"Oh what a tangled web we weave when first we practice to decieve."
Don't know who said it, or if I quoted it correctly, but my grandfather taught me that, and I have never forgotten it, although, like this nurse, I have lied in those kinds of situations.
Let me give an example of a major web I got trapped in. New job as CHHA (cert Home Health Aide) supervisor. First pt I have to see is returning from the hosp, so I have to do a re-assessment. The DDD program supervisor tells me she is having a hard time placing CHHA's in this home b/c it is so filthy, the carpet is sticky, yes, the carpet! The pt won't let them wash her, and she is covered in stool in the am, won't change her diapers, so urine has leaked all over the place, and the carpet. Makes it seem like there has been an ongoing problem, etc.
First I review the chart. There is very little mention of these conditions in the chart. DDD sup tells me aides don't want to tell the pt they don't like going there, don't want to hurt herfeelings, but in this apartment complex, the same CHHA's see multiple pt's. Forget confidentiality! It blew me away when one pt told the DDD sup where and when she could find an aide at any given time! Anyway, pt finds out CHHA's are seing another pt, contacts DDD sup, she gives some excuse apparently, tho she made me feel like she was straight with the pt. So here I come. I plan to review every single right AND responsibility with the pt. Right to live her life as she chooses, YET a responsibility to provide a clean and safe envir for us/herself. And inform her of consequences, etc... She must let CHHA'swash her, that is why they are there for personal care, and she needs to change diaper more often to prevent skin breakdown.
Go to meet her. My heart breaks! She is a disabled nurse, has had CVA x3 L arm so contracted and crippled it is not usable, weak shuffling gate, she can't balance with a walker and won't use her quad cane b/c she can't carry things. So, she is using a very shaky rubbermaid stackable drawer cart as her assistive device. What can I say, I don't know of any DME that fits what she needs. I did review R & R, emphasizing CHHA's would like pt to be fresh and clean before cooking for food sanitation reasons. I don't havethe heart to tell this woman I am d/c ing her. There has never been any corrective action documented and this clearly did not develop overnight!
I call the doc's office. They are home visiting docs. The intake RN asks what's going on, if she had been the one to open that case, she would not have accepted it, and she says if it continues, they will not be able to care for her anymore. GREAT! DO they tell her? No. Next day I went back to pt house to have her sign care plan, CHHA and DDD sup were present, we reviewed a plan, she will have a light bkft prepd by CHHA day before or have a bkft bar and juice box type thing at bedside for am, then when CHHA comes, first order of biz is a bath. I can tell she doesn't like this, but DDD sup says, please try it, we need to keep a CHHA with you, likeI told you. I figure, she really can't not have help. This day there is feces on the BR floor, the CHHA is getting ready to clean it up. God bless her. This is an everyday thing.They don't want to walk on her floor since it is regularly covered in urine, food, and stool, and Lord knows what else.
CHHA's tell me she got a letter from the landlord, demanding $650 to tear up carpet and place tile.This woman doesn't even have money in the bank account for her groceries when the CHHA's go to the supermarket. They have been buying her food. I told her, the CHHA's cannot buy her food, period.
After talking with MD's nurse again, explaining how I feel we have to give her a chance as the previous nurse never dealt with these issues. She saw my point, so she got off my case, but suggested I contact adult protective services (APS), as they have been known to give homes an overhaul, and the pt doesn't have to pay. So I do.
I called DME co's to check on equiptment, no luck. Then I checked on status of diaper shipments, since CHHA says she needs to have someone call to place her diaper re-orders, and she only changes her diaper 2 x day . DME girl says she can do auto order. Turns out this lady only likes to use the pull-up diapers (she told me in my asessment). Her order was for a case of regular diapers, and one case of pull-ups 72 per case. OK, you do the math, 72 div by 30 days a month, maybe that explains the 2 diaper changes a day. Medicaid will allow her to get 2 cases of pull-ups, so I called MD back and asked them to fax DME that order. All of these little things are so simple to fix. But no one ever bothered to get passed the smell in that apartment.
I went back to tell the pt what I did about the diapers, and asked if that was OK, she was happy, but she was angry that someone sent the social worker. She asked who did that? I said I did. I told her my main reason for doing so was to save her from having to pay the $650 for the tile floor replacement. But she says the social worker said someone told her she did not change her diapers and refused to be bathed, Hey that was what I was told. I thought the MSW would be a little more discreet, so now I am the *****! Fine, if it helps the lady in the long run, I can live with that. I kind of BS'd my way out of admitting to that. She has to learn that my only reason for my actions is that I have her best interest at heart. Not the whole truth, I admit, but still the truth. After all I feel I need a little time to establish some kind of rapport, while still making the CHHA's happy, so she can keep getting help. I am told all other agencies had d/c'd her. If we d/c her, she won't be able to get anyone. Then I got the MSW from APS's phone number from pt, called her and she reams ME a new one, saying she noticed no odor in the house! For crying out loud, my eyes were almost tearing! Then she says no one told pt of any of the problems they were having with her. I did begin the process of telling the pt our concerns. I mean her landlord informed her of c/o from other tenants, so is she a little forgetful, or manipulative? Or did THEY lie?? Who knows, that will come out in the wash. I don't know, but she is a pitiful sight to look at, that is for sure. Plus the MSW has no idea all the work I put into this case, it has consumed my first entire week, leaving no time to prepare an inservice for a week from now, since prior nurse did not make sure all the aides are up to date, now that is my problem too! MSW gives me a lecture on maybe our values aren't the same as hers, DUH, I felt like saying I have that info myself, on my HH website, thank you, but it IS her problem, b/c if we cannot keep CHHA's in there, she will end up in a nursing home, if she has no help at home, and no way to see MD. Boy she got me pi$$ed! And it WILL be APS's problem if no CHHA's will go there, they will have to try to get her declared incompetent to remove her from the "environment of her choosing" when she is evicted, which the psychiatrist says she is not.
I admit itwould have been too mean to be completely honest with this pt, in my first week of knowing her! These other people haven't been honest with her for the last year!!!
I would be interested in hearing what you guys suggest. I have to have a joint visit with APS at the home on Monday. I volunteered for this, I didn't haveto be there, so all the cards will be laid on the table, and I will be the person this lady will never trust again. This sucks! All I want is for everyone to be taken care of and happy.