Noncompliant and hostile patient- where is the line drawn?!

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Hi all!

This is my first question on here. I registered specifically to find out what other HH policies are on this kind of situation.....so here goes!

I have a patient on home health/waiver that I've taken care of for about 5 years now. She was burned severely in 2013 and has facial deformities, skin grafts, finger amputations bilaterally so limited use of hands . She has been on a TON of pain medication. She's 4'11" 100 lbs and she gets td fentanyl 75 mcg q 48h. Used to be q 72 but somehow she managed to convince the pain dr that she needed it more often. She also takes Oxycodone 5-10mg qid "Prn" and gabapentin. This patient has been very difficult from the beginning. Emotional lability and hostility have been frequent occurrences for the duration. There's so much to this lady I can't even type it all. However- long story short.... she's been through 3 different pain md's and failed MULTIPLE drug screens over the past 5 yrs. yet somehow after she's fired from one dr she always finds another one to dupe for a while. Most recently, she just started with a new pain dr about 3 weeks ago and has ALREADY tested positive for meth. She also had a meth pipe in her home which was reported to the dr. She found out that one of the nurses reported it and is now very hostile and angry at me(she thinks I reported it- it wasn't me but I would have if I had been the one that saw it.) and stated she doesn't want me to see her anymore but since we are a small community and only have 2 RNs here, we don't have any other option really. My question is- at what point can I refuse to see this patient without fear of repercussions for patient abandonment. And what responsibility does my employer have when all of this has been reported multiple times? I feel unsafe in her home for many reasons. The don has said he's working on getting her a 30 day notice but he's said that before and has yet to follow through bc the ceo sees dollar signs when we have waiver patients so she always says we need to keep her on. Anyone have any insight into how I can stop seeing this patient?! Thanks.

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Specializes in Complex pedi to LTC/SA & now a manager.

She said she no longer wants you as her nurse. Generally that = you can't abandon someone who fired you.

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Make the decision mutual. No nurse is forced to see a client that they don't want to see and who does not want to see them. However, the agency can force the issue and decide to no longer employ you for any of their clients. I certainly would not want to continue with this client as you describe them. But when there is only one game in town, kind of hard to walk away from employment.

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Call in an anonymous complaint to the DEA/Sheriff dept about her illegal drug use. Problem solved.

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We've considered the anonymous tip thing but considering recent events with us reporting her drug paraphernalia we are sure she would know it was us. The problem is, if neither of us see her, the next closest nurse has a 50 mile drive to see her. Our agency covers about a 150 mile radius. It's 3 areas that are all about 50 miles apart so typically the nurses that live in the town of the patient get those patients. So at what point are we allowed to refuse to see her bc we don't feel safe? I'm just hoping our company will come through for us and quit thinking about money over employee safety. :/

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We've considered the anonymous tip thing but considering recent events with us reporting her drug paraphernalia we are sure she would know it was us. The problem is, if neither of us see her, the next closest nurse has a 50 mile drive to see her. Our agency covers about a 150 mile radius. It's 3 areas that are all about 50 miles apart so typically the nurses that live in the town of the patient get those patients. So at what point are we allowed to refuse to see her bc we don't feel safe? I'm just hoping our company will come through for us and quit thinking about money over employee safety. :/

Ha! Good luck with that! (insert sarcastic chuckle here).

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Specializes in Home Health.

I really hope your agency will support you- that's a difficult situation. We don't serve patients who are active drug users due to the staff safety aspect. We will sometimes draw up a contract with "challenging" patients outlining terms they must follow if they want to stay on service with us (including maintaining a safe environment in which we can provide care)- is that something you could try?

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Specializes in Hospice.

I cannot believe what I am hearing. I must work at Utopia Home Health and Hospice. A patient was rude to me. The patient was warned and another nurse was reassigned. She was rude to a second and she was discharged from the agency. (This was a patient with no cognitive deficits or mental health issues, just rude and entitled.)

In our agency, the policy is employees come first. The company believes that when employees come first, they will take care of the patients and that will take care of the company.

It is the best job I have ever had.

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Yeah I feel that's how it should be. Especially when I've worked for this company for 5 years and have had no other problems with patients except this one and one who threatened my life. He was discharged immediately. I don't really understand why this one hasn't been when multiple nurses and CNAs have reported her. She was unable to get along with a certain HHA about 4 yrs ago, so the agency sent another HHA that had to drive 50 miles to see her. Talk about stupid! I mean how many positive drug tests do you have to have ?! It's unreal. Anyway, my director did come and chat with her and pretty much told her she better treat us with respect while she is finding another agency to serve her. (Gave her a 30 day notice) I just can't believe she's gotten away with all of this for 5 years!!!!

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I really hope your agency will support you- that's a difficult situation. We don't serve patients who are active drug users due to the staff safety aspect. We will sometimes draw up a contract with "challenging" patients outlining terms they must follow if they want to stay on service with us (including maintaining a safe environment in which we can provide care)- is that something you could try?

That's a great idea!! I am going to discuss that with my DON. Thanks

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Specializes in Case Manager/Administrator.

Unfortunately in todays environment we do have a lot of people who have personality disorders. We need to recognize this is an axsis II diagnosis and these are the hardest people to deal with but it can be done by changing the way you practice. Working in the prison system requires good verbal skills. When dealing with people like this think of a bartender or waitress, think how snarky they are and can turn an ugly situation into something funny to laugh at. They usually have a comeback that slides in and makes you smile. I love people like this. Here are some great tips I always taught medical staff when they joined up for a prison job, it applies in any type of environment...

1. Practice boundaries when you go into the home. If the patient asks you to do something extra you should always say no. This is scope creep and after a while you will end up doing dishes, grabbing something out of their closet it could be a number of things but the point is if you do for one you better do for all and that extra time could be one more patient on your schedule.

2. Be the director of your visit. Know/anticipate what you will need and bring it inside with you (in a bag), efficiency is key to completing your work on time so you can go home to your family. Let the patient know what you are going to do during the visit and do just that. You can be business like and still provide good quality caring care.

3. If there are concerns in the home be upfront with them and your supervisor. Meth pipe certainly warrants this. The smoke can linger on your clothing and you too can bring this stuff back to your job or home...think about this carefully.

4. When the patient is being a stinker be direct with them and say it appears this is not a good time for you, and for me to provide you with healthcare nursing services. You have my phone number and you can call for a reschedule and I will see if I am available. I tell them straight up ..because this current appointment is not a good time for you, this visit will be documented as services offered but you refused.

5. Before I get to the refusal of documentation I try briefly to assess the patients "mood" I will come with a clean silly joke or 2 that I know the patient would think is so corny it is funny, If I knew my patient was passionate about something I would try to connect with the latest "have you heard news", or hey last time I was here you said XXX and was wondering if you heard anything else from this? It is always superficial but it gets the patient taking about something they want or are interested in. I remember with one patient I had them talk about nothing but tattoos, another hair styles. It was something they were interested in. I even brought picture of real funny hair styles and while I was working on their wound they would tell me how long they thought the style took and how much hair product it would take (this was a SNF outpat rehab patient). It is just a matter of connecting in a superficial way but to the patient where they are at it is something.

Good Luck.

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