides who also have a degree in business. CEO's do not have a clue as to what the patients need or how hard the staff works.
I am an RN who has a bachelor's degree in finance. Maybe I should be in charge (not a job I want)- at least I would have a clue.
My nursing home story: share, I must. I discharged a patient from the telemetry unit that I was floated to, back to his nursing home. The monitor tech. informed me, at 1900, that I forgot to remove the telemetry monitor from said patient. They, the monitor techs, go on about how expensive the monitor is. The nursing home is not far from the hospital, and even closer to my apt. After my shift, I went to the nursing home to retrieve the monitor. I explain to someone who I am, and the situation. I presumed that someone has been waiting for someone to retrieve the monitor. I presumed that the monitor would be waiting for me at a desk, safely tucked away. Nope! Said someone told me to go to the patient's room. No escort, nothing. I found the telemetry monitor. To my dismay, still attached to the man's chest!
I can't say that the patient had not been assessed. However, I thought to myself: how many times have I assessed a patient and "found" an unaccessed infusaport, that I was not told about in report? How do you not see a telemetry monitor? Are there nursing homes that monitor cardiac rhythms?
I'm not being judgmental. I do not know of the conditions in homes. However, that was a wow moment!
That just makes me so sad. Who deserves that? You know, you work hard your whole life, and when its finally time where you can't care for yourself and you have to depend on others, crap like this happens. I hope I'm a spry old bat and when I die its sudden and unexpected. Good for your for reporting it.
I can't defend what the poster described in his ED. There is no defense.
I have one suggestion, though. The OP needs to work in a LTC facility for at least 3 months. Then come back here and maintain his/her moral outrage.
While my heart breaks for a helpless old man, it also breaks for overworked nurses who do the best they can. Knowing it's inadequate. Then getting blasted by people who don't have a clue.
Hey, guess what? I will still maintain my moral outrage. Know why? Because I care about people.
Sure, there are two sides to every story and LTC is one of them. I wasn't bashing LTC facilities. I was bashing THIS LTC facility and those who were responsible for this kind of care. All of you that work at LTC facilities and are going on and on about poor staffing and high patient ratios, I absolutely get that. It's not some new, unknown issue. It's a long known fact that LTC facilities are understaffed and overworked. However, you can only defend yourself with that argument to a certain point. When it negatively affects a patient's health, you are no longer allowed to use that defense.
I don't spend my days seeking out LTC facilities and nurses and aides to bash. I spend my days taking care of people. It's what I like to do. Guess what? The ER can be understaffed too. And know what else? We can be busy AND understaffed. Do I use that as an excuse to neglect checking in on my patient regularly or taking care of their needs? No. There is no excuse for neglecting a patient.
Hey, guess what? I will still maintain my moral outrage. Know why? Because I care about people.
Sure, there are two sides to every story and LTC is one of them. I wasn't bashing LTC facilities. I was bashing THIS LTC facility and those who were responsible for this kind of care. All of you that work at LTC facilities and are going on and on about poor staffing and high patient ratios, I absolutely get that. It's not some new, unknown issue. It's a long known fact that LTC facilities are understaffed and overworked. However, you can only defend yourself with that argument to a certain point. When it negatively affects a patient's health, you are no longer allowed to use that defense.
I don't spend my days seeking out LTC facilities and nurses and aides to bash. I spend my days taking care of people. It's what I like to do. Guess what? The ER can be understaffed too. And know what else? We can be busy AND understaffed. Do I use that as an excuse to neglect checking in on my patient regularly or taking care of their needs? No. There is no excuse for neglecting a patient.
Let the flaming begin!
As a nurse who works in a nursing home, I'm very sorry to hear about your patient OP, it sounds dreadful. I think we would all agree with you that there's excuse for neglecting a patient. But, if you had 50 or 60 or more to look after with the help of a few CNAs, could you look after them all properly? Could you check each one as often as you would like? Could you guarantee you would never miss something? Could you ensure that no-one's health was ever negatively affected? Especially given that most nursing home patients need far more care than your patient did.
I will never excuse poor care or neglect, but I would love to be able to hear the NH's point of view on this. Many residents who appear to be fully oriented actually aren't and it can take quite some time to work this out. The resident who says 'no one comes near me all night' may truly believe that, but in my experience it's rarely true, even in the most understaffed nursing home. If it is true, I agree with you that it's not acceptable.
I do have to agree with the posters who have mentioned staffing - I wonder how many residents are in that nursing home and how many staff are rostered, especially overnight. If there is one nurse to 50 or 60 or more residents overnight, it's almost impossible to provide good care to everyone. Those numbers aren't an exaggeration; many nursing homes are staffed like that.
Residents in nursing homes can develop a red excoriated groin in no time, some are red more often than not despite the best care. Cellulitis can develop quite quickly too, it's possible that it was brewing sub-clinically for a day or so but then flared up on the day - perhaps it was even the reason for the fall.
Anyway, none of that matters really. I wish that reporting the nursing home would make a difference, but I don't think it will. If they are investigated and found wanting, it will be the staff who get the blame and told they have failed. Management at a high level (not immediate nursing management such as the DON) are the ones who decide staffing levels, the vast majority of nursing home staff do the best they can with what they have, but those management people will not be told they have neglected patients or provided poor care, they will nod gravely and be outraged that their staff have.
I wish we as nurses could understand each other a little more. It's easy to fall into the trap of blaming the other side. I don't have any answers, I wish I did. I love working with this population despite the short staffing, the increased acuity of the average nursing home resident, the increased expectations, and the poor image of this area of nursing in the minds of many people. I do hate the attitude from some in acute care that nursing home nurses are really pretty hopeless.
Would it be possible for your hospital to develop some kind of outreach or collaboration with your local nursing homes? We have done this quite successfully where I live and it has made a big difference in the area of communication - we have a standard set of forms that go back and forth from the NH to the hospital and then back to the NH and it contains all the information needed by both sides. Hospitals and nursing homes got together and agreed on a format that suited them both, that was as easy as brief as possible and as easy as possible to fill out fully and gives each side most of the information that is needed when a resident goes between the organisations. It took a bit of work because each side wanted to use their own forms, had their own particular needs, etc, but it came together eventually and has helped a lot.
I know there are very poor nursing homes out there and this has to change. I don't think it ever will until we, as a society, truly value older people and consider them as important as anyone else. The child care centre down the road has mandated ratios, something like one staff member to 5 children, depending on their age. These are healthy children who do not require any medical care. Yet the nurse in the nursing home may have 25 or 30 or 50 or even more (depending on the shift) medically complex fragile older adults who are actually anything but stable.
Recently admitted a woman from a NH with a report of anuria. I DC her foley and a large amount of pus came gushing out. The worst pyuria I have ever seen, no urine output, excoriated labia and lady parts, a WBC of 33.8, BP's in the 80's, confused, an ileostomy that hadn't been changed for over a week, and with a CVAD with more dried blood under it that bioclusive covering it. I was appalled. I phoned the NH, and hes RN said "I did not notice any signs of infection. No pyuria. No excoriation. She just doesn't look good." The nurse then proceeds to tell me "the aides do foley care when they do bed baths, but they get her up into the shower." Pt tells me she can't get out of bed and hasn't had a real shower in years. "They give me a bath almost everyday, and they were supposed to change my (CVAD) dressing 2 nights ago."
She was so septic. I was so angry and upset. Her nurse told me there was no charge nurse, no nursing supervisor on staff. I have to wait until a manager comes on at 0900. Better believe I am going to be on that phone.
Recently admitted a woman from a NH with a report of anuria. I DC her foley and a large amount of pus came gushing out. The worst pyuria I have ever seen, no urine output, excoriated labia and lady parts, a WBC of 33.8, BP's in the 80's, confused, an ileostomy that hadn't been changed for over a week, and with a CVAD with more dried blood under it that bioclusive covering it. I was appalled. I phoned the NH, and hes RN said "I did not notice any signs of infection. No pyuria. No excoriation. She just doesn't look good." The nurse then proceeds to tell me "the aides do foley care when they do bed baths, but they get her up into the shower." Pt tells me she can't get out of bed and hasn't had a real shower in years. "They give me a bath almost everyday, and they were supposed to change my (CVAD) dressing 2 nights ago."
She was so septic. I was so angry and upset. Her nurse told me there was no charge nurse, no nursing supervisor on staff. I have to wait until a manager comes on at 0900. Better believe I am going to be on that phone.
Please make suree you report them to the appropriate state agency/law enforcement
Would it be possible for your hospital to develop some kind of outreach or collaboration with your local nursing homes? We have done this quite successfully where I live and it has made a big difference in the area of communication – we have a standard set of forms that go back and forth from the NH to the hospital and then back to the NH and it contains all the information needed by both sides.
I was going to mention this idea. The Emergency Nurses Association (ENA) developed some "Safer Handoff" materials that specifically address nursing home-to-ED-and-back communication.
I'm glad we're all keeping this civil -- I know this is a touchy subject, and it is easy to take sides ... but I know we're all on the side of the patient, in the end.
sunny4you
10 Posts
Let's face it, there are 3 shifts and why didn't any progress notes that are sent with most/all ER pt's that come from NH indicate the current problem with the pt. ....remember not all NH take care of their pt's as they should and also, not all family members are as involved as they should be. So, actually its number one, the caregivers at these NH'S that are responsible and not all pt's are aggressive/non-compliant be it for whatever reason. Remember, there are great NH's and less than sub-standard NH's!!!!!