‘Patron saint of Patience’ is at end of her rope. Please advise.

[Mapleandhoney2468]

I’m a new grad HHRN working at an agency without great support, but fortunately have a mentor who doesn’t work for them who has been awesome, but even she is not sure what to do here. I have a patient who has scared away all his healthcare staff except for me. In other workplaces I was nicknamed the ‘patron saint of patience’ so perhaps this is why I’ve lasted longer than the rest or maybe I’m the stupid one for not dropping the patient 2 weeks after SOC which is what other HHRNs at my agency would have done. The patient got kicked out of his previous insurance for noncompliance, then home health doctor service for this insurance discharged him for verbal abuse, then PCP discharged him officially a few days ago for noncompliance. Patient is overly demanding (very specific about how he wants things or what kind of products are sent or how things are done and calls 1-2 x’s a day to all healthcare staff). Patient keeps asking me to do things out of my scope of practice or that do not adhere to the standards of practice, which I feel puts me in a very difficult spot and is not fair to me and of course I refuse. Both the case manager at patient’s insurance and I are at the ends of our ropes. The patient has now 2 noncompliance letters with this insurance. For at least the next 3 weeks, this patient will have no doctor at all until he sees his new PCP (that is if he actually agrees to leave his house to see new PCP). Do I still see this patient? I have no one to report patient’s reportable symptoms to. I’ve been very stressed by this situation and I want to remove myself from this toxic situation, but I don’t feel I can without ‘abandoning’ said patient as no one in their right mind will take over for me as his RN. I would leave current agency due to lack fo support except I don’t have enough experience to start at another more legitimate and better organized agency yet. Current boss says I can see patient and mentor is unsure but thinks no I can’t see patient. Insurance case manager says you don’t need the doctor to continue visits. I am getting a lot of different answers. Please advise. 

[artsmom, BSN, LPN]

Tough situation. Under who's orders are you currently practicing? If his prior MD is signing order's you should be covered there but it sounds like you (because of the way the patient is behaving) are not able to provide the care that is needed. If there are current issues with his health and he has no active PCP he needs to go to the ER. I personally would refuse to see him- how can you care for/treat someone that manipulates all of his caregivers. If your manager feels he can be seen/followed by your agency, she/he can go see him then. 

I just got out of a situation like this and it was a nightmare but I had a great manager that worked with me closely to get me out of it. 

You say you don't have enough experience to go somewhere else but I bet you do. My current job holds us to high standards but we hire new grads/new to home care all the time. They are trained properly and supported appropriately in these nightmares. 

Best of luck.

[amoLucia]

Bottom line - who is paying for care??? If insurance is requiring a new PCP for continuity of care and thus continuing pay't, then that should be the the answer. Is he paying out-of-pocket for his supplies? Is there a date for discontinuance of services?

Without valid orders, you're in a pickle. I guess you could still make skilled visits, but NOT for wound care.

I'm just echoing PP artsmom wise comment.

[Olivelove20]

Can your agency not discharge him for non-compliance? Someone has to be writing the orders for the 485 - that is who you can report to but if that physician isn't willing to accept responsibility, then I'd firmly and politely tell your boss someone else will need to see him as you aren't willing to risk your license.

I feel certain another agency would hire you in a minute - even w/limited experience. Put your applications in elsewhere stat.

[amoLucia]

Is there something in the rules about a 'safe discharge'? Otherwise, it'd be like a discharge AMA in the hosp.  I doubt that the pt would sign for anything. 

Personally, I'd just refuse to continue seeing him. Your DON can see him! You very likely could obtain another HH position. Who covers for you on your days off, weekends, holidays?

[Mintezia]

I had a previous case where I was told by the agency that the client "went through four pages of nurses". Unfortunately you do have clients who take complete advantage of their nurses. And it is on them, not you. Usually if a case has openings to me it's a red flag. During these times it might be difficult to staff a case fully. As others have suggested, find another case.

At some point it is a possibility he will be dropped from the agency due to lack of staffing. 

[Mapleandhoney2468]

Thank you all for your advice!! I feel much less alone with this. This was the worst part of my time with this patient so far. Things are better now but the drama never ends with this patient whether caused by the patient or other healthcare staff. Case manager and I had a serious talk with the patient and he has since turned his attitude around and is working with a therapist on the anger issues. I had issues with old doctor throwing a temper tantrum of sorts (the patient really brings the worst out of people). Unfortunately the new doctor was MIA with 1.6 stars on Google reviews so it has been impossible getting orders for scans, labs, and meds. I had patient switch to another new doctor with 4.6 stars on Google reviews so we’ll see how that goes. Honestly this one patient alone required the work I put in for three, but I feel good overall about how this one turned out. I really hated how on edge I was throughout the process though, but what really changed things for us was the patient finally choosing to let go of that toxic negativity when he realized he would eventually have no one to do anything medical for him if he didn’t quickly change his ways. Soon I will be moving far, far away from this patient and the patron saint of patience will live happily ever after…. Until the next nightmare patient ?