Shady als calls given to bls. How do you deal?

[NorthCalEMT]

Oh, you think it's a confidential process? How many other crews were treating John Doe at ABC SNF on 12/1/12 at 1300? Heck, how many crews were at ABC SNF on 12/1/12 at 1300?

Very true! I did think about that. Even though my opinion of my supervisors request to inform him first before reporting are already known... and if my supervisor is imposing the company's will with the reporting either to secure calls or any other reason; because the hospital RN reported it and it was reported roughly around the same time my partner and I were at the SNF, I think it's safe to assume the SNF might "assume" it was us either way. Who knows...?

I was under the impression it is a confidential process and every attempt is made to keep it that way. So, how does the process work after a report is filed? Does a social worker arrive at the accused/suspected SNF and mention the PT's name from whom the report was filed for? or a time? or do they go off of the information they received 'audit' every aspect of the SNF?

 

[JPINFV]

I was under the impression it is a confidential process and every attempt is made to keep it that way. So, how does the process work after a report is filed? Does a social worker arrive at the accused/suspected SNF and mention the PT's name from whom the report was filed for? or a time? or do they go off of the information they received 'audit' every aspect of the SNF?

I honestly don't know. About a month after it was filed I got a call directly from my company's CEO regarding it and she accepted my reasoning and stated that my story matched my partner's story. A while later I received a letter (I was the primary person on the paperwork, but my partner and I didn't have to each individually report the matter) saying that they were going to do an inspection and that we could go and "observe" but couldn't say anything or ask any questions.

 

[hogwiley]

I can understand why a supervisor might want a new EMT to report the abuse to him. Quite simply most new EMTs dont know enough to know whether what they are seeing is actually abuse or neglect.

How many EMTs have ANY experience caring for patients in a long term setting? Very few, and they recieve zero training on it either, so they really dont know enough to know any better unless its something fairly obvious, which it rarely is.

I agree you should be a patient advocate, and its better to error on the side of reporting, but given the lack of training in this area by EMTs, its understandable the supervisor wants to know.

 

[Farmer2DO]

I can understand why a supervisor might want a new EMT to report the abuse to him. Quite simply most new EMTs dont know enough to know whether what they are seeing is actually abuse or neglect.

How many EMTs have ANY experience caring for patients in a long term setting? Very few, and they recieve zero training on it either, so they really dont know enough to know any better unless its something fairly obvious, which it rarely is.

I agree you should be a patient advocate, and its better to error on the side of reporting, but given the lack of training in this area by EMTs, its understandable the supervisor wants to know.

No, it isn't. As said above, it's the law. The supervisor doesn't get to impose company policy above state law. Period. Ever. They can have a policy where they notify the supervisor that they've reported the suspected abuse through the proper channels (which may or may not be legal to require), but my experience with this type of situation is that the company would prefer to squash these reports before they happen, so that their contracts aren't hurt.

Again, an EMS supervisor for an ambulance service doesn't supersede the law.

 

[exodus]

I believe what he means is that they need an immediate 911 unit to transfer the pt not a IFT unit that will have a longer ETA. But you must work where AMR provides the same level of care for 911 and IFT(I.e. BLS 911). HEre our transfer units are BLS and 911 are ALS. Also AMR btw. So they are different.

That's what I mean

 

[Tigger]

I can understand why a supervisor might want a new EMT to report the abuse to him. Quite simply most new EMTs dont know enough to know whether what they are seeing is actually abuse or neglect.

How many EMTs have ANY experience caring for patients in a long term setting? Very few, and they recieve zero training on it either, so they really dont know enough to know any better unless its something fairly obvious, which it rarely is.

I agree you should be a patient advocate, and its better to error on the side of reporting, but given the lack of training in this area by EMTs, its understandable the supervisor wants to know.

I don't know any supervisors with any experience in long term care either. What would a case of non-straightforward abuse or neglect look like anyway?

 

[hogwiley]

What would a case of non-straightforward abuse or neglect look like anyway?

Well the point was that to someone who hasnt worked around elderly patients in a long term care setting, a lot of things WOULD look like abuse that as it turns out are somewhat normal. The most obvious one being bruises and skin tears.

I just went on a call recently to a facility where the patient was dehydrated and seemed malnourished. The EMT I was with suggested this was evidence of neglect and said they probably just leave the patient lying there all day and night. The patient had lewy body dementia(among other things), was on an NDD1 diet with honey thickened liquids, and had a braden scale of 9(meaning if you dont properly reposition them every 1 to 2 hours, they get a decubitus ulcer). I asked him if hed ever tried to feed and hydrate a person with severe dementia and that type of diet on a daily basis(nevermind doing the same for 10 other people who probably arent much better off)? In some cases its virtually impossible to keep the person properly hydrated short of using IV fluids or a peg tube or NG.

I think its tough to uncover abuse in the elderly after the fact. When I worked as a CNA it was something you kind of had to see happen, or in the case of neglect something the oncoming shift could uncover, usually as part of a pattern. Skin breakdown was one warning sign. You can tell when someone had been lying in urine or BM for a long time or hadnt been repositioned or toileted regularly, but had just been quickly cleaned up at the end of a shift. You can check pressure points like heels and knees and ankles to see whether the patients been properly cared for.

But even skin breakdown isnt always a clearcut sign. Ive seen a decub start on someone because they insisted on sitting in a wheelchair for a couple hours without being repositioned. Another thing a CNA might look at are their toenails, as funny as that sounds. Seems silly but in many cases you have to use a dremel or grinding device(very carefully if they have diabetes) on a regular basis. Or you can sometimes tell if their dentures are taken out regularly or just left in 24 7 by looking at the inside of their mouth. There are a bunch of other warning signs an experienced CNA would spot right off the bat that MIGHT flag neglect, but I doubt even an experienced EMT or Paramedic would notice.

 

[hogwiley]

I should also add the reason CNAs are experts at spotting abuse and neglect, even better than RNs, is because if they dont spot it, it might very well be them who are accused of it. Being falsely accused of abuse was a continuous occupational hazard.

At the start of every shift we always checked out our people to make sure everything was ok with them, and reported anything that wasnt, if for no other reason than to cover our own A$$.

 

[Meursault]

I think its tough to uncover abuse in the elderly after the fact. When I worked as a CNA it was something you kind of had to see happen, or in the case of neglect something the oncoming shift could uncover, usually as part of a pattern. Skin breakdown was one warning sign. You can tell when someone had been lying in urine or BM for a long time or hadnt been repositioned or toileted regularly, but had just been quickly cleaned up at the end of a shift. You can check pressure points like heels and knees and ankles to see whether the patients been properly cared for.

But even skin breakdown isnt always a clearcut sign. Ive seen a decub start on someone because they insisted on sitting in a wheelchair for a couple hours without being repositioned. Another thing a CNA might look at are their toenails, as funny as that sounds. Seems silly but in many cases you have to use a dremel or grinding device(very carefully if they have diabetes) on a regular basis. Or you can sometimes tell if their dentures are taken out regularly or just left in 24 7 by looking at the inside of their mouth. There are a bunch of other warning signs an experienced CNA would spot right off the bat that MIGHT flag neglect, but I doubt even an experienced EMT or Paramedic would notice.

Very interesting. What else don't I know about signs of neglect? Any advice on differentiating criminal neglect from acceptable neglect (for SNF patients) and inevitable consequences of disease?

 

[Aidey]

No, it isn't. As said above, it's the law. The supervisor doesn't get to impose company policy above state law. Period. Ever. They can have a policy where they notify the supervisor that they've reported the suspected abuse through the proper channels (which may or may not be legal to require), but my experience with this type of situation is that the company would prefer to squash these reports before they happen, so that their contracts aren't hurt.

Again, an EMS supervisor for an ambulance service doesn't supersede the law.

What exactly does the law say though? What is the threshold for reporting? This is where a supervisor may have more knowledge than a brand new EMT. As Hogwiley pointed out, not every little thing is abuse/neglect. Is every skin tear, dirt brief, bruise or fall a reportable incident? What happens if you go to pick up a patient and it is dinner time, and the pt doesn't get to eat, is that neglect? You get the picture. There is a lot of gray area, and someone who doesn't understand what is going and makes a report on could cause a lot of problems without ever understanding that they were the ones who screwed up.

 

[CentralCalEMT]

Let's face it. As mean as it sounds, private BLS IFT companies in LA are NOT EMS organizations because of their management. Granted a lot of the EMTs try their best, but in the end EMS is about the patient. IFT companies are about the profit. Let's take a scenario that is common in LA. 80 year old female with ALOC and weakness. That is triaged as an ALS level response no matter what EMD protocol you use. The sending facility wants the patient not to go to the nearest ER, but to an urgent care across town where the patient's primary care doctor has an agreement with. They can call 911 or a private IFT company.

911 is notified. They respond within 5 minutes, treat the patient and transport them to the most appropriate receiving facility. The SNF is angry. The primary care MD is angry. The IFT company gets no money. HOWEVER, the patient wins in this scenario. This is real EMS.


IFT companies, on the other hand, will take that same ALS level call, dispatch a BLS ambulance code 2 (because there is no non 911 code 3 BLS response down there) across town in rush hour traffic that takes 45 minutes to get there and transport the patient to an urgent care all because Dr. Quack who has not actually seen the patient wants it. There is little to no QI from LA County EMS agency so it is done completely under the table. The SNF is happy because their patient went where they want. The IFT company is happy because they made $1,000. The ONLY person to lose out is the patient who now has a CVA that is past the window for agressive treatment and the urgent care ends up calling 911 anyway. That is NOT EMS.

The reason why companies do not let their employees call 911, drive code 3, divert, file complaints or do anything else is not because "the supervisor has more experience." Their supervisors do not know what they are doing in general. ALL it is about putting profit over people. If you do not trust your people to be EMTs, why are they working there. It is because they do not want to piss off their cash cow SNFs. With about 75 companies in LA, if you piss off a SNF even while doing the right thing, they will not call you any more. And, there are 74 other "don't give a crap about patient care, give me the money" companies salivating about making more money.

 

[Farmer2DO]

What exactly does the law say though? What is the threshold for reporting? This is where a supervisor may have more knowledge than a brand new EMT. As Hogwiley pointed out, not every little thing is abuse/neglect. Is every skin tear, dirt brief, bruise or fall a reportable incident? What happens if you go to pick up a patient and it is dinner time, and the pt doesn't get to eat, is that neglect? You get the picture. There is a lot of gray area, and someone who doesn't understand what is going and makes a report on could cause a lot of problems without ever understanding that they were the ones who screwed up.

Here is a link to California's Mandated Reporter Law for elder abuse:

http://www.sfhsa.org/415.htm

EMS would be included in this law as WHO should report, and WHEN they should report includes: when the victim reports abuse, when the reporter observes abuse, or "When an injury or condition reasonably leads the mandated reporter to suspect that abuse has occurred."

That's it. There's no provision for having to make sure there IS neglect, but only that there is SUSPECTED neglect. It's actually a crime to NOT report it, which could include fines and jail time. It's not the reporter's job to know if it truly occured, or investigate, or only report the ones that truly are. If they suspect it, they're required to report it. The state has their own ways of investigating, and (at least in New York State) trust me, no one is getting an unfair investigation, just because of a report.

The reason why companies do not let their employees call 911, drive code 3, divert, file complaints or do anything else is not because "the supervisor has more experience." Their supervisors do not know what they are doing in general. ALL it is about putting profit over people. If you do not trust your people to be EMTs, why are they working there. It is because they do not want to piss off their cash cow SNFs. With about 75 companies in LA, if you piss off a SNF even while doing the right thing, they will not call you any more. And, there are 74 other "don't give a crap about patient care, give me the money" companies salivating about making more money.

Well said.

 

[Farmer2DO]

I should also add the reason CNAs are experts at spotting abuse and neglect

Experts? They have college degrees in spotting abuse and neglect? They have specific, formal, documented training in spotting abuse and neglect? And if they're experts, then they could testify in a court of law about the abuse?

 

[hogwiley]

Experts? They have college degrees in spotting abuse and neglect? They have specific, formal, documented training in spotting abuse and neglect? And if they're experts, then they could testify in a court of law about the abuse?

You are reading too much into the word expert. I obviously didnt mean CNAs are some sort of forensic experts. But since you mention it, yes, when I was a CNA we had periodic, documented training in spotting and reporting abuse and neglect. It was a big part of both CNA school and the job. Does this mean your typical CNA should be the end all be all reference for what is abuse or not, of course not.

Obviously there are MANY incompetent CNAs who are far from being experts on anything, but for these people working as a CNA is like walking through a minefield, as there are MANY opportunities as a CNA for someone to effectively and permanently end their medical career through being charged with abuse, either abuse they caused or abuse they tolerated or failed to report.

Believe me, when your future medical career, reputation, and employment all depend on watching for potential abuse and neglect in people who you are deemed responsible for, you tend to become pretty good at spotting it. Good luck finding a job in the medical field if youve ever been fired from a CNA job for abuse or neglect, regardless of whether the state found you guilty or not, and I witnessed many CNAs fired for exactly that reason. Most of them werent cruel or intentionally abused anyone, but were simply overwhelmed by the job.