Patient responsibilities; would you admit this pt?

[wonderbee, BSN, RN]

I work for a private HH service (like who doesn't?). Prospective pt. lives alone, alert and oriented x3, was called to expect visit. A second call was made on the road about a half-hour before arrival to have medications, d/c instructions, etc ready upon arrival. Upon arrival pt. in wc appears disheveled and tells me to make him coffee. I tell him I'm not there to make him coffee and it will be dark soon and not safe to drive as it is rural. As we sit down to do admission, he begins railing on about how I was supposed to have been there hours ago and I'm supposed to spend 4 hours a day with him. I realize he has caregiver services from the Department of Aging and try to explain to him that we are separate services. He gets testy and is cursing until I redirect him and I bring to his attention that in order for us to work together, he's going to have to be respectful. I realize that the patient is an alcoholic and has been hitting the sauce. He admits it and to being in and out of rehab. His list of meds is long and alcohol abuse is going to be a compliance issue. I make a mental note. I ask to see his meds and he accused me of "losing them" and he won't take my bull****, asking me why I didn't tell him before I needed to see them. He doesn't remember my phone calls of earlier saying "you people just think you can come any old time without calling. I realize this man is probably having blackouts in addition to likely mental illness and possibly dementia. This is now the third nasty interaction within the space of half an hour and I can't get through the admission process. He's angry when I again redirect him and says I'm calling him a liar. I feel my blood pressure rising and my face getting hot. This is my cue to stop whatever it is I'm doing and get out. I tell him I cannot admit him under the present circumstances citing that I don't believe we can establish a therapeutic relationship. He says he will "be good". I excused myself and walked out that door.

I feel truly bad for the man. Much of this is his disease process. On the other hand, my fight/flight reaction kicked in which, admittedly is sensitive due to previous life experiences with drunks. He will present compliance issues and is already noncompliant. He has services from the state and adult day care is being arranged. I didn't see how HH could benefit him if he is drunk all the time and can't remember our instructions, much less even our phone calls. I will call the MD on Monday to advise of non-admit and why.

Would you have admitted this pt?

[jnette, ASN, EMT-I]

Certainly not. You did the right thing. I've refused to admilt a patient with similar actions, and ETOH wasn't even an issue with him. The agency has the right to refuse any patient.

You would have been in over your head there, and you'd never know what to expect when walking through that door each time. Not good when you're there by yourself.

You gave him several opportunities and you did your best. I'd have done the same as you.

[TazziRN, RN]

no way! you did the right thing. he probably honestly didn't remember you calling him but we do not have to put up with abuse. that situation was not only verbally abusive, there was the potential of it escalating into something that compromised your safety. if your agency has a "red flag" list of people that should not even be considered for admission in the future, put his name on it.

[Sabby_NC]

Gosh just reading your post unnerved me.

Do you have to do admissions on your own?

We have admit teams of 1 RN and 1 Social Worker. They always go out together.

You did what was right in this circumstance but it does not matter what ever the situation is if you DO NOT feel safe, then get out.

Another little side is always reverse in so if you have to get out in a hurry your car is facing the right way!

Please take care.

[TazziRN, RN]

Sabby, hospice is different than general home health. In our area the Hospice people go out in RN-MSW pairs too, but not for general home health. We be it.

[Sabby_NC]

Sabby, hospice is different than general home health. In our area the Hospice people go out in RN-MSW pairs too, but not for general home health. We be it.

Thanks Tazzi for informing me about that.

Then she defo did the right thing in getting the heck outta dodge eh?

Kinda scary not knowing what you could be walking into at times.

[nightmare, RN]

Reading your post and the way the man "forgot" things makes me think he has possible Korsikoft's (sp!)syndrome.Chiefly caused by alcoholism ,sufferers confabulate , in other words they remember bits but the bits they don't remember they make up to fill in the gaps.This man certainly needs in -patient care but home care would need at least two at all times for safety as he has the potential to be aggressive .

[wonderbee, BSN, RN]

Reading your post and the way the man "forgot" things makes me think he has possible Korsikoft's (sp!)syndrome.Chiefly caused by alcoholism ,sufferers confabulate , in other words they remember bits but the bits they don't remember they make up to fill in the gaps.This man certainly needs in -patient care but home care would need at least two at all times for safety as he has the potential to be aggressive .

Yes, I believe there is an organic component which is why I felt guilty about leaving him in a lurch. He should not have been discharged until arrangements for adult day care were firmly in place.

We do walk into some potentially hazardous situations. It can be a risky business. I think what got me going on this one that led to the post was the cool, not exactly supportive response I got from my DOCS on reporting the non-admit. If we're that desperate for business, maybe we should close our doors.

Thanks to all you peeps for being supportive.

PS. After posting this, I read up on Korsakoff's Syndrome. The description of the syndrome fits this patient very well, even down to the ataxia. This is one of those diagnoses I learned about in NS but filed in the back of my brain's round file. I guess eventually we run across everything.

[caliotter3]

As the others have said, you were correct in your actions. Don't feel bad about what happened. Your description of the cool reception you got back at the office also does not surprise me. It seems sometimes that the managers have forgotten what it is like to be in the field and just what is possible versus not possible. Too much is expected of the field staff in creating and maintaining "miracles". I would have suggested that you get some feedback on this type of situation from your supervisors for future reference, but something tells me you wouldn't get any useful input. Perhaps you could at least follow up with the other agencies involved, or with a group that is devoted to helping the aged population at home, or even the adult protective services people. This man needs more help than he is currently receiving and thoughts to evaluating him for admission to a facility or group environment should be discussed by those who can make such decisions. He definitely does not fit the criteria for being able to benefit from home health visits.

[tencat]

Absolutely NOT. The only thing you may have done 'wrong' is not getting out of there sooner than you did. I think it was handled appropriately. Don't ever ignore that 'little feeling' about the danger of a situation.

[TazziRN, RN]

We do walk into some potentially hazardous situations. It can be a risky business. I think what got me going on this one that led to the post was the cool, not exactly supportive response I got from my DOCS on reporting the non-admit. If we're that desperate for business, maybe we should close our doors.

Then your DOCS needs to go out and do the admit herself, if she wants that pt so bad. Even if he wasn't aggressive, with his symptoms he is NOT appropriate for home care, not if he's living by himself.

My DOCS is not perfect but at least she's more supportive than yours. If we come in and say we refused an admission because of personal safety, or pt safety, she backs us up.