Patient Advocate Documentation Help Please

[A New Start]

I need help. I started LVN school in August. In the first week my mother in law went into tachycardia a fib and of course went into CHF. Then she had a small CVA followed by a couple of weeks of TIAs. I won't recount the whole thing. Here's the problem.

She's always been hard of hearing. In fact, almost deaf. She refuses to wear her hearing aids ("Makes my ears sore!"). She had mental status problems early on after the CVA. But our family noticed that the staff at the various facilities were confusing dementia with her hearing problems.

Example on nurse report: Entered room and told Pt, "I have your coumadin." Pt said, "Thank you! I like Kool Aid." Pt frequently answers inappropriately.

We have repeatedly asked staff at every facility to ask questions of her to reveal her understanding. She's very good at reading lips, but if she doesn't know you well, that doesn't help much. My wife and I have run this drill dozens of times. We've warned mom about how she comes across when she doesn't answer appropriately. She nods her head and goes right back to playing the "I'm not deaf charade."

We're in a great facility now. No complaints at all about the staff. They are transparent and non defensive as they can be. We are at day 22 at this facility. 78 days and counting on Medicare SNF benefits. Rehab has done a super job. She has gained 4 pounds. Performing all ADLs. Blood thinning still difficult to keep in tolerances. (She has a low platelet disorder as well) But she's much better and looking for the door. We're now trying to get a team assessment plan.

My wife and I went to the facility yesterday and asked for ALL records. Dr's notes, Nursing notes, Dx s, Rx s, PT and OT assessments..............everything. And they brought them out with no resistance. Yeah team! But here's the problem. She's on Aricept. She was put on it at the LTAC without our knowledge. She was having severe nausea. I found out about it and asked it be dc'd until we talked to the Dr. Nurse says, "OK". Transfer to current SNF. New doctor. I told D.O.N. about Aricept and hearing problem. She said, "Ok. I'll look into that." Yesterday, we find out she's still on Aricept! Dr is never available. Comes in at erratic times. Won't return phone calls.

I'm beginning to get PO'd, and I'm not using a medical term here! I found nothing in her notes yesterday about family interaction at any facility though we've had to interject ourselves numerous times. (you don't want to read it all) I'm going to have to do clinical s with some of these folks I've had conflict with. And I hate that.

But the fact remains. She is not showing signs of dementia to us! (her family) And nobody listens or takes note of that. Of course her brothers and sisters call her on the amplified phone, and we know to get in her line of site and ask questions to confirm understanding.

How do you get the whole team's attention? Am I going to have to call a Medicare or State Omsbudsman? The Joint Commission? The state Department for the Aged and Disabled? The DHHS? The FBI? What!?

Someone please give me a kind professional courteous way to at least get this into the record once and for all. I know I'm not a nurse. The staff at the other facilities rolled their eyes and ran from me a lot. I hate that. I'm not trying to be a big shot, or difficult. Just let me know what the plan is. Simply keep us informed. The dementia Dx changes all future planning of course. It may be true and we just have to accept it. That's fine. We just want ALL the incoming data (subjective and objective) considered and noted. Are comments from the family irrelevant to care planning? How do I proceed with determination and professional courtesy?

Thanks! I'm glad you're here.

[DolceVita, ADN, BSN, RN]

Some of you might not approve of this but....

When my mum was in hospital post-op and clearly not oriented to at least time and place they assumed she was always like that. When I saw her post surgery I said "what is wrong" with my mother. They said they thought she was always like that. When I said no they said "it must be the morphine making her dopey". I said that I had seen her on morphine before and she NEVER was like this (mum was raving about buried treasure and all sorts).

So couldn't get the nurses attention...tried the doctors in at the nurses station. I think they thought I was hysterical.

So I picked up the phone and called my mother's surgeon's office. When the front-end voicemail said "if you are a physician trying to reach DR XXXX please press 2". So I pressed 2. Lo and behold I was on the phone to her surgeon's PA. Essentially I told him that he had better get a doctor in to my mothers hospital room in a very few minutes.

It worked. In came a "hospitalist" (poor sod) who examined her asked me a few questions then he ordered STAT bloods, ECG & CT. Turned out my mum had acute hyponatremia -- NOT a good place to be. It took ages to get her back to normal.

By the way I may have to do clinicals at this site too but it was a high turnover hospital floor. If they remember and are still annoyed I couldn't care less.

So my point in all of this is get creative if you need to. My first suggestion is to write a letter to her doctor and copy you mother's facility (use full names). State what you think is wrong and what steps you would like taken. I would add in the dates/times that you have spoken to or left messages with HCP & staff at the facility. This does not have to be a confrontation letter -- just lay it out with the facts, your observations and what response you have recived thus far.

Essentially what you want is for someone to pay attention. Are you her POA? State that in the letter as well. Then include that you wish to review her care plan etc., if you do.

As for the clinicals...you shouldn't be doing clinicals at a facility you already work in nor should you do clinicals at a facility where you have a family member resident. However, as she is your in-law get your other half to put her name to the letter.

Make sure the cc (copies to) are clearly marked on the letter so everyone knows they have been mentioned. Just make sure you are clear what you want from the doctor and what you want from the facility.

Good luck.

[A New Start]

I appreciate the help. Thank you. But after thinking about it this afternoon, I think I'm going to change goals. Nothing I think matters if my mother in law doesn't put those hearing aids in and demonstrate mental competence to the staff. That's what is going to get reported to Medicare and the Drivers License Bureau.

So I'm going to find a way to get those hearing aides in her for a few days. I'm going to put the pressure where it belongs. It's up to mom to decide what gives her the best chance for independence. Does she want it? And here's how to get it.

I don't have to be rude or cruel, but I can put it in a way her nurses can't. Then after she demonstrates competence, I'll ask for a reassessment. That's supposed to be done periodically anyway.

No need to be combative, or overbearing with the staff. As I've said, they have been great. Let the responsibility lay where it belongs. Patience and communication skills usually trump power and domination.

I guess I just had to think that through. Thanks again, A New Start