Over and done with, but still bothering me

[Burlshoe114]

Anyone with anything constructive to say, please feel free to add your thoughts on this scenario....

(Experienced HH advice really wanted!!!)

I am 6 months into HH nursing after working for years in an inpatient hospital environment. Things have been going pretty well up to this point, so I'm not sure what to think of this situation/scenario...

A month ago I inherited a patient who had been bounced around our agency for what I ultimately found out was years. He was a FTT dementia patient on Medicare/Medicaid who was basically non-verbal and also non-English-speaking, who had a catheter that was being irrigated twice a week by the agency with acid solution, and the catheter was blocking more and more over the past 6 months, requiring catheter changes about every two weeks. I got him because the previous RN was tired of going out to his AFH home twice a week, and she felt overloaded with cases. So he was handed over to me.

The report in the chart was that the patient had no family, had a state guardian who was slow to return calls (if they were returned), had a PCM who was reachable only by fax, and the patient had no urologist or any other MD on his case. The chart also showed that the AFH owner had been delegated with the task of irrigating the catheter, but the HH RN was still scheduled to go out to the AFH twice a week to do the irrigations.

No mention of why the HH RN was still going out to the home was ever documented in the chart, and on case conference, the previous nurses said they kept going out because the catheter kept blocking (which it was), but the AFH was delegated to do the irrigations.

When I asked the AFH owner why she wasn't doing the irrigations, she would typically say something along the lines of "I don't know," or something to the effect of "That's your job."

I saw this patient for about 5 weeks and watched his catheter keep blocking and blocking. I suggested the caregiver help coordinate getting the patient to a urology consult since he was getting more clogged, and got a string of reasons why it would be hard on the patient, and no further help than that. Her attidude was one of "I really don't care or want to be involved with this."

I went to my managers, and they suggested a MSW consult to see about possibly moving the patient to a Skilled Nursing Facility, so the catheter could be managed better on a daily basis. The PCM was faxed and he didn't seem to object to the idea.

I can't vouch for what went on between the MSW agent and the AFH owner, but she was very offended and took the consult as meaning she wasn't providing good care for the patient. This was not the intention. The intention was that the catheter was failing, and there was no medical intervention being provided to the pt outside of continuing to irrigate a catheter that was constantly blocking and the AFH was not helping to get the patient to a urologist and was sounding like she was opposing other interventions outside fo SN coming to irrigate twice a week.

I went back to management and asked my senior nurse to help me with the case since I couldn't get back to the office, and the patient was coming up fast on a recertification period and I wasn't comfortable continuing the patient's care as it had been, given the failing catheter irrigations.

Since my direct manager was out on FMLA, I asked her to also involve the Agency Director to get her help in deciding what to do. The director said to fax a care summary to the PCM and the guardian and ask how they wanted to proceed. Since I didn't have time to do the chart reasearch and still do all my visits and documentation, I asked the senior nurse to please help me with this. Which she did.

Well, I guess the history she typed up and the wording she used was viewed as "inflamatory" and "finger-pointing" by the Nurse Delgator and AFH owner. They were both very offended that their care had been questioned and they denied that they had ever opposed taking the patient to see a urologist, and they denied ever not wanting to be involved with the patient's care, and they said that the only reason why the AFH wasn't irrigating the catheter was because nurses from the agency kept coming out to do it, and the case history was "full of lies." This turned into a three-day, multiple conference call bonanza where ironically, very little energy and focus was on the fact that the patient had catheter needs that were not getting addressed and a lot of energy was spent discussing the bruised feelings and reputation of the AFH owner.

Of course during this whole verbal explosion, guess who got to endure being called a "liar," someone "who doesn't know her job," etc from the AFH owner (who is so stellar?)

At the end of the call, I offered to take myself off the case to appease the AFH owner and return the case back to the previous case manager. This was agreed upon (with a last parting insult towards me from the AFH owner), and I have no idea what has happend from here, since I went out to do my visits, and then called in sick the next day as I couldn't work, couldn't do much of anything besides be furious at the whole situation.

The problem - I can't stop being mad. I feel like I followed the direction from my managers and my seniors, and still wound up taking the hit for the case going sour.

Any words of wisdom?

[caliotter3]

I am like you. I can't let go of things and would probably be mad for about five or six years over this. I do not feel that you were quite backed up by your bosses as you could have been, even if all they did was to inform you to let it slide off your back, while they were paying lip service to the AFH owner. You know it really is up to the agency honchos to correct this long standing problem and it looks to me that they just dusted off the problem and put it back on the merry go round. Be glad you are off the case.

[Nurse Barb RN]

My only real input now that you are no longer responsible for this patient is to ask yourself what you would do differently if a similar situation arose in the future. Sometimes when we are in the moment, we do not get the clarity or the support needed to do our job (care and advocacy for the patient). Clarity comes from hindsight. What's done is done and at this point cannot be changed. Assuage your anger and your ill-placed guilt by being prepared for the next time...as prepared as we can be for a future that has not happened yet. Personally, I think you did well with what you were given...

[Burlshoe114]

A little follow-up on this...

So the HHA was fired by the pt's guardian. My manager was back today and said the case is being escalated to Risk Management. I'm not 100% sure what this means, but I'm just waiting and hoping for the best.

What would I have done differently? That is a hard question to ask, because even to this day so many things are unclear and communication between everyone involved was so poor and things had been allowed to continue on for so long that there is no "A-ha! THAT'S what I should have done!" moment appearing.

Communication was the biggest barrier in all of this.

How do you get people who have abdicated their role in something and geniunely feel they don't need to be involved to become involved in a timely manner? How do you get the attention of management that something is really wrong when they are pulled in 50 different directions and don't see your case as a priority needing something more than a 5 minute summary and a quick fix? How to you get doctors, guardians, nurse delegators involved when they are not perceived as reachable for support?

I think if I could have changed anything, I would have assummed less. I would have not assummed the RNs before me had done their job well. I would have not assummed that the AFH understood what was going on with the patient and his catheter. I would not have assummed management knew what was going on with this patient and had a clear idea of his case (even though I brought him up several times at Case Conference).

But, again, this is a little like saying "If I had only married Bob instead of Ted I would have been happy." You just don't know.