New nurse stressed in homecare!

[guest114]

Hello everyone! My name is ally, I am an LPN and work in homecare for the past two years.

Currently I find myself struggling and am reaching out to more experienced nurses for help. I have worked with mostly the same patient; who is trach/vent, peg, foley, TPN, the whole nine yards. The family situation is somewhat is a mystery to me, even after being here almost a year and half now, both nights and days. There is a woman who takes full responsibility for this patient, ill call her Anna.

Anna has learned every aspect of the patients care from wound care to setting up the TPN, because most of the nurses on the case are LPN's and this is outside our scope of practice. She says she is a "friend" of this woman who is mostly unresponsive and nonverbal. She pumps her full of morpine all day long, and I'm sorry but this just seems immoral to me. There is literally a bariatric sized hospital bed set up in the middle of a very small livingroom that is stuffed full of brown fedex boxes and medical supplies, even a cart stocked full of medical supplies and equipment, all in this extremely small house.

There are three bedrooms, all of which are also filled with boxes, medical supplies, and other junk. The caregiver sleeps on a couch next to the patient, and the nurse sits at a table on the other side. There are signs all over "do not this..." "turn off that" mostly just ridiculous pet peeves of Anna's, things you have to deal with when sharing your home with people. The kitchen stove has been turned into a medical preparation area and there are charts and clipboards that must be checked off during each shift (not a requirement of my employer, these have been created by ANNA). There is a large white board in the living room, that a grid has been created on so Anna can visualize vital signs and I&O for every shift from her sleeping quarters ie the couch.

Anna has not left the house in over 18 months...for anything!! Groceries, medications, and anything else that she needs is delivered to the house. I cannot for the life of me figure out who this woman is living in this patients house, and why she has assumed all care for this woman. Sometimes I am very concerned because she takes things into her own hands that she is not qualified to do. Lately we have been having issues with the foley, and she decided the needed to DISCONNECT it and flush with a large bulb syringe...probably one of the more dangerous things ive seen her do. She also puts honey on bed sores... And because I am fairly new to nursing she is hesitant to take my advice. Thankfully a very experienced nurse came and showed her the appropriate techniques.

Basically, this is a constant battle, Anna is never happy, she is convinced the patient is coherent and has full blown conversations "with" her. She gets angry when others dont feel the same or arent excited as she is about small eye movements or something that a medical professional really knowns is just a tremor or some type of dyskinesia. I understand denial and all that, but the cable and all the bills remain in the patients name who is basically comatose, and this is even her house and this woman Anna has taken total control.

In the extended time I have been working here, I think family may have visited once, but I never saw them..When the agency needed to inform a family member of an incident she freaked out...She treats the nurses terribly and we are only here to help, every day i leave with a huge mental burden and just looking for some advice on how to deal with a difficult homecare case. Mostly the social aspect of it. Thank you in advance.

[caliotter3]

This sounds as if it is becoming too much for you to deal with and maintain your own mental health. The easy answer is to leave the case. You can decide on your way out whether or not you should bring any concerns to adult protective services. You can not be faulted for having misgivings, but you can be faulted if it is found that you failed to report something you are obligated to report as a mandated reporter. Trust that any time you have said something to management at your agency, they have brushed you off, or ignored you. If not, then you need to have a frank discussion with your immediate supervisor.

[nursel56]

I agree with everything Cali said. Also, if I am on duty I am legally responsible for the patient, so I would not have anyone pumping morphine or providing nursing interventions on my watch. I don't know why wound care and TPN are out of the scope of practice for an LPN in your state, but it should be documented in the chart that someone else is setting that up or otherwise carrying out items in the Plan of Care for which you would be responsible to complete.

Have you ever spoken to her primary care provider or doctor? Has social work or social services ever been involved in her case? Is the lady competent or does someone else have Medical Power of Attorney? These are all things that can and should be known by you in order to follow the medical plan of care and what to do when things go haywire.

At the very least, like Cali said, talk to your immediate supervisor.

[guest114]

for some reason my previous reply did not post. Basically its like I am the only nurse left that will come here, because I am truly passionate about nursing and love my job. She will send a nurse home if she senses they have a cat or dislikes her perfume...I have made my agency aware of all that goes on here, but they seem desperate to keep me on. She also has told the agency she does not want the nurses administering any narotics, handeling TPN, or giving certain injections. Social work became involved when the patient had to be admitted to the hospital for an infection and she had the doctor send her back home as quickly as possible and will not return back to the hospital for any reason. It literally took the entire fire dept to move this patient with a special stretcher and bariatric ambulance. The patient had SEVEN seizures at home and she refused medical intervention. She literally does all she can to have complete control and I don't know if its getting to a point where I am putting my license at risk..When it comes to speaking with any doctors she takes all phone orders and gets all lab results. I have no idea whats going on wit the patient unless I go out of my way to find out, she is annoyed by questions and we cannnot discuss anything in front of the patient even though we are all sharing about a 20 foot space in here..

[caliotter3]

You have described conditions under which I would refuse to work. There are limits to how much I will allow my hands to be tied while still maintaining legal responsibility to my patient and my job.

[nursel56]

Ally, if they are desperate to keep you on you have the ethical and legal right to insist they allow you to perform the duties you are licensed to do, as well as held legally responsible for when you accept a patient under your care. I don't know whether Anna is a family member or a paid caregiver but either way I wouldn't touch that case. Not only because of the legal issues, but because of the frustration of being bossed around by someone who's credentials are sketchy at best. I wish I could offer more hopeful advice! I do commend you for being such a caring person, though.

[turtle0206]

Hey! I feel your pain I am also a new grad visiting nurse. I see anywhere from 6 to 12 patients a day and am finding similar struggles as you. First off find a couple experienced nurses you can rely on. I am so lucky to have a supportive team and without them I'd be lost! lol

As far as your Anna situation I also had a similar issue. Be careful because if you report something to her that is intended strictly for family then you are held legally accountable. There are a few things you could do (mind you, your agency may operate differently than mine and maybe some other nurses on here would disagree but these are my personal suggestions...):

1) talk with PCPs office ask if they know anything about this Anna character

2) call the family (proxy or PCG) and ask them to clarify what Anna's role is. obviously do this when she is not around.

3) talk with pt's caseworker. if the pt doesn't have a caseworker maybe you can refer the pt to an elder service support group. Or maybe your agency already has assigned caseworkers.

4) have an outright discussion with Anna. Clearly outline exactly what your responsibilities are as the visiting nurse. I think asking you to do these "check offs" on the clipboard is a little ridiculous and I don't think you would be wrong telling her that you were not ORDERED to do this by the doctor or your agency. (maybe give your agency a heads-up before having this talk lol)

5) if all else fails, talk to your supervisor about the situation. Tell her/him about "Anna" and see if they have any suggestions for you.

Whatever you do, get some answers! As someone else stated, we as nurses are mandated reporters and if you see an issue it needs to be reported to elder abuse. This environment must be very uncomfortable for you, I hope I was able to give you some ideas. :) good luck!

Edit: I just saw a more recent post you put where the PCPs office isn't telling you of changes. This is unfortunately a very common struggle in homecare. rarely do I learn of a med change, upcoming appointment or test unless the patient themselves tell me. But in this situation maybe you could talk to a nurse at the PCPs office. Tell them that Anna and the family are unreliable in reporting changes and you would really appreciate if they could keep you notified of any. provide them with your number and agency fax number. I've had to make these requests before sometimes they listen and sometimes they don't lol but it's worth a try