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When Outcomes aren’t Good Enough

nevada-nursing-licenseSo, I have looked at charts for close to ten different agencies in the past month or so for various and sundry reasons.  Two stood out for me in a way you should think about if you give me a minute.

Both charts involved psychiatric patients living in a congregate living situation with paid caregivers.  They lived in different states and the living situations were different but the similarities are there, nonetheless which is why the second chart caught my attention.

In both instances, there was a ten day gap between the last visit and the time the patient went to the hospital and yet the schedules called for weekly visits.  There were indications that it was not safe to push the visit back and possibly even a PRN visit should have been made.  Both agencies – completely unrelated – had a policy that supervisors should be notified of missed visits and neither nurse followed the policy.

One nurse will stand before the board in defense of a nursing license and the other one will be scolded by yours truly.

The difference is not that one nurse took better care of the patient or that the patient’s condition was any better in one patient than in the other.  The difference was dumb luck.

One patient died from a subdural hematoma.  The other was treated and went back to the facility.  The questions I have are:

  • Did the nurses in each instance visit patients according to when it is convenient for them?
  • If they were employed at a hospital, would they work whichever shift they chose?
  • If a patient really doesn’t need to be seen but once every ten days or so, why not schedule the patient for every ten days?
  • Could either nurse have picked up on something that may have prevented the hospitalizations?

Honestly, I don’t know.  In fact, I sort of doubt it but who knows?  And I am not the only one asking these questions.

In 15 years of of ICU work, I saw a lot of patients die.  It never, ever felt right when a full code patient died on my watch.  The sleepless nights, the endless record reviews, the self doubt all take a toll.  After a while it got better because the brutal questions I asked myself are worse than any a malpractice attorney could ask.  And honestly, not all of the answers were in my favor.  I have made pretty much every mistake there is to make but luckily, nobody died because of them.

The nurse whose patient died will have a lot of questions that will never be answered because an assessment wasn’t made for ten days prior to the hospitalization.  My deepest sympathies lie with that nurse.

What can you take away from this?  Both nurses are guilty of exactly the same thing.   Both put off a visit until later in the week, neither one called a supervisor and the polices of both agencies were ignored. Each situation had a radically different outcome which was likely beyond their control.  Whether or not they saw their patients or notified their supervisor when they did not see the patients was clearly within their control.

Don’t be the subject of a future post.  Follow your schedule.   It is not a suggestion or a recommendation. It is what is expected of you from your patients, your employer and your state board of nursing.

11 Comments Post a comment
  1. Laurie Soares #

    How scarey is this, but oh too familiar. I will present this to our management staff and get feedback as to how this can be prevented from happening. Communication and continuity is key to preventing this situation that could seriously destroy a nurse’s career, self confidence and well being. Your comment about being employed by a hosptial and working whatever shift they would like is a perfect comparison to what happened here. The hard reality is it really is the same thing. Clinical management oversight needs to be tight and a constant. A true realtiy slap….Who would think….

    January 22, 2013

  2. This brings up a really good point about a scheduling issue that we see often. I use the comparison to working in the hospital, also. Somehow, when nurses go from the hospital to home care, they think all the rules have changed.

    January 22, 2013
  3. Gail #

    I have argued this point before. The nurses insist that if they noted a “missed visit” in the chart due to, let’s say, Doctor’s Appointment, notified the physician, and scheduled the patient for next week, then it’s copacetic; visits are 1w9 on the schedule but there is more than 7 days between actual last visit and actual next visit, the missed visit “counts” as a visit. I say NAY. I think that’s skating on thin
    ice. Lord knows, I don’t have all the answers or even the questions, but, well……Below is the actual exchange:
    Me: “General Concern: Wound was newly healed 7-30-12, but patient was not seen again until 8-9-12 and had broken open 4 days prior to that visit. Pt not scheduled for a visit sooner than 10 days later? Do you know what happened here?”
    “If she didn’t call and let us know about the new wound we would not know it was there and C found it on the next scheduled visit. We had decreased her to 1x weekly. They say as long as it’s once a week, it doesn’t matter how far apart the visits are.”
    I always love it when I hear, “THEY say.” Who are “THEY”? Everything turned out OK, but, here again, blind luck?

    January 22, 2013
  4. rm #

    We pay our nurses by the hour and schedule for them. I recently had to sit before an administrator who was frustrated about the nurse seeing too many patients in a day (overtime). He wanted to know why I couldn’t have just pushed one of those visits to another day. I feel like sending him this post.

    January 23, 2013

    • I really do understand the financial concerns but a couple of hours of overtime compared to lawyer’s fees, damaged reputation and a nurse chewing up and spitting out her soul is nothing. If one or more of the visits could have been moved, fine. In order for that to happen, you need to first know enough about the patient in order to make that decision and that takes time as well. Even then, you should call the patient and ask if they are okay and if they mind having the visit pushed back. I don’t see a significant savings.

      If your nurses are making enough visits to be paid over time while on salary, you are doing good. In most agencies, the productivity of nurses drops in half when nurses are paid by the hour. He should count his lucky stars.

      January 23, 2013
      • rm #

        Productivity is always a challenge with our model,

        January 24, 2013
      • Gail #

        I believe that you have mentioned “Increase in productivity” when nurses are paid by the visit rather than by the hour in several blogs. Is this anecdotal or can you reference a source? What is to say that the (not so scrupulous) nurse rushes through 7-8 visits whereas the more conscientious one does 5-6 visits and gets paid less for doing a better job? Just wondering. I am sure that all OUR nurses would do the 5-6 visits completely and correctly, but… know what I’m getting at?

        February 22, 2013

        • Very good question, Gail and I regret that my answer is only anecdotal. I would love to see how others weigh in. In my experience (key words), salaried nurses have been universally less productive than their paid per visit counterparts.

          It seems to me that either scenario, a nurse getting paid for minimal productivity or a per visit nurse rushing through visits is equally dangerous and also, equally avoidable by tight case management. However, in the salaried nurses, even when meeting productivity standards, they are not able to make visits on patients who do not exist so when the census drops, expenses drop as well.

          There is also a management vantage point whereby a team leader or DON thinks consciously or unconsciously that they are going to pay the nurse anyway so why not increase visits for a patient especially when the census is low. This is very generous but regardless of the intention, it is never appropriate to make visits that are not covered.

          I really would like to hear from others. Is pay per visit the way to go or has somebody found a better way?

          February 26, 2013
        • Gail #

          I meant they would all do the 7-8 visits completely and correctly, not cut corners, or rush their care….. But it still seems so arbitrary; and I’m not saying anyone would do this, but if you saw 7-8 patients, what would prevent “dawdling” to increase an 8 hour day to a 10 hour day and get paid more? Who would do that? They’re out there. I’ve seen hospital nurses do it too. They stay over to “catch up” on charting because the patients were so demanding. Sure that can happen sometimes, but every shift she/he works, it’s 1-2 hours of overtime? Tight case management? I like the sound of that. Implementation suggestions???????? Thankee.

          March 14, 2013

  5. This is a great article with lots of useful advise……..thanks for sharing!

    February 2, 2013
  6. rm #

    I am in California, our wage law states that we must pay over time even if the nurse is paid by the visit. So if someone has 7-8 patients in a day and takes 10 hours. We not only have to pay for the visits but the OT as well. The majority of the HH agencies around here do not pay by the visit.

    Productivity must be looked at on a daily basis and if census drops then nurses are called off. We schedule for the nurses and if something falls thru we have a formula that states what a 4hr, 6hr and 8hr day looks like. Our outcomes are the best in our area and much better than the state or national average. We have good patient satisfaction scores.

    But productivity is still a struggle and at best frustrating.

    February 26, 2013

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