Suspected Abuse, Uninterested LPN

[Sasha]

With all the excitement from my other thread, I nearly had forgotten this other question I wanted to pose. I thought about this a lot, discussed it with several people and so on and so forth. I've thought about what I could have done, and want other opinions

I had my first run in with suspected elder abuse yesterday.

My patient was a fairly elderly woman being cared for by her daughter. Private Residence to Nursing home for a few days for some reason or another, but the woman was set to go back to the daughter. My first clue that something wasn't kosher was when we walked in the daughter said "Hold your breathe, the smell is atrocious." Walked into her house, not too bad... Into the room with the mother, and it was horrid. We put her on the stretcher, and inside the truck I assesed her more thoroughly than any patient I've ever assesed on IFT. She had bruises in various stages of healing, we rolled her so I could get a look at her back. Several bed sores. Found the source of the smell. It appeared her diaper hadn't been changed in days due to the fact the feces in the diaper were dried and her buttocks were beet red. She had very poor skin turgor, BGL just read "low", she seemed sluggish, per daughter that was not normal, etc. Hypertensive, 160/100. She was extremely emaciated, nothing but skin and bones, literally. The pillow between her legs didn't appear to have been laundered in weeks. She had facial droop and listed off to the side, but her daughter said "She does that sometimes" but no dx of Bell's Palsy, but eh. I'm just an EMT and I'm sure there are a ton of things that could cause facial droop and unilateral weakness.

Called dispatch via landline, asked for permission to reroute to an ER based on our assesment findings and also informed them that we both suspected abuse.

Patient have a valid, signed DNR? Yes.

Denied. Continue to nursing home, report your findings to the nurse and notate it in the report

So we started truckin' to the nursing home. I sat on the bench seat, next to the, she pulled at my steth while taking my second BP, but calmed down when I took her hand and held it. For the rest of the trip I held her hand and stroked her hair. Non verbal, but tried unsucessfully with the "Squeeze my fingers once for yes twice for no"

At the nursing home, I found her LPN after we sat her in the bed, put bedrails up . I tried to give report to the LPN but she was unreceptive. She didn't listen, just threw the occasional "Mmmhm". Hypertensive, "Mmmhm" BGL just reads "Low" "Mmmmmhm" Told her I and my partner suspected abuse and why "Mmmmhm"

Would it have been appropriate, since the nurse was unreceptive and uninterested, to go to the charge nurse or whoever was above that LPN?

Anything that could have been done differently? Was it reasonable to deny the reroute to the ER?

My heart broke for that lady, and I'm very sad for her.

 

[Sasha]

Nevermind, problem solved. JP helped me in the chat.

 

[medic417]

Legally you have to make your own report if you suspect abuse. Your report is not a verbal to nurse or doctor it is to adult protective services. Failure to report suspicions is a crime.

I feel for you. It always hurts to suspect someone is being hurt and having those in charge not care. Honestly as soon as you told them your suspicions they should have provided you with the number of the protective services. Please make a report now for the patients sake. Even if your wrong it causes no harm. They actually initially will send someone to check in on her and evaluate to see if you were right. Keep a log of your report. Our state agency actually provides a case number so if it ever is claimed you did not report you can produce that number and protect yourself.

 

[JPINFV]

First off, DNR or no, a patient that has a BGL of "low" goes to the hospital. It's DNR (Do Not Resuscitate) not DNT (Do Not Treat). Just because a patient has a DNR order doesn't mean that they are not to get emergency medical treatment.

Even though I posted this in chat for Sasha, I feel cases like this need more exposure to EMS. First, everyone should check there protocols. I'm willing to bet money that EMTs are mandated reporters in every state (to be honest, I'm surprised that EMTs are only mandated reporters for suspected vulnerable adult abuse in Florida). If you suspect abuse, you don't legally have a choice in the manner, you must report it. Reporting abuse should not be a tool to get back at a patient or facility nor for isolated incidents (stuff happens). Also check with your local

Florida Elder Abuse info:
main webpage: http://www.dcf.state.fl.us/abuse/

Reporting of Abuse of Children and Vulnerable Adults
Florida Abuse Hotline 2007 [linked to from the abuse page]
...
Mandated Reporter

Although every person has a responsibility to report suspected abuse or neglect, some occupations are specified in Florida law as required to do so. These occupations are considered “professionally mandatory reporters”. A professionally mandatory reporter of child abuse/neglect is required by Florida Statute to provide his or her name to the Abuse Hotline Counselor when reporting. A professionally mandatory reporter’s name is entered into the record of the report, but is held confidential (§ 39.202, F.S. and 415.107, F.S.)

[EMTs are listed as a mandated reporter for vulnerable adult abuse]
Page 5.
...
ABUSE, NEGLECT, OR EXPLOITATION OF VULNERABLE ADULTS The Florida Abuse Hotline will accept a report on a vulnerable adult when:

• Any vulnerable adult, who is a resident of Florida or currently located in Florida

• who is believed to have been neglected or abused by a caregiver in Florida; or

• who is suffering from the ill effects of neglect by self and is in need of service, or

• who is being exploited by any person who stands in a position of trust or confidence, or any person who knows or should know that a vulnerable adult lacks capacity to consent and who obtains or uses, or endeavors to obtain or use their funds, assets or property. • Reports of exploitation cannot be accepted after the vulnerable adult is deceased.
page 6

...

Definitions:
For adult reports:
"Abuse" means any willful act or threatened act by a relative, caregiver, or household member which causes or is likely to cause significant impairment to a vulnerable adult's physical, mental, or emotional health. Abuse includes acts and omissions.

"Caregiver" means a person who has been entrusted with or has assumed the responsibility for frequent and regular care of or services to a vulnerable adult on a temporary or permanent basis and who has a commitment, agreement, or understanding with that person or that person's guardian that a caregiver role exists. "Caregiver" includes, but is not limited to, relatives, household members, guardians, neighbors, and employees and volunteers of facilities as defined in subsection (8). For the purpose of departmental investigative jurisdiction, the term "caregiver" does not include law enforcement officers or employees of municipal or county detention facilities or the Department of Corrections while acting in an official capacity.

page 8

 

[VentMedic]

At the nursing home, I found her LPN after we sat her in the bed, put bedrails up . I tried to give report to the LPN but she was unreceptive. She didn't listen, just threw the occasional "Mmmhm". Hypertensive, "Mmmhm" BGL just reads "Low" "Mmmmmhm" Told her I and my partner suspected abuse and why "Mmmmhm"

The LPN did not witness what the house was like and has not had a chance to examine the patient. She probably thinks you are dumping your reporting responsibility as a certified EMT on her. While it is good to report your suspicions, do your own paperwork through the proper channels.

As JP stated, the medical issues should have been made clear to dispatch for a reroute to the ED. However, some of the medical problems may be treatable at the NH and a physician or NP may see the patient on admission.

 

[JPINFV]

"Neglect" means the failure or omission on the part of the caregiver or vulnerable adult to provide the care, supervision, and services necessary to maintain the physical and mental health of the vulnerable adult, including, but not limited to, food, clothing, medicine, shelter, supervision, and medical services, which a prudent person would consider essential for the well-being of a vulnerable adult. The term "neglect" also means the failure of a caregiver or vulnerable adult to make a reasonable effort to protect a vulnerable adult from abuse, neglect, or exploitation by others. "Neglect" is repeated conduct or a single incident of carelessness which produces or could reasonably be expected to result in serious physical or psychological injury or a substantial risk of death.

"Vulnerable adult" means a person 18 years of age or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to a mental, emotional, long-term physical, or developmental disability or dysfunctioning, or brain damage, or the infirmities of aging.
Page 9

...

Pages 10 and 11 have information on making the report.

http://www.dcf.state.fl.us/abuse/publications/mandatedreporters.pdf

Online reporting agent: http://www.dcf.state.fl.us/abuse/report/

Telephone number and report form with fax number: Http://www.dcf.state.fl.us/abuse/howtoreport.shtml

On the fax report, "other individuals" includes your partner. I know in California, only one report needs to be filed to cover both EMTs that are part of an ambulance crew as long as it's mentioned.

I would also file an additional incident report about the this call with your ambulance company. You will get called about it and it's nice to be able to say "Well, I did tell you about it, didn't you get my incident report?" Also make sure to mention that, legally speaking, you have no choice in the manner. EMTs are listed specifically as a mandated reporter.

In addition, I advise to everyone to go to their local EMS protocol/elder abuse site and make up a mandated reporter packet containing:

• *Procedure for making a report per EMS protocol and local oversight agency (Health and Human Services, elder care agency, ombudsman, etc.)
  *Report form
  *Preaddressed stamped envelop (good for storing all the paperwork)
  *company incident report form.

You don't want to come to an internet forum looking for what to do. You also want to have the material necessary to make the report out as soon as possible. When I made my one dependent adult abuse report I pulled my unit out of service till it was done. You want the scene and any conversation with staff and the patient fresh in your mind as you write it.

Also make sure that the receiving facility is aware of what happened and your intended course of action. No, they can't report it for you (hearsay), but they may have other social services options to employ that you don't.

 

[JPINFV]

As JP stated, the medical issues should have been made clear to dispatch for a reroute to the ED. However, some of the medical problems may be treatable at the NH and a physician or NP may see the patient on admission.

I would argue that stroke like symptoms and hypoglycemia should get a "Go directly to ED. Do not pass go, do not collect $200" card. Dispatch is not there, dispatch did not examine her patient. Maybe I'm a little too caviler or wreckless, but I wouldn't have asked dispatch to reroute, I would have told dispatch that i was rerouting for hypoglycemia with patient presenting stroke like symptoms (I know, hypoglycemia can mimic a CVA).

 

[Laur68EMT]

I would argue that stroke like symptoms and hypoglycemia should get a "Go directly to ED. Do not pass go, do not collect $200" card. Dispatch is not there, dispatch did not examine her patient. Maybe I'm a little too caviler or wreckless, but I wouldn't have asked dispatch to reroute, I would have told dispatch that i was rerouting for hypoglycemia with patient presenting stroke like symptoms (I know, hypoglycemia can mimic a CVA).

That's exactly what I would have done. We are her advocate. Good lesson for all. I hope things turn out well for her.

 

[traumateam1]

I would argue that stroke like symptoms and hypoglycemia should get a "Go directly to ED. Do not pass go, do not collect $200" card. Dispatch is not there, dispatch did not examine her patient. Maybe I'm a little too caviler or wreckless, but I wouldn't have asked dispatch to reroute, I would have told dispatch that i was rerouting for hypoglycemia with patient presenting stroke like symptoms (I know, hypoglycemia can mimic a CVA).

Exactly! That is exactly what I would have done, informed dispatch that we were taking patient to emergency department. Dispatch is likely to ask for a landline as to why, but they won't (or at least shouldn't) argue with you, as they aren't there and they can't see what you are seeing. It's all a learning curve, but based on the patients presintation of possible abuse, and then the whole physical presintation of her, and her vitals.

Hope everything works out good for her.