Jump to content

You know it's going to be a bad visit when....

Posted

Specializes in Home Health.

....you open the door, and the odor of urine gags you.

Today, I got a resumption for a pt who is well known to me, from when I was her case manager 3 years ago. She was a problem then, and we still keep accepting her back on service. :rolleyes:

Anyway, one of the last times I admitted her, she was to get a PCA from Medicaid. She was unhappy with her present PCA company (different than us) and wanted a recommendation for a new one. I gave her one that was very reliable. She asked me to call for her, so I did, and she was to get a PCA the next day. They never showed, and she reported me to my sup, which fortunately I had documented the process very well, and my sup knows me better than to be a BSer when it comes to that.

Anyway, this young lady is IDDM, s/p old amputation W/C bound, but still cannot manage transfers from bed to W/C etc.. I was to do a second visit on her after the PCA complaint, but she didn't answer the phone, or door, and it was locked. I left a note and a message for her sister. I hadn't realized at that time...yet...how many times she fell. So then her sister called the agency to report me for not calling 911 or the guard station because she had been stuck in her BSC overnight. (She was so concerned I guess when she got my message she waited til the next day to check on her)

So, I get this pt today, and she doesn't answer the phone. Call the hospital, she is d/c. I called every emer contact, no answer, or machines, or they don't know if she is in her apartment. (Or care I suspect.) So, I go, and I speak to the guard at the station, and asked him if he would unlock the door if I couldn't get in, he said no problem. This woman already lied about me, so I hate the thought of entering her appt, then being accused of taking something. I go up, knock on her door, a neighbor say she's in the hospital. I explained they told me she was D/C (I know what you're thinking HIPPA, but it is the culture of the building to help each other.) He says try the door, if its unlocked, she's home. It's open.

The smell of urine is overpowering! I call out to her, and she says very quietly, Im in the bedroom on the floor.....she didn't mention in a puddle of urine so huge the entire floor was wet! Her housedress was dripping. She had no obvious injuries, so all I needed to do was get her up, but she is BIG, and I knew I couldn't do it myself. I called down to the guard, and asked if he is allowed to help me. He says he's not supposed to, but if it comes to calling 911, he will, turns out he's an off duty city cop, and he says I know how those guys hate getting called out for floor lifts. So the pt tells me to go next door to her neighbor I was speaking to in the hall. I do, and he very generously came over and we had a hell of a time getting her up. She couldn't get her butt onto the W/C the wet dress kept slipping off the plastic seat and she would keep sliding back, gently, to the floor. We get her super duper W/C, and it has brakes that are better, and we get her into the chair. I swear, It was such a strain to lift her, it's a good thing I had a panty liner on, because my own pants would have gotten soaked. Once in the W/C, which I had lined with a big towel, I gave her a wash cloth and basin, and she wasked herself up and I cleaned up the room as bet I could. Then we got her all dried up and re-dressed. All I can say is good thing I know her and it was a resumption, because I didn't have to do as intense of an assessment, I already know her social/CG situations etc... She had none of her meds in the home, and no way of getting them til Monday (her family will likely blame us for that too). She is pretty non-comliant anyway.

In the process of all the lifting, we had her in a close hold, and all of my clothes were moist with her urine. My shoes, and not just the bottoms, were wet. I mean, it was gross!!

It was my last visit, and I was going home to do paperwork anyway, so I walk into the house, my husband and dtr are in the kitchen, and I just start stripping naked. They looked at me like I was nuts, and were afraid to ask questions. I took my clothes to the washer, started it, and walked back up from the basement to the second floor shower buck naked, lol. that was a really loooooong hot shower! I didn't know what to do with my new leather shoes, but my dtr suggested clorox wipes. Thankfully, it didn't hurt the color, so I scrubbed them down with those, and no odor remains, thank goodness.

So, how was your day??

Monica RN,BSN

Specializes in ER, ICU, Nursing Education, LTC, and HHC. Has 20 years experience.

Hi Hoolahan... I have been following a lot of your posts for quite awhile now, as I am now back into the home health setting. I am the DON in our agency, and I have patients as well. I have 12 patients I see in addition to operations of the agency.

I can identify with this story.. I have been in home care on and off for over 15 years, and it is amazing some of the homes we will encounter..

have a good day!

What a wonderful day you had hoolahan!!!!! Good thing she was your last patient of the day. It made me laugh out loud when you recounted your stripping naked in front of your DH and dtr. My family has also learned not to ask question- they have learned over the years that my day can be very interesting in hh. Often they are too afraid to ask what my day has been like for fear that I will actually tell them!

It is very frustrating when you spend so much time and energy trying to help a patient and just end up getting blamed for everything. It's a good thing that this patient has a history with this patient. They know what she is like. I can understand you being hesitant about going into her apt with the possibility that she was not home. Who knows what she would have accused you of.

You mention that none of her meds were in the home. Isn't it interesting how some of the families will blame us for things we in no way have anything to do with yet can't be bothered to do one thing for their loved one. I'm very glad you didn't offer to get her meds for her at the drug store- who knows what she would have accused you of stealing.

We certainly wear many different hats in hh. You were nurse, weight lifter, HHA, and cleaning lady all in one day! I applaud you for treating this lady with kindness (as it seems like you do despite I'm sure the desire to tell her what you feel). Hopefully one day she will see the light that hh is one of the only groups of people that helps her.

Nurse Ratched, RN

Specializes in Geriatrics/Oncology/Psych/College Health.

Good lord, Hoolio.

I always hate to single out one specialty of nursing as more difficult than others, but HH nurses ALWAYS get a special tip o' the hat. You never have the faintest notion what you're getting into.

So, what do we gotta do to get this woman off service? It sure seems like she needs to have more supervision than she does. I'm presuming everyone but the people actually doing the caregiving think the situation is just hunky-dory, right?

I love animals, I really do, but when you go into a home that has them everywhere and you cannot even put your bag on the chair for them, it is a bad visit.

Just a couple of thoughts I had when reading your post. Im thinking that maybe a social worker needs called in to investigate the neglect or lack of care this patient has. Seems like this patient is not able to care for herself anymore. Probably a asst living home would be more appropriate. Another thought I had about asking people not involved with her care to help lift her off the floor. Without knowing if she really was injured ,I would have called 911, they would have probably done a work up for possible dehydration, if nothing else(oh and of course uti). I think if the neighbor or security guard were injured lifting her, your problems would have gotten much bigger.Yes, doing homecare take alot of special skill, and usually nothing goes by the book, but I also know you have to always think outside the box, and protect yourself while doing it.

hoolahan, ASN, RN

Specializes in Home Health.

Monica, I don't know how you do it, having a case load, visits, and being the DON. Lord, I wish our DON even considered the possibility of doing a day in the field just once a year!! You just dinged the top of my respect-o-meter :)

Trav, I did complement her for losing about 40 pounds since I had last seen her 2 or 3 years ago! I have gone to drop off Rx for pt's, knowing the pharm would deliver it later, but having done pill counts with this one in the past, she probably wouldn't take them anyway. She had insulin in the home, so at least she had a start.

Ratched, I am under the assumption we are never getting her off service! I suspect she is using drugs too, quite rampant in her building, and like another female I had, in a different low-income housing building, I am guessing one day we will go in and find her DOA.

Barefootlady, I have had a few homes like that too. The cat pee is especialy bad! One house the folks and the dog were so old and feeble, they all just seemed to sqaut and pee right where they were. At least I wondered if they did when I wasn't there, the dog I know did, saw him do it!

Sandy, believe me, MSW has seen her many times in the past. She also has a MSW caseworker for the title program who sees her q 60 days or more often as the case may be. We used good body mechanics when we lifted her, I got the feeling the neighbor had doen this many times in then past! Actually, I was worried I would hurt myself, which is why I knew there was NO WAY I could have lifted her myself and flat out told her that first thing. I am surprised myself that today, my back doesn't hurt, and I hope the neigghbor is ok too. WE do call 911 to help us lift when we have to, and they get so pissy about it, but what else can a person do? I would have if I had to. She was trying to pull herself up to a sitting position, and had no problems moving all extrems', she just couldn't get her enormous butt off the floor with one leg. She probably slid to the floor, just like she did with us the first 3 tries. This one is a master manipulator. I will do what I can for her, within my boudaries. She is capable of calling 911 herself later if she needed to. Then she can blame me for not doing it at the time!

The "sweet" elderly and blind IDDM tells you that they used to work in a funeral palor and "see" (OK, here it comes . . .) dead people. Not only are they visible, they are audible. I have seen too many things to discount this, but on the next question, I discovered they "sometimes" give commands for violent acts. Turns out the doc missed a history of mental health treatment for "anxiety"-- treatment was with Zyprexa. Don't forget that their food is "poisoned" at times and adult day care is out because "people talk about me". Guess it is a good thing I'm a psych nurse!!! No current risks and very involved family (thank goodness) so referrals are being lined up.

How about the open for a "venous stasis ulcer"; stasis dermatitis is soooo bad there is no visible wound until the third visit. On plantar surface of the heel and the pt swears the doc never looked at the bottoms of their feet!!! You want an odor story . . .

renerian, BSN, RN

Specializes in MS Home Health.

I have had similar incident but frequently with stool.. it is very gross.

renerian

hoolahan, ASN, RN

Specializes in Home Health.

Nancy, are you sure she wasn't a pt of mine first?? I had one just like her!!! Even told my director I said she could have cookies!

Update. Today I blew my stack, and I am truly not sure I can do this per diem anymore. The pt above? Well, she told the next nurse I never did any paperwork with her or asked her any of the questions on the oasis!! Remember I said she had lied about me before??

Well, the supervisor called me in and counseled me for not doing paperwork in the pt's home and not doind a proper assessment!!! I am so furious!! OK, I did nto whip out the oasis in the home, because A. I observed her inability to transfer, her incontinence and the reek of urine throughout the whole house, her ability to wash herself, etc..I did not think it was necessary to ASK her these questions. I have had her as my pt in the past, so I KNOW her CG situation, etc...

And, to top it all off, I said to the sup, you know this pt is manipulative and a liar! She says "well I'll grant you that." Is it not possible for seasoned nurses to od an oasis without asking the questions ver batim?? I was so paranoid today, I took twice as long to do my oasis, making sure the pt's saw me doing it in the home.

I mean, this is ridiculous. The word of the manipulator is taken over mine. I don't care how much I need the extra money for Christmas, I am cancelling all my per diem days for that I scheduled for the next 4 weeks, then I am probably going to resign. Time to apply for a manicurist job in a salon for extra money. At least I wont have to be stabbed in the back after being kind to someone. I swear, nursing really sucks anymore.

Doesn't the CMS stress use of objective observation on the OASIS? How many patients tell you "Oh, I can shower juuussstt fine honey" but when you ask them to show you how they get in and out of the tub, they can't lift their leg over the edge?! Was she able to tell your supervisor exactly what you didn't ASK her? You are per diem, why not just refuse to work with this patient? You are not obligated to service a patient that is unsafe unsupervised due to environment OR noncompliance. If the agency wants to keep beating their head against a wall, you don't have to offer your noggin! This is why I write books on some of mine; I include lots of juicy quotes to support my observations. Saved my rear many times and my old agency had been named in a lawsuit for "abandonment". I was a supervisor at the time and I documented EVERY message this person left, right down to the last one where we were told we were "fired-- I have another agency coming in now" (not a news flash as I worked my fanny off to link her). The attorney reportedly read my last few communication records and apologized for wasting our time.

Now ask me if I got a bonus for this :rotfl: :uhoh3:

hoolahan, ASN, RN

Specializes in Home Health.

Yeah nancy, you would think! But every time I complain about the agency taking back a pt they shouldn't, they turn around and blame me for opening a case if I thought it was unsafe. Intake accepts no responsibility for screening whatsoever! That is just so unbelieveable. I have worked intake in 2 other agencies and that is NOT how they operate. My agency literally is known for "taking anything." What they will never seem to understand is that if you accept a case, esp if you KNOW the person is a problem, then you are abandnoning them if the hospital was not given a opportunity to make other, safer, arrangements for her discharge.

I am sick of being the whipping girl. I'm done. At least for a while. I already work FT at my insurance company job, I'm tired, and I don't need this kind of stress over a PT job. It's just not worth it!!

CseMgr1, ASN, RN

Specializes in Case Management, Home Health, UM. Has 39 years experience.

Yeah nancy, you would think! But every time I complain about the agency taking back a pt they shouldn't, they turn around and blame me for opening a case if I thought it was unsafe. Intake accepts no responsibility for screening whatsoever! That is just so unbelieveable. I have worked intake in 2 other agencies and that is NOT how they operate. My agency literally is known for "taking anything." What they will never seem to understand is that if you accept a case, esp if you KNOW the person is a problem, then you are abandnoning them if the hospital was not given a opportunity to make other, safer, arrangements for her discharge.

I am sick of being the whipping girl. I'm done. At least for a while. I already work FT at my insurance company job, I'm tired, and I don't need this kind of stress over a PT job. It's just not worth it!!

I, like you, also work FT for an insurance company, and am seeing more and more instances of sloppy or non-existent discharge planning by hospitals and providers, which is contributing to the problem(s) you describe above. Sad, but true... :o

I just quit home care at the end of December 04 after about 5 years in the field, and I am so familiar with all that is posted here. However, I never did my oasis in the home - some of them I wanted to escape from as quickly as possible . I always make a copy of the current oasis before submitting it - and during the next certifying period, I document any changes in my note book, so that by the time i am ready to do the oasis again I can compare. Most of the oasis is basic anyway, and if you are following the client on a weekly basis, you know the changes.

It is a bad visit when the agency asks you to cover a case - SIMPLE WOUND CARE - you step into the house and this elderly client is hooked up to oxygen, nasogastric feed via a pump, is on a water mattress, has in a catheter, is barely conscious, has bedsores everywhere, and a crazy daughter as caregiver, who insists that her daddy does not need skilled care in a supervised setting- three hours later you emerge feeling so dirty you do not even want to step into your car or your house -Of course I called my coordinator ranting like a lunatic - her response was that the daughter was trained to do all of the above and the nurse was just to monitor that it was being done correctly - the daughter also did the dressing changes when the nurse was not there - we were going in 2-3 times weekly -SIMPLE WOUND CARE -

(This happened to a coworker) - it is 6 am and dark on a cold winter morning. You pull up in your SUV, and pull out your cell phone, and begin leafing through your address book to get your client's number. You hear a tap on your window and look up to see that your SUV is surrounded by men, one of whom is holding up a police badge and motioning for you to roll down your window. When you do so you are told to keep your hands away from your bag and to step out of your vehicle. You try explaining that you are a home care nurse - but to no avail - you are not allowed to go for your ID - Meanwhile your client who was looking out for you is upstairs yelling "that is my nurse. Are all of you crazy?" After the confusion you are allowed to go to your client - apparently they were on a drug bust and thought that you were the contact person. :rotfl:

NRSKarenRN, BSN, RN

Specializes in Vents, Telemetry, Home Care, Home infusion. Has 44 years experience.

Claver had a similar experience.

It was my first experience with a Cancer patient that had several tumors size of grapefruits and a small watermelon on his back (forget type of CA). Patient was in denial about the amount of pain experienceing cause thought wouldn't be strong enough pain drug to treat him. Finally got PICC placed and IV morphine.

Wife of owner of house and best friend of Hospice patient needed to wear a key around her neck to the safe where Morphine cassette stored. IV team and I were concerned as always two other seedy guys sitting in the LR/Kitchen when we arrived. Just always visited btwn 9AM-3PM "safe time".

Pulled up at 9AM one day just as police removed the 2 other guys from home due to dope dealing....morphine cassette never touched! Next visit, Hospice patient and his female friend had moved into her old home as she realized couldn't save new husband!

-------------------

on a lighter note:

When the family accusses you of giving the patient "the black death pill" , no amount of persuasion that the IRON TABLET is perfecly safe, is to treat patients anemia and her strength will improve after a few weeks.

Better to get the iron pill w/stool softener ordered as comes in red or green shade!

....you open the door, and the odor of urine gags you.

Today, I got a resumption for a pt who is well known to me, from when I was her case manager 3 years ago. She was a problem then, and we still keep accepting her back on service. :rolleyes:

Anyway, one of the last times I admitted her, she was to get a PCA from Medicaid. She was unhappy with her present PCA company (different than us) and wanted a recommendation for a new one. I gave her one that was very reliable. She asked me to call for her, so I did, and she was to get a PCA the next day. They never showed, and she reported me to my sup, which fortunately I had documented the process very well, and my sup knows me better than to be a BSer when it comes to that.

Anyway, this young lady is IDDM, s/p old amputation W/C bound, but still cannot manage transfers from bed to W/C etc.. I was to do a second visit on her after the PCA complaint, but she didn't answer the phone, or door, and it was locked. I left a note and a message for her sister. I hadn't realized at that time...yet...how many times she fell. So then her sister called the agency to report me for not calling 911 or the guard station because she had been stuck in her BSC overnight. (She was so concerned I guess when she got my message she waited til the next day to check on her)

So, I get this pt today, and she doesn't answer the phone. Call the hospital, she is d/c. I called every emer contact, no answer, or machines, or they don't know if she is in her apartment. (Or care I suspect.) So, I go, and I speak to the guard at the station, and asked him if he would unlock the door if I couldn't get in, he said no problem. This woman already lied about me, so I hate the thought of entering her appt, then being accused of taking something. I go up, knock on her door, a neighbor say she's in the hospital. I explained they told me she was D/C (I know what you're thinking HIPPA, but it is the culture of the building to help each other.) He says try the door, if its unlocked, she's home. It's open.

The smell of urine is overpowering! I call out to her, and she says very quietly, Im in the bedroom on the floor.....she didn't mention in a puddle of urine so huge the entire floor was wet! Her housedress was dripping. She had no obvious injuries, so all I needed to do was get her up, but she is BIG, and I knew I couldn't do it myself. I called down to the guard, and asked if he is allowed to help me. He says he's not supposed to, but if it comes to calling 911, he will, turns out he's an off duty city cop, and he says I know how those guys hate getting called out for floor lifts. So the pt tells me to go next door to her neighbor I was speaking to in the hall. I do, and he very generously came over and we had a hell of a time getting her up. She couldn't get her butt onto the W/C the wet dress kept slipping off the plastic seat and she would keep sliding back, gently, to the floor. We get her super duper W/C, and it has brakes that are better, and we get her into the chair. I swear, It was such a strain to lift her, it's a good thing I had a panty liner on, because my own pants would have gotten soaked. Once in the W/C, which I had lined with a big towel, I gave her a wash cloth and basin, and she wasked herself up and I cleaned up the room as bet I could. Then we got her all dried up and re-dressed. All I can say is good thing I know her and it was a resumption, because I didn't have to do as intense of an assessment, I already know her social/CG situations etc... She had none of her meds in the home, and no way of getting them til Monday (her family will likely blame us for that too). She is pretty non-comliant anyway.

In the process of all the lifting, we had her in a close hold, and all of my clothes were moist with her urine. My shoes, and not just the bottoms, were wet. I mean, it was gross!!

It was my last visit, and I was going home to do paperwork anyway, so I walk into the house, my husband and dtr are in the kitchen, and I just start stripping naked. They looked at me like I was nuts, and were afraid to ask questions. I took my clothes to the washer, started it, and walked back up from the basement to the second floor shower buck naked, lol. that was a really loooooong hot shower! I didn't know what to do with my new leather shoes, but my dtr suggested clorox wipes. Thankfully, it didn't hurt the color, so I scrubbed them down with those, and no odor remains, thank goodness.

So, how was your day??

GOD BLESS YOU! you are a better nurse than i.......... this is a prime example why i will never ever do adult nursing.............ever...... all kidding aside, i commend you, and i envy you. I am an RN, and i cant find a job i like because i will not do this kind of stuff.....

Guest
This topic is now closed to further replies.