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SoCalRN1970

SoCalRN1970

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  1. SoCalRN1970

    Bait and Switch... It keeps happening. WHY????

    Well, welcome to hospice... it's alot of smoke and mirrors. I have been in hospice 8 + years. Only two of my employers ( and i have worked alot of perdiem or part time hospices.. too ) have never done the bait and switch. I will say the worst thing I did. I agreed to work lets say for the wage of 31/hr. It was a verbal offer I recieved from the manager of *** office. I worked my first 40 hours.. got my check and was paid 3 dollars less an hour. I asked about it. The manager claims he never offered that rate. MY ADVICE.. GET YOUR JOB DESCRIPTION OUT, AND MAKE YOUR OFFICE STICK TO IT. ALSO WITH ANY NEW JOB.. GET A WRITTEN OFFER LETTER EVERYTIME. Had I done that. I wouldn't of been making -600 a month less than what I was really offered.
  2. SoCalRN1970

    Sticky situation.....please help!

    FYI for what it's worth. I worked at a small hospice ( it wasn't a small business it was affiliated with a huge medical center ) but we had like 20 = 30 patients at any given time. Our consents showed we provided actually 4 levels of care, routine, GIP, respite and CONTINUOUS CARE. Truth is. We NEVER offered continuos care. We didn't have access to that kind of service, didn't contract with an agency and our own staff could not provide 24 hour coverage. To provide this is a COP at least for us at that time. My administrator who worked in hospice for years.. said 'yes, we provide cc." " We are available 24 hours a day and we can do visits if need be." I didn't complete a year at this agency as the hospital shut it down just as I was looking for placement elsewhere. HOWEVER. I did call the state and medicare to alert them of this practice. I did give my name... and hoped this kind of corruption would not happen again if that big major medical center opted to reopen it's hospice again.
  3. SoCalRN1970

    Sticky situation.....please help!

    Dear RNWAH, I need to say thank you for elaboration. So many regs and compliance issues are super simple to fix, but what you described is a HOT MESS! All it would take is a disgruntled pateint or family to call your local state regulatory hot line and boom an audit. I will day would never happen the question is more like.... when?? I am concerned about what your roll is and what you are doing. What will happen.. and I have seen this happen. Smaller agencies or short staff agencies using internal management who are nurses to do the foot and field work. Charts are hurting and regs and COPS are not being met. I don't want to sound like a negative nilly, but sorry, you are NOT providing good care to your patients. How can you? Missed visits? Missed reports to the MD, IDG issues. You company is NOT providing good care. It takes a good smart witted family member to call the state that is all. Clean up your resume.. put it online monster career builder or whatnot. IF you are able to take another field job elsewhere ( you are already working as one anyway ) and leave on the fly. What will happen otherwise. An audit or survey. Plan of corrections and dificiences a mile long and MANAGEMENT will be to blame. You will more than likely be terminated by this non accountable company. I have seen this happen in the past. Pass the buck, fire your staff who has been working under horrific conditions and blame them. I'd also contact CMS, the state and your other accreditation agencies in your state. AFTER you leave.
  4. SoCalRN1970

    Sticky situation.....please help!

  5. SoCalRN1970

    Sticky situation.....please help!

    MY BIG CONCERN.. was this patient you admitted "appropriate for hospice"?? I have worked at Vitas and a smaller but larger hospice doing admissions for a few years. #1 Both agencies I worked for had often sent em out on the fly with no info except name address ect. A referral from the doctor is all it would take. I would assess thoroughly and get a history from patient or family best I could. I had about a 90% admit rate. ( Vitas tracks all stats ) But, often I would not bring someone on. Either they didn't' meet criteria or they were not ready. Admits happen at times with only a name.. but it's the nurse who is doing the admission to assess weather or not it's a clinically appropriate admission. Sista that is your license. I was sent to do an "admission" with no consents signed and the dpoa was not available for a couple of days. My boss.. told me to "admit her" and send her home in an ambulance.. to her board and care. I told my boss, I can't legally touch her unless I know there is a consent. She said.. "oh he gave it to me..". YOU BET I INCLUDED THAT IN MY NOTES. VERBAL CONSENT OBTAINED BY XYZ MANAGER STATED ON THIS TIME THIS DATE... I left that agency a week later. I was asked to document false happenings in order to bill for decline on patients I knew were not appropriate months ago. I was told.. be quiet or quit my job.. I quit.. I suggest if you feel uneasy about your office.. leave now. You don't like doing what your asked? Don't do it and leave. The other compliance issues you speak of are vague. Are you out of compliance with certifications? Billing improperly? Not seeing patients on frequency stated? Not meeting COP's of medicare? THere are alot of isssues with could of touched furhter in detail.. Being non compliant on visits but up to snuff on certs and medicare billing practice.. or non compliance on COPS?? Please clarify.
  6. SoCalRN1970

    Hospice nurse with no nursing experience

    I also wondered why one would wait 5 years before taking the boards? There are alot of reasons I am sure.. But... if you don't use it you lose it. I know that I was extremely lucky.. and I mean lucky to have been hired as an IP, and get my license within 3 months of graduation. I worked for 6 years... acute beside, and did float pool for 2 of those years, I held certification in Tele, Chemo Cert, and Post Partum.. lots of surgical and med experience too. I also worked 3 years home health as a case manager. BEFORE I DID HOSPICE. Yes, I have strong assessment skills, I have not uncomfortable admitting that. I also am not uncomfortable saying, had I not had this experience.. I wouldn't be independent, think on my feet and have effective clinical management of my hospice patients. I came to hospice 8 years ago. I was a very strong clinical RN. BUT!! I needed to be supported and trained. I would say, with that background. A good 2 years before I felt comfortable enough walking into a situation where family is nutsy cooko and telling them here is how it is. Its second nature now. but it was hard as hell early on. I would suggest one thing.. WORK HOME HEALTH A YEAR. then consider hospice.
  7. SoCalRN1970

    Imposing compassion?

    In the end... we can not force our beliefs or opinions one way or another. We can not treat patients to our standards without approval from the patient or DPOA. The best and only response I have done to clear my conscience is to do what I posted earlier. Document everything. Also have that hard to do interaction where you don't judge ( although how hard is it not too, but keep your opinion to yourself) that " I understand and respect your concerns regarding xyz patient. However, I must be honest with you, that I have to document that I have spoken to you about options xyz that have been declined. Mind you, I understand and respect your opinion. But, for potential liability issues on my end, I must document resources offered and that they were declined to be part of the permanent record." This puts the accountability on the loved ones.. NOT THE NURSE and it very respectfully lets the family know this is their own doing and the nurse or hospice team is not responsible. In the end... this clears my mind, knowing I did what I can and also released the team and myself from claims.." you didn't take care of mom"... or whomever. Accountability is often skated passed, but this is no skating by the pain med with holding dpoa who whatever they are.
  8. SoCalRN1970

    Hospice nurse with no nursing experience

    There is a huge learning curve for the speciality of hospice. One as an RN must have sharp assessment and clinical skills. These can not be taught but rather learned on the job. Hopefully your employer will make good on the "gonna train you" part. So many hire and then lack the support internally for a new nurse. I wish you luck.
  9. SoCalRN1970

    Imposing compassion?

    The patient who was seeking treatment with herbals etc was alert. This was her wish. It was very clear. Patients who are not able to communicate and show non verbal signs of pain, and the family prohibits proper pain relief this is a different situation. This is actually more common than the last scenario. So much instruction has to be done when the only real barrier to effective treatment is family not "wanting to OD, or dope up" their dying loved one. I have gingerly pointed out signs of pain non verbal etc. and often have had to explore families or rather dpoa's concerns that may be a barrier. There have been times patients are actively dying, in pain showing classic pain and family is still afraid to medicate with morphine or any other medications. Often is just education and support that can assist with effective pain relief Only once, have I had family out right deny pain medication on a end stage dementia patient who was moaing, grimacing and showing pain as at least a 6 on a 1-10 scale. I conducted a one on one family meeting with the dpoa who was not allowing pain medications. I showed her the non verbal pain scale that I use to document levels, the increased pulse and outward agitation. I educated the dpoa that one of my goals is to educate and instruct on pain medication options and support for such symptoms. If outward declination is made, then I document what I offered, what was instructed and it becomes part of the permanent medical record that xyz dpoa declined intervention. The accountability approach with a tender kit glove was enough with some support " The decision is completely yours, but I must document that I offered xyz approach and this has been declined." It will be part of the permanent medical record as this shows my attempted intervention and the reason it was not done.... It was enough to sway the head strong dpoa. But I also have to accept the possibility that this may not of turned out this way. If that would be the case, all IDG members including the ordering physician would be notified and included within documentation. An APS report should be done in the event that neglect has been identified ( possibly... ) just to CYA. I have learned early on in my career, that I can not always impose my feelings or beleifs on those who have the legal say so. To do otherwise could be assault. BUT! I would do everything within my power to document, explore, intervene with all IDG and MD and document... document document.
  10. http://www.nytimes.com/2011/06/12/fashion/what-to-say-to-someone-whos-sick-this-life.html VERY GOOD ARTICLE. I have seen many families, friends and extended family friends, cousins, friends from childhood all kinds of dynamics and relationships when it applies to that of a terminal hospice patient. Being sick or facing end of life is a subject many are not comfortable with. Our culture is often one that does not freely speak of death or dying as a natural occurring part of life. It's often awkward for those who wish with all their might to make it "better" for the one who is sick. This article has inspired me to think about the advice I'd give to those of a love one who is looking at end of life. When you say "Is there anything I could do" really rarely would a patient direct you to do something. Instead of saying that action would be better. An action could be as simple as bringing a favorite magazine, food or music or personal care items if needed. These are little things that most would not ask for. Terminal patients often lack energy. One of the toughest things that face patients with large family / friends is the ability to be "awake" to visit. A 30 minute visit or even a 15 minute visit can be incredibly fatiguing to a terminal patient. Bringing little ones, mulitple people or a party like environment are extremely taxing on someone with any advancing terminal illness. Boosts of energy are often followed with long periods to regroup and essentially recover from social exertion. ************* This is a sensitive subject when it comes to the world of hospice. I have seen nothing short of a circus types of environment, kids playing, screaming, music on loud, tv on , conversations about the patient in front of the patient as if they don't hear and enormous amounts of people holding vigil... and a primary caregiver in the middle of it all with a migraine because she or he doesn't know what to do and doesn't want to hurt family friends, neighbors feelings, but wants a quiet comfortable environment. Being an advocate is essential with a situation like this. But being an independent 3rd party not directly related to patient has it's benefits. I have often taken the party group aside and paint the picture of what's happening, stimulation, noise levels, etc. Having the heart to heart has allowed two goals for me. #1 A quiet peaceful environment for the patient who is passing. #2 diversion of displaced anger onto me the HOSPICE RN vs. the primary caregiver who doesn't know how to ask family friends neighbors to leave... Often being the bad guy is not a great feeling, but in situations like this, I don't mind at all. Just my thoughts tonight.
  11. SoCalRN1970

    Imposing compassion?

    We as Hospice Case Managers can not fix it all. I understand the struggle with this as most nurses do in this speciality. I had a family that believed in holistic medication only. NO pain meds despite having severe pain on a 1- 10 scale being 10+ almost constantly. We were denied keeping a comfort kit in the home, and all the family would medicate the patient with was herbal remedies. This was my scenario. I was "at my wits end". It was care planned, and I met with the family and patient on several occasions. They all agreed to stick to the current regime that they allowed only. I built a sense of trust, offered the best adjunctive treatments I could that would be accepted. Heating pad, methol rub for pain, cooling measures for temps and oxygen. This is what the patient wanted, this is what the family wanted. In the end, the patient died not a very comfortable death, but this is what the patient and family desired. I had failed on my personal goal of keeping this patient comfortable? No. This was Mrs. S's death not mine. One of the most difficult aspects of our specialty is not imposing our own set of beliefs and ethics onto other. Sometimes we just have to document education and document what was offered and declined to CYA.
  12. SoCalRN1970

    Hospital career after hospice nursing

    I love it when I see a new grad wanting to jump into hospice. But this is really not the case. It's a case of desparation to get into a middle zone while a position might be offered downe the road at an acute hospital if I read it right. Hospice is truly a calling. It is really not a transitional speciality. New grads can be trained in hospice but the work itself is autonomous. Nurses especially RN's are meant to be independent on their feet thinkers and often new grads do not have this developed early on, and if they do, it's because they were perhaps an LVN or LPN previously... Its rare. Saying that, I'd truly think this poster should stick to what her heart is set on.
  13. SoCalRN1970

    Is it time to leave hospice??

    I feel the same.. hunt down he share holders. Our office had multiple complaints I mean multiple... ( 5 ) that I know of and many more not admitting to the corporate integrity line. NOTHING WAS DONE in the 6 months I was there. No kidding.. Odyssey does not care... no matter how much crap propaganda they shove down their employees throats.. it's a all garbage.
  14. SoCalRN1970

    Is it time to leave hospice??

    Hello all, I am in a crossways of sort. I have just spent the last 7 months working as a hospice case manager and I am beyond burnt. I feel horribly sad admitting this. I resigned from an agency that has been utter chaos since I stepped foot in the door. I had half day orientation in the field, was kicked out on my own, then openly reprimanded as I went along learning. I didn't have a name badge for over a month, no office voice mail for 3 weeks and a pager that didn't work and didn't still when I turned it in. I was suppose to have a local service area that was promised to me and it was ANYTHING but. I had one patient that was over an hour away from our office.. nuts. I had a QA non nurse manager changing patient assignments several times without consulting with anyone.. case manager, family etc. I had a manager who never worked a day in hospice and was utterly clueless to the inner workings and dynamics of those we serve. Worse of all, I got so very tired of saying, I am sorry for things I could not control. No return calls from office management, constant service failures with our pharmacy, patients being denied certain aspects of the hospice benefit despite it being a part of the package elsewhere. It was like OMG.... I can't put my name on this product or service anymore. I tried to support the office, but I will say.. it's a hot pile of you know. I knew that this office had a position open for another team manager. I have the experience.. plus I knew the office needed the support and knowledge... I was told " ah, you don't have the leadership skills for this position... !!" That was the final straw.. Saying that. I left short of my resignation... and so glad I did. I have another agency I am starting with.. but. something different has just crossed my path!!!! Kaiser contacted me regarding a very interesting case manager position... one that need a clinical backing... and would be dealing with patients but telephonically and on site in certain SNFS. Very different then the crapola place I just left. I am so beyond burned out from my last 7 months.. I am thinking of leaving hospice all together. Some agencies like the Big O are only interested in the $$$$ I can honestly say that this has been a horrendous experience and they won't even make it to my resume.. as far as I am concerned.. I have been in school the last 6 months not at Odyssey. THanks for letting me vent.. I fear I am burned beyond recognition.
  15. SoCalRN1970

    Lip care for patient on oxygen

    I'd suggest KY. It's been used before with great response..and it's alot less expensive then the items you mentioned.
  16. SoCalRN1970

    Abuse in the home

    Hello there.. I have been very fortunate to have had pretty good outcomes when it comes to issues with abuse. Not always physical, but rather emotional, financial or neglect. APS for the most part has it's hands full. Often they open a case and may follow up, but only in extreme cases are actions taken I have had a few cases of abuse that I had to deal with as a Hospice RN. #1.) This patient was under a conservatory as she had no family. Her court appointed conservator has arranged 24/7 pcg with a lovely lady who was caring for this little lady in her big gorgeous home. The patient had dementia, but was on service for another issues. I had witnessed nothing but wonderful care for this patient that was until I found a sort of an issues that triggered a Red Flag. One afternoon I showed up a bit early to my appt and found my patient on the patio with another dementia patient ( unknown ??) while the two caregivers were visiting in another room. I decided to make an un announced visit to the home next time around. The court conservator relied upon my reports to assure all was taken care of in the home. I showed up later one day to find extended family members in the patients home.. having a party. I also decided to walk through the home and assess the rooms I never looked in on. You got it.. multiple family members lived in this home.. rent free.. while the hired pcg got paid for caring for the patient. The conservator was notified and the pcg and family were immediately asked to leave the home.. APS would of been of no use here. #2) I had an eldery man with CHF end stage new on hospice who had a wonderful full time pcg in his home caring for him. This young man came from an agency as well. The patients family lived out of the area and was indeed involved but by telephone only. I was caring for this man and the agencies "owner" took it upon herself to "talk to me" about what she felt was needed for the patient including a hoyar lift and a wheel chair "to go out to the garden". Mind you this man was actively dying. To turn him took his breath away. I had to set the boundaries with the agency who in the end backed off.. But that wasn't the end. I got a call from a "neighbor" of this patient who wanted to "talk to me " about his care. I returned the call to find out that she wanted confidential information on the status of this man, which I would NOT give. She then informed me that she noticed "pink" eyes and decided to call me about this. I thank her and moved on to the visit. I found my patient with no signs or symptoms of conjunctivitis, but found a weird bottle of "restasis" on his bedside table. This was not part of my patients med profile and I found out that the neighbor told the patients care giver.. DO NOT GIVE MORPHINE.. and here, use these eye drops of mine for his pink eye. I notified the next of kin. I explained the situation and advised that she contact this over stepping agency and neighbor that they are NOT in charge of the patient.. APS? could of been involved as the agency was instructing their pcg to go against our careplan. The neighbor was interfering with the plan of care. But getting the family involved even if from afar was the answer. Sorry to ramble on, but patients are really vulnerable. There are many ways to stop abuse short of APS.If family is available even if by phone.. get them involved. If not APS is your only solution at this point
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