One of my residents fell out of the hoyer 3+ weeks ago. Didn't hit her head, but smacked her back on the leg of the lift. Nurse calls MD to send her to the ER, because she's SCREAMING in pain. No bones sticking out, so MD says, no, don't send her out. Family says "Well, if the doctor says no, then no." Doctor popped in the next day and the nurse had to basically DRAG him down the hall to look at her. She's got Vicodin on board, and she's still crying. He still says, nah, she doesn't need X-rays. He says it's muscular. So three-plus weeks later, she's STILL screaming every time she's turned, or even if you move her leg. Shouldn't it have healed a little bit by now? She doesn't remember the fall, so she thinks the staff is hurting her, and she's gotten pretty combative. It breaks my heart.
So, since I'm a CNA, and I don't know beans other than my resident is hurting, and she's not getting better, can somebody please explain this to me? We're wicked pissed at the doctor. He just waves his hand and says "she's fine."
I was wondering as well if an incident report was made and followed up on. If a fracture or injury DID occur and the place of care did not properly investigate it could come back to bite them in a lawsuit big time.
Also, isn't there a way to circumvent the admitting MD? Maybe call in the House DR when the MD isn't available and see if he could write and order for an X-Ray based on his assessment of her?
What if the son has POA? Do we legally have the right to over ride his decision? Just a question. There are many things I don't fully understand re: POA of medical and financial. Not that I agree with the decision, I myself would probably send the pt to ER and pay the consequences, at least I could sleep at night, knowing that I did what was best for my pt. Just curious about the whole POA thing, as I said before the whole POA thing is confusing for me.
Specializes in ICU, PICC Nurse, Nursing Supervisor.
Get a hold of the medical director, he can override this. Also the family can demand the patient be sent out as well, so someone needs to take them down to the room and show them exactly what is going on. Im not sure about this but if the nurse thinks the patient is in need of emergency care, cant the patient be sent anyway. Dont flame me , I just thought I heard this somewhere. Isnt is considered abuse to allow the patient to be in this kind of pain. You can also get the Social worker involved because if the family is not willing to send the patient, maybe there is some other issues behind the closed doors we dont know about. I have had several people become custody of a guaridian (court appointed) . I hope for the best for this patient, the nurse is in a situation she should never be in!!!
Specializes in Education, Acute, Med/Surg, Tele, etc.
This is a sad situation, and not too uncommon at all! Many LTC's or in my case assisted living, have certain family or MD's that refuse to take patients to the ED despite.
I have learned to use my best clinical judgement because frankly...I am the MD's back up, and who will get the trouble thrown their way for NOT sending her in for x-ray evaluation if indicated! Sometimes...well I will be honest, I use some tricks of the trade, like calling and really talking to the MD in person and really sticking home the fact that the pain is severe and items like if they are able to bear weight on it, pedal pulses...really prove the reasons I feel it is essential. I have also called on the weekend to on calls who ALWAYS seem to send patients that are not theirs in...I find this helpful when you hit a brick wall! Also...I can have the MD order a portable X-Ray sent to my facility...only thing is I have to not forget to let the MD know I have this service. I also have urgent care clinics (with x-ray) and those seem to be more acceptable to family and MD's...somehow much more user friendly and cost friendly...so I normally can get someone to approve sending them there!
Also, I have the clinical judgement skills to send her in anyway, part of the checks and balances system that I am upheld by law to do!
The best thing a CNA can do is be kind to the patient, have the nurse come in an assess pain as you are doing things that cause it so they can do a proper assessment of pain, document very well and alert the nurse to please read your documenations (there have been so many times I have come back from a 2-3 day off spell (I am part time) and I had no idea these things are going on and all the sudden I am assumed to know...really communicate with your nurses please...never assume they know the latest, always ask and double check if you are unsure if they are up to date). And of course care for the patient in a proper way to lessen pain, and be encouraging and compassionate.
This way a nurse can make a good clinical judgement on the situation, and you will have to leave it in their court for a while as they use their skills to determine the right course of action in a given situation...sometimes CNA's are not thrilled with a nurses choice...but many times, they don't know or understand the dynamics of the entire picture of the patient, MD, family and situation and we nurses have to consider it all (I am rather open with my CNA's and if they ask "well...why didn't you..." I explain it and they understand and usually are more proactive in helping me either overcome the hurdles that stop me from doing the action they want, or they help me and the patient to make it through a rough spot the best we can...
Specializes in LTC,Hospice/palliative care,acute care.
what if the son has poa? do we legally have the right to over ride his decision? just a question. there are many things i don't fully understand re: poa of medical and financial. not that i agree with the decision, i myself would probably send the pt to er and pay the consequences, at least i could sleep at night, knowing that i did what was best for my pt. just curious about the whole poa thing, as i said before the whole poa thing is confusing for me.
according to the ombudsman and state dept of health in pa-yes,in certain circumstances the poa's decisions can be over-ridden...in the case in this thread at least portable x-rays in the ltc with appropriate meds to address the c/o's of pain control should have been obtained...if the family says "no transport" that does not mean "do not treat".. if the resident is suffering something must be done..i have seen a few situations recently in which families refused invasive testing and treatment-twice the dept of health has given us deficiencies because we did not follow through and do something -really our documentation was lacking and that's why things looked so bad to the state.i don't believe that any of our residents were suffering like this one in this thread appears to be....................................................................................................so here are the results from the inspection i was speaking of-i changed some identifying info--------------------------------------------------------...~resident xxx had a current physician order for a speech therapy screening due to the resident being observed gagging when eating. review of the speech therapy screening form dated aaaa 7, 0000, revealed that the resident was to be re-screened on aaaa 9, 0000 to determine if a video swallow was indicated (a test to see if the food swallowed goes into the stomach or not). interview with staff 6 on aaaa 16, 0000, at 11:45 a.m. revealed that the re-screening was not done and that the resident was still gagging at times when eating. .......resident xxx will be re-screened for swallowing by the speech therapist to determine if video swallow is indicated. order has been written.
resident need will be considered, not family demand. so-how do you like them apples? in this case the resident was very very old and had stopped eating and also had a good advance directive.(he also had ca but had refused treatment a long time before this).we are an ltc and do not have an in-house hospice protocol so whenever staff attempted to force feed him he gagged and made faces and turned his head away and usually flat out said " no-i don't want that".....and for some reason in our ltc we have alot of staff that thinks they have to try to force feed residents...in the meantime his poa -a freaking hospice nurse said " no speech tx-no video swallow" after the intial screening on the 7th and the order was dc'd......and then he died and it was moot....i don't know what would have happened if he had lingered longer-would the state have gone to court to get guardianship and force the speech tx and video on this 100 yr old fella? so now we" must consider resident needs over family demand" makes advance directives useless scratch paper,doesn't it? poor families can't be their loved one's advocate to see that their wishes are carried out here in pa.......this is an example of how out of touch these surveyors can really be.
according to the ombudsman and state dept of health in pa-yes,in certain circumstances the poa's decisions can be over-ridden...in the case in this thread at least portable x-rays in the ltc with appropriate meds to address the c/o's of pain control should have been obtained...if the family says "no transport" that does not mean "do not treat".. if the resident is suffering something must be done..i have seen a few situations recently in which families refused invasive testing and treatment-twice the dept of health has given us deficiencies because we did not follow through and do something -really our documentation was lacking and that's why things looked so bad to the state.i don't believe that any of our residents were suffering like this one in this thread appears to be....................................................................................................so here are the results from the inspection i was speaking of-i changed some identifying info--------------------------------------------------------...~resident xxx had a current physician order for a speech therapy screening due to the resident being observed gagging when eating. review of the speech therapy screening form dated aaaa 7, 0000, revealed that the resident was to be re-screened on aaaa 9, 0000 to determine if a video swallow was indicated (a test to see if the food swallowed goes into the stomach or not). interview with staff 6 on aaaa 16, 0000, at 11:45 a.m. revealed that the re-screening was not done and that the resident was still gagging at times when eating. .......resident xxx will be re-screened for swallowing by the speech therapist to determine if video swallow is indicated. order has been written.
resident need will be considered, not family demand. so-how do you like them apples? in this case the resident was very very old and had stopped eating and also had a good advance directive.(he also had ca but had refused treatment a long time before this).we are an ltc and do not have an in-house hospice protocol so whenever staff attempted to force feed him he gagged and made faces and turned his head away and usually flat out said " no-i don't want that".....and for some reason in our ltc we have alot of staff that thinks they have to try to force feed residents...in the meantime his poa -a freaking hospice nurse said " no speech tx-no video swallow" after the intial screening on the 7th and the order was dc'd......and then he died and it was moot....i don't know what would have happened if he had lingered longer-would the state have gone to court to get guardianship and force the speech tx and video on this 100 yr old fella? so now we" must consider resident needs over family demand" makes advance directives useless scratch paper,doesn't it? poor families can't be their loved one's advocate to see that their wishes are carried out here in pa.......this is an example of how out of touch these surveyors can really be.
this is what i am talking about. why even bother to have advanced directives?? thanks for the reply... it's all very confusing and changes from instance to instance.. :uhoh21:
Specializes in LTC, home health, critical care, pulmonary nursing.
Okay. Yesterday, I talked to the ADON, to see if there was a way she could override the doctor. SHE DIDN'T EVEN KNOW THE FALL OCCURED. She was furious. And rightly so. The DON knew, but never told her. She called the doctor and got an order for x-rays. And off we trotted to radiology. And I think some of you may have gotten the impression that this pt is not being treated for pain; she is. The nurses are very good about assessing her for pain, and treating her accordingly. But it still hurts.
The ADON and the nurses I've asked, all insist that if the MD and POA say no, there's not a darn thing we can do.
TriageRN, God bless the nurses who take the time to explain to CNAs why things are done or not done.
I would have written this incident down, named the doctor and his refusal to allow patient treatment, recorded everything just in case this comes back to haunt those working with this patient.
Whether the DON or administrator "over-ride" the MD or they just talk turkey and tell the MD they feel an xray is warrented since the patient is complaining of pain so long after this injury. it needs done now.
This ADON needs to find another place to work. She will be a fall guy for this DON if she is not careful.
i agree with the poster who said to contact the medical director. also there have been times as a ltc nurse that i have just sent a pt to the er w/out a dr's order if i felt that they needed to go. in a situation like that the nurse should have sent the pt to the er and worried about the "consequences" later. IMO if you have used your professional judgment and critical thinking you are in the best position to make the decision that the pt needs to go to the er. in ltc, the dr is not there, it's the nurses that really know what's going on with the pt. as nurses sometimes we need to go out on a limb and do what we know to be best for the pt. if the nurse in the op's situation had just sent the pt to the hosp (because it sounds like the pt has a fracture) who really would blame him/her? i wouldn't, and neither would any reasonable nurse or dr.
Specializes in LTC,Hospice/palliative care,acute care.
Okay. Yesterday, I talked to the ADON, to see if there was a way she could override the doctor. SHE DIDN'T EVEN KNOW THE FALL OCCURED. She was furious. And rightly so. The DON knew, but never told her. She called the doctor and got an order for x-rays. And off we trotted to radiology. And I think some of you may have gotten the impression that this pt is not being treated for pain; she is. The nurses are very good about assessing her for pain, and treating her accordingly. But it still hurts.
The ADON and the nurses I've asked, all insist that if the MD and POA say no, there's not a darn thing we can do.
TriageRN, God bless the nurses who take the time to explain to CNAs why things are done or not done.
Let us know that the x-rays reveal if you can....The ADON and nurses you have spoken to that claim nothing can be done are wrong-tell them what the dept of health told our ltc- "Resident needs must be considered BEFORE family demand" It's hard when you are the nurse and you have to advocate for your patient against the doc and poa -but we have to do it... I am confident that if they were called in anonymously they would have made the same determination regarding your resident that they did with ours-the doc would have had to relent ... Go to the nursing home compare websites-you can search inspection results and print them out yourself....
stn2003, RN
132 Posts
I was wondering as well if an incident report was made and followed up on. If a fracture or injury DID occur and the place of care did not properly investigate it could come back to bite them in a lawsuit big time.
Also, isn't there a way to circumvent the admitting MD? Maybe call in the House DR when the MD isn't available and see if he could write and order for an X-Ray based on his assessment of her?