Changes…Part III

“What it would require is for me to work the extra 20 hours as well as my regularly scheduled 25.5 hours. It would require my regular clients to adjust the times that I normally arrived, but it definitely was able to be done.Lost in the Storm

By mid week, there was a problem…………………….” 

AND

“When I arrived today, the facility staff stated that the client was to be seen by her doctor tomorrow and the sore was spreading…Holy Crap on a Crutch….this day was only getting longer….and my diabetic client was still waiting. But, the bigger problem was  waiting for me in the basement….

Basements…I really do not like basements. Unless there is a tornado bearing down on me, I find  basements are usually the breeding ground for molds and spiders. Because of molds and spider, basements are not my favorite locations to find medication cabinets; but that is where this facility decided to store the client’s medications.

The cabinet was of press board with a laminate finish. It had 4 shelves;  a shelf for each of the facilities clients. There was a hasp and a Master lock on the outside for security and on each shelf was a small plastic basket that held the blister cards. Each shelf had cash box with a small pad lock. The cash boxes held narcotics.  Not a much of a sophisticated set up, but functional all the same.

Next to the cabinet was a small desk that had a low shelf under the desk top.  On top of the desk were plastic medicine cups where the facility staff would punch out the client’s meds and transport them to where the client was sitting in the upstairs TV room. A small fold out chair was in front of the desk where one could set to chart.

The lighting in the basement was a small watt light bulb; not the best. When I sat at the desk, my body would block out most of the lighting, so it was less that adequate. Just another dingy old basement that harbors mold and spiders. I didn’t feel comfortable down there. 

From the first visit, I had a gut feeling of dread about this client and this facility. As I noted in my last posting, the actual need for a nurse to come into this facility didn’t exist. I was coming into this facility to fulfill a guideline for Medicaid. As I lamented in my last posting, my entering into this facility was an inconvenience for everyone…

From the beginning, the hour that I arrived was at meal time. Not the best time, but it was when I could come.

It was the same on this day, the client was eating her supper so  I went to the basement to fill her medication box.

I didn’t learn until later  that I should have never gone down to the basement alone. The correct procedure was for the staff to go to the basement and bring the client’s basket with her meds upstairs to me and when I was finished, they returned it to the basement.

That never happened. Instead, when I arrived, the staff either handed me the keys or indicated where they were located and I proceeded to go to the basement.

On this Wednesday, I washed my hands extra long because of the potential staff infection in the home and the staff pointed to the keys that were lying on the kitchen counter. 

I went downstairs, unlocked the cabinet and took out my client’s basket from the cabinet and placed it on the lower shelf at the desk. I pulled up the chair and placed my bag at my side next to the chair.

The first blister card that I took from the basket was a new medication. As required, I wrote the name of the medication, the directions and the doctor’s name on my nurses notes. I mentally noted that this was a new doctor and it was an unfamiliar doctor to me. This wasn’t all that out of the ordinary.

Most of my clients have many doctors. They see specialists for their complicated diagnosis and having several medications ordered from differnt several doctors is not that unusual.

But, this doctor’s name caught my attention. We have several doctors from India, Korea, Pakistan etc. in this area, but it was out of the ordinary to find one who is Thai.

I recognized this name as Thai because, years ago, I worked at a Job Corp. It was the early 80’s and not long after the Vietnam War. At this Job Corp, there were many  Vietnamese, Thai and Hmong.  I became familiar with the names and could tell the nationality of the student by paying attention to the spelling of their names. Because of this past experience,  I noted that this was a  was a Thai doctor which was slightly unusual to find one practicing in the Midwest. It was just one of my musings while I prepared to dispense my client’s medications.

As I proceeded to fill my client’s med box, I continued my musings about the Thai doctor and wondered why this particular medication was ordered. It didn’t fit with any of my client’s diagnosis.

The new medication was a muscle relaxant. This muscle relaxant wasn’t the kind of med that is given for an injury, but rather, it was prescribed for someone who has spasms resulting from compressed nerves in the spinal cord or compressed fracture of the vertebrae.

I had researched this medication because I had another client on this medication, but my present client didn’t have any condition that would indicate her need for this medication. It was puzzling me.

The directions were for 3 pills 4 times a day which equalled  12 pills a day. That was a lot for an initial dose. The card that I picked up was for a 2 pm dosage. The other times, breakfast, lunch and supper, were on separate cards. This was a lot of pills.

I was tired and my focus was on getting this client’s med box done and getting on to my diabetic client. As I mindlessly punched out the pills of this new medication,  I just couldn’t get passed wondering why this doctor ordered this medication and when did my client see this doctor anyway.

As I continued punching out pills from this blister card, I couldn’t get away from my questioning this medication…something was not right…

 

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Changes… Part II

 

“What it would require is for me to work the extra 20 hours as well as my regularly scheduled 25.5 hours. It would require my regular clients to adjust the times that I normally arrived, but it definitely was able to be done.Lost in the Storm

By mid week, there was a problem….”

Wednesday was one of two long days for this week. It was around 5:30 PM and it had been in the 80’s. Dan disconnected the old Roadmaster’s climate control when the air conditioner needed recharging. He did this because we didn’t have the money to recharge it so, to prevent the compressor on the air conditioner unit from running continuously, he  took it off.

This saved the compressor, but it also allowed the heat from the engine to enter the passenger compartment.  On hot days, the internal temperature inside is the heat of the engine plus whatever the temp is on the bank sign…hot!!!  By this time on a hot day, I am fatiqued and getting weary…weary and worn from the heat as well as the hours.

On this day, I was pushing myself. As I entered this client’s door, I was going on my 10th hour and I had one more client to see. I would not be getting home until after 8 PM. I needed to finish this day and go home.

As I walked through this client’s door, I had many things on my mind.

I was concerned about the switching of my usual schedule. The fact that my first client was an insulin dependent diabetic and I normally saw her in the morning, was a real concern. Today, I would be seeing her 8 hours late which made her insulin as well as her other medications 8 hours past due.   I needed to get my present visit done quickly and drive the 30 minutes from this location to her as soon as possible.

I was also processing my present client’s latest changes in her condition.

She was a relatively new client to me. I had visited her a couple of times before today. Normally, it takes about a month to get to know each client and their individual needs. It takes a month to know the client’s condition and its idiosyncrasies, which pharmacy they use for their refill medications,  but most importantly, it takes time for a trust to form between the client and their nurse. Without trust, the nurse cannot do his/her best for the client. With trust comes truth.

This particular client’s situation was a puzzle to me. She lived in a facility for the elderly mentally handicapped. Until her payment provider switched from primarily Medicare to Medicaid, her medications and all of her needs were provided by the facility in which she lived. She has lived there for years.

 Now, the waiver required her to be seen weekly by a licensed nurse and for the nurse to place her medications in a weekly med box planner. The facility staff would have to assist her all the same.

It was the guideline, but, in this situation,  it seemed so unnecessary. The medications for the clients in this  facility is a  common practice. It is similarly provided  in my sister’s group home.  All of the medications are in blister pack cards and the facility staff punches out the medicines at the prescribed times through out the day.

Because of the change in payment and to fulfill the guideline,  It required a nurse to come fill the med box. I had to punch out all of the pills for the week. Generally, most  nurses  detest blister packs. Whether they are over the counter meds or prescribed, blister packs are a royal pain. When you  punch out the pills, force can  crush the meds and some meds are not to be crushed.  Because of the way pills are compounded, many loose their effectiveness or the amount that is absorbed should they be come crushed. With blister packs and pills, crushing  cannot be helped.

 The idea behind the blister pack is one of liability. Because the guidelines prohibit untrained staff from “pouring” or administering medication, blister packs prevent tampering or handling. It is designed to go from the pharmacy directly to the client without anyone else handling the medication. This relieves the facility staff from touching the medication and they are to only assist the client with opening the medication. They are restricted from placing medication in the client’s mouth.

The proper procedure is for the facility staff  to take the blister pack card to the client, assist the client in punching out the medication  and the client is to take the medication. If you have a client with several medications, it takes a lot of time. Time that is  multiplied by the number of clients in the home. 

To save time and walking,  most facility staff punches out the client’s meds and place them in a medicine cup and deliver them to the client. Even though this compromises the purpose of the blister cards,  that is what is done. It also makes having a licensed person coming into the facility a complication for both the nurse and the facility.

 All of this processing and applying my common sense to that all of this and my conclusion that it is all redundancy just doesn’t matter. My opinion doesn’t  apply to Medicaid guidelines nor affairs of liability.  Being in this facility was a matter  of doing my job and my job  was to see to this client’s care.

I had other concerns about this client.

On Monday of this week,  I came to this facility to make a medication change that was ordered by her doctor. The medication change was directed by the results of the blood work that I drew the week before. This was going to be an every other week occurrence.

It was my intent to do my nursing visit at that time, but the pharmacy had not delivered her refilled medications as yet, so I would have to make a second visit this week thus my visit on this day.

Because I am paid per visit and I am only approved for one visit a week, I knew that I would not be paid for coming back to fill her med box. My first responsibility is to the client, and if returning later in the week is what is required, money or not, I will make the second visit for that week. For me, it is not about the money. It is about the client.

While I was there on Monday, one of the facility staff members mentioned that my client had a “sore” on her abdomen. They continued to tell me that one of the facility staff had been off work because there was MRSA in the home.

My ears perked up. Medicine  resistant bacterial infections scare me. I have had my own personal experience  involving streptococcus which resulted in a cellulitis. Because of my long list of allergies to antibiotics,  I was hospitalized for  4 days. Because of this past experience, this development with my client personal concern and caution. In light of my own risk, I suggested that the facility staff make a doctor’s appointment for the client.

My mind was whirling.  No one reported this infectious condition being in the home.  I don’t like walking blindly into this kind of situation. Even though I practice safety precautions and wash my hands innumerable times a day, I know that this kind of infectious disease is a danger to me and to my other clients.

I couldn’t understand why the Case Manager didn’t tell me about  this after she took the admission information from the intake visit of this client. Maybe, she was not aware of the infectious condition inside this facility.

So,  I called her and reported the condition. She stated that nothing was said at the time of the intake interview and she agreed that the client should be seen by her physician and for me to not expose myself to this possible infection.

When I arrived today, the facility staff stated that the client was to be seen by her doctor tomorrow and the sore was spreading…Holy Crap on a Crutch….this day was only getting longer….and my diabetic client was still waiting.

But, the bigger problem was  waiting for me in the basement….