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….


6 thoughts on “Changes… Part II

  1. You have such a lot to keep in mind as you go about your work!

    And it’s all critically important, too — you must need huge concentration, which is especially difficult at a time like this.

    I’m in awe.

  2. Yes, Roads, it does take a lot to keep focused on my clients and what is required especially when I am tired from the heat and long hours.

    At this time, the looming anniversary was also creeping up on me and I had no idea what its toll would take. I will explain more in the next posting.

  3. Jonas,
    Your comment brought a smile to my face. The basement proved to be the place where my life took a major change.

    I will try and get the next posting ready so you won’t be hanging from the cliff for too much longer.

  4. Holy crap on a crutch? Have u been hangin’ out w/ me too long kiddo? All kidding aside MRSA is nothing to mess with – have had several friends battle it and it’s stubborn and terribly dangerous. I know u worry about your patients but we also worry about u. Can’t have you getting ill! Hugs!

  5. Yes, Linda, I have been hanging with you and it has rubbed off. Seriously, “Holy Crap on a Crutch” is the phrase that came to my mind when this all went down…and I can’t think of another that is more appropriate. *smile*

    Yes, MRSA, is very serious. I later learned that this infection was being passed throughout this facility for over a year. To effectively deal with this infection, the home needed to be evacuated and disinfected in total to eliminate it from being passed from one client and staff to another. But, to do that, another facility would have to be secured because placing these clients in other like facilities would expose to this infection…so, the home isn’t cleaned and the infection spreads…and spreads quickly. Plus, it indicates that the facility staff is lacking in hand washing..

    MRSAt is one condition that strikes fear in my heart and I was so glad that the case manager referred the client to her doctor so that I would not have observe the sores and be exposed and for that, I was most grateful.

    The next posting will have a bigger “Holy Crap” moment.

    Thanks for reading.

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