Don't Sit Under The Moon-Pie Tree With Anybody Else But Me....

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I did not believe the information,

Just had to trust imagination,

My heart was going boom boom boom,

"Son," he said, "Grab your things, I've come to take you home"...

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("Solsbury Hill", Peter Gabriel)

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UPDATE on Mr. Kessel:

Remember Mr. Kessel? The mentally ill and dysfunctional patient who showed a loaded pistol to his neighbor and stated that he "was going to use it the next time one of us road nurses came out"? And remember, also, my discouragement after I notified Adult Protective Services and the local Sheriff's office---but they did absolutely nothing about the situation?

Well, surprise surprise......

I found out last week that Podunk's Adult Protective Services actually DID do something about it. Whodathunkit.

For years, I have been very discouraged, holding scant little faith in "the system", because up to this point I have never been able to get APS to do a single solitary thing whenever I have reported situations to them in which patients were in dangerous or abusive situations, were unable to care for themselves physically or medically, or were in some other circumstances that would put themselves or others in jeopardy.

But, FINALLY, they did intervene--- in Mr. Kessel's case.

What they did was send two APS personnel out to do a second, "follow-up visit", to Mr. Kessel----and to my astonishment, they managed to convince him to come to the hospital in order "to take a shower". Which was great, because heretofore Mr. Kessel had claimed that he could not get up to walk to the bathroom (even though he is perfectly able to do such) and had developed the habit of sitting in his armchair continually, day and night, mired in his own feces and pee. It was painfully obvious that Mr. Kessel was NOT in his right mind and that, therefore, he desperately needed psychiatric help as well as physical caretaking. He was also physically ill due to his not having taken any of his blood pressure, diabetic, or other medication in weeks---perhaps months.

He was so filthy that day, wearing tattered clothing encrusted with poop and dried pee, that prior to taking him to the hospital the APS employees asked him to remove his putrid clothing. The APS employees then dressed him in a clean hospital gown and clean underwear for the trip to the hospital. Upon arriving at the hospital, Mr. Kessel was then convinced to sign himself into the hospital's psychiatric unit for evaluation.

And that was good because now his doctor could begin the pursuit of a court order to keep Mr. Kessel committed to a psychiatric facility, as a ward of the State of Texas, in order for him to undergo evaluation and treatment of his conditions---both medical and psychiatric----until he was stable enough to be placed in a group or nursing home.

Can you believe it? The system actually worked for once. Thank God.

Because, in my opinion, poor Mr. Kessel seemed to have become completely immobile and unable to care for himself due to his obvious mental illness. I truly believed that he might eventually become a danger to himself, either inadvertently or purposefully, by not taking his diabetic and other medication. And I also believed that he might become a danger to others because of his homicidal behavior of loading his pistol and talking about using it on road nurses.....

But all is well because now he will get the medical and psychiatric treatment he needs.

And hopefully he won't be shooting at any road nurses...

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Anyhoo, the week wore on...

Although I am on the road seeing patients a lot these days (due to Belinda still being out on maternity leave), I am also the Manager of our branch office.

And that means that one of my managerial duties is that I have to supervise the other nurses--- especially how they perform procedures during their patient visits--- and also on how well they write up those visits. Everything has to follow Medicare guidelines since our agency only accepts Medicare clients. (Other companies accept Medicaid or private insurance, and their guidelines are similar although different.)

Medicare is very adamant about the ultimate goal of home health care: that of the road nurse's performance of assessing a patient's physical condition, communicating the patient's condition to the doctor, the performance of nursing tasks such as drawing blood or providing wound care---and also providing very specific teachings to the patients about their illnesses and medications so as to enable the patient (or their family) to eventually manage their medical conditions and medications independently.

To ensure that road nurse companies are providing the above services correctly per Medicare regulations, monitoring agencies make regular visits to all home health agencies to check for themselves whether or not Medicare guidelines and requirements are being followed.

Such visits by monitoring agencies are usually done via a "surprise visit" by an inspector---and it's always done when you're least expecting it and you're caught piddling around at your desk in aimless bliss, tapping your feet and trying to yodel to the tunes of country & western music blasting from a nearby radio--- while drinking cold Dr. Pepper between bites of a banana Moon Pie.....

And let me tell you from personal experience, the surprise arrival of a stern inspector (who usually strides through the front door clutching an ominous-looking clipboard and briefcase) can cause a hapless road nurse Manager to completely lose the chance of making a "good first impression"--- due to said Manager's sudden choking on her Dr. Pepper and banana Moon Pie in mid-yodel while simultaneously jumping up out of her chair in abject fear.... well, you get the picture.

Because the inspector then has to wait impatiently while the poor nurse Manager coughs up the Dr. Pepper and pieces of banana Moon Pie, all while frantically taking even MORE swigs of Dr. Pepper in the hopes of stopping her mortifyingly embarassing choking episode----which most definitely also contributes to the ruination of the aforementioned "good first impression"....

Thus, I must constantly, as the Manager, keep my nurses up to par on their procedures while "in the field"--- and also their teaching documentation. I do the latter by auditing their charting on a fairly regular basis due to my frank petrification and fear of a surprise visit by an inspector.

Because if an inspector comes and finds your office "deficient" in one or more of the categories they are inspecting, such inspectors can cause untold misery to the administration personnel (aka me) and the owners of the company. In fact, road nurse companies can even be shut down if they are found to be not operating adequately per Medicare guidelines.

And so, in between being on the road seeing patients, I must also cram in some time each week to audit the charts to ensure that the other nurses are documenting correctly.

There's lots of things in the patients' charts that I audit, but a big one is how well the nurses are teaching the patients about their diseases and meds. The nurse must not only document what she taught the patient but also HOW the patient responded to those teachings. In our company, the nurse can't just get away with documenting whether or not the patient "verbalized understanding" of the teachings. Our company's policy is that she must also include a patient's direct quote.

For example, if one of our nurses goes on a patient visit and teaches the patient something about the disease of congestive heart failure, a disease which can be aggravated greatly by the presence of too much fluid in the patient's body, then the nurse will chart (a) that she taught the patient about congestive heart failure, and then (b) that the patient responded something like: "I will remember to always take my diuretic pill just as my doctor prescribed".

Naturally, such documentation has to be written in a professional way.... hopefully..... but remember, this is Podunk. And I can't tell you how many times in my road nurse career here that I've sat in a road nurse daily report session and had to listen to the Manager berate everybody for using the word "y'all" in our charting or faxes to the doctor. The Manager always stated that it "didn't sound professional".

In fact, I've even heard exasperated Managers yell: "Dammit, now y'all need to stop using that damn word y'all, do y'all hear me?!!"

Anyhoo, now that I'm a Manager myself, I must audit patient charts to ensure that my nurses are documenting correctly. And this week I chose to audit some our young Jane-Anne's charting. Yes, Jane-Anne....our rookie road nurse. The same Jane-Anne who is an utterly and completely honest, corn-fed country girl who takes instructions thoroughly literally....

Bless Jane-Anne.

Jane-Anne means well and all, but she's still very young and frisky. Even though she's pregnant, she loves to play and joke around, just like a spring-born colt, and is frequently distracted out of performing her patient assessment and teachings by accepting a patient's invitation to sit down at the family dinner table to have chicken s'ketti--- or sweet tea and cookies--- and she also frequently gets caught up in the family's daily activities and wastes an hour by watching "The Price is Right" on the television, yelling loudly along with everybody else her bid of "ONE DOLLAR!"

Jane-Anne is not the greatest charter (medical slang for documenter) in the world, but I always carry high hopes that I can teach her as we go, each time I audit her charts. And this week it was time for me to stop procrastinating and look into her documentation.

So I piled a bunch of patients' charts on my desk while Jane-Anne was out of the office--- and I dove in.....

When I looked at the first patient visit note written by Jane-Anne, I thought for a minute there that everything was okay. The front page of the note looked pretty good. She had charted vital signs, body system assessments, and other physical information just fine....

And then I turned the page over...... to where the teaching part is located--- most specifically the area where she had to write the patient's "direct quote" after her teachings......

And even though this time I wasn't drinking Dr. Pepper or eating a banana Moon Pie, I still began choking, coughing, and practically having an apoplectic fit----trying to stem a strong desire to run screaming down the street like a damn lunatic----because of what I had read on that particular note. In fact, as I continued to thumb through more of Jane-Anne's notes, all I could do was simply stand there, stunned in disbelief, continuing my silent fit of utter mortification, my offended eyes beginning to pop out of my skull like those of a gigged frog.

Here is a sample of "direct patient quotes" that Jane-Anne has charted as responses to her teachings:

Jane-Anne taught about the pathophysiology of the condition of "Muscle Weakeness". She wrote that the patient replied: "Well, nurse, I knew that I'd get weaker when I became older."

Jane-Anne taught about "Fall Safety in a Home Environment". She wrote that the patient replied: "But what kind of fool would put furniture right in the path that they walk in?"

Jane-Anne taught about the pathophysiology of the disease of "Congestive Heart Failure". She wrote that the patient replied: "Dammit, I just knew it was heart failure..."

Jane-Anne taught about "The Benefits of Cessation of Smoking with Lung Disease". She wrote that the patient replied: "Well, you can forget about that because I ain't never gonna quit smoking."

Jane-Anne taught about "The Importance of Following the Doctor's Prescribed Medication Regime". She wrote that the patient replied: "Oh. Okay."

Jane-Anne taught about the disease process of "High Blood Pressure". She wrote that the patient replied: "My blood pressure just can't be that dang high. Are you sure you read it right?"

Jane-Anne taught another patient about the disease process of "High Blood Pressure". She wrote that the patient reqlied: "So... what you are saying is that blood pressure is some kind of force in my vessels?"

Jane-Anne taught a patient about "The Importance of Keeping Your Doctor's Follow-up Appointments". She wrote that the patient replied: "Well, okay then, nurse, but last week my doctor's appointment was right in the middle of 'The Price is Right' and so I rescheduled it."

Jane-Anne taught a patient about the disease of "Gout". She wrote that the patient replied: "Well I guess it's a good dang thing that I take that medicine, isn't it? Which medicine do I take for gout anyway?"

And then..... the patient quote that actually caused me to practically fall down out of my chair in a dead faint was:

Jane-Anne taught about "Measures to Prevent Constipation". She wrote that the patient replied: "Well, I didn't do very much yesterday---it was just little pebbles, really. But today I had a MAMMOTH bowel movement! I wish you could have seen it, nurse."

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Sigh....

Anyhoo, the strange week just pressed on----and I was having a few troubles, myself.

On Friday I went to see an elderly man who lives in a retirement community. When I arrived, he was sitting in the attractive lobby of the community's main building. And so I amiably sat down in a chair next to him and started chatting.

I wasn't going to have to do anything to him like draw blood or anything, and the retirement community's staff doesn't mind if we sit out in the lobby with our patients--- and so I decided to perform my visit on him right there in the lobby.

I placed my nurse bag on an end table nearby, unzipped it, and retrieved my stethoscope and blood pressure cuff. I was aiming to teach this patient on "Type II Diabetes" that day because the retirement community had notified me that the patient's morning blood sugars had been running high. We suspected that the patient had a secret "stash" of sweets, smuggled in to him by well-meaning family members.

But as I began talking with the gentleman, I noticed that he kept looking over my shoulder. And this bothered me. I wanted him to pay attention to me. I was trying to talk to him about his blood sugar and how it wasn't a good idea to sneak-eat snacks like banana Moon Pies, buttermilk pie, shoo-fly pie and other concentrated sweets.

(Is "sneak-eat" a real word?)

(Dammit---now I want some shoo-fly pie...)

Where was I?

Oh yes, I was interviewing the patient in the retirement home lobby.

Anyway, as I continued my interview with the patient, he continued to be distracted, and continued to glance over my shoulder. I knew he was hard-of-hearing and so finally I asked him:

"Mr. Benson, is your hearing aide turned on? Are you having trouble hearing me?"

He shook his head and replied: "Oh no, nurse. I can hear ya just fine. I'm looking at that fish behind you."

Fish????

I turned around and looked---and noticed that I was sitting directly in front of the lobby's beautiful fish acquarium. And sure enough, one of the acquarium's larger fish had come right up to acquarium's glass right behind me--- and was hovering there in the water, seemingly trying to peer out of its acquarium home.

I turned back around to face the patient and said: "Okay, fine. The fish is sitting there. Now then, let's continue our discussion about your diabetic diet...."

But no matter how much I kept talking, Mr. Benson kept looking over my shoulder. He kept pointing out the fact that the stupid fish seemed to be "staring right at me". And each time Mr. Benson said that, I'd politely turn around to look at the acquarium----only to find that the patient was right. That damn fish WAS gazing at me.

In fact, that stupid fish was looking me RIGHT IN THE EYEBALLS.

I tried to ignore the fish. I tried to keep my composure and perform my interview with the patient. But the dang patient continued to be distracted by that infernal fish.

Now I was getting REALLY irritated. In fact, I was getting VERY irritated that this FISH was INTERFERING with my patient VISIT.

And so, upon AGAIN being informed by my patient that the blasted fish was "staring at me", I finally turned around to face that stupid fish--- and I tapped rudely on the acquarium glass. "Go away," I told the dumb fish. "Go along to Dead Man's Chest or some other fish hang-out somewheres--- and find somebody else to ogle!"

And then I turned back around to face my patient, to again continue my interview and teaching session. But I found that I still couldn't do my interview properly.... because now I was distracted myself!!! I kept feeling that stupid fish's eyes on me and it bugged me. And as I sneaked another peek at it, I noticed that the damn fish still hadn't changed its location. The dadblasted fish was STILL THERE..... STARING ME RIGHT IN MY EYEBALLS.

Now I was pissed off. I was tired, I was hot, and I was ready for the weekend--- and the last thing I wanted was for some damn fish to mess up my afternoon.

And so, after another failed attempt to keep my patient's rapt attention, I lost my temper and turned around impatiently---and again tapped on the acquarium glass. And then, while looking that offensive fish right in its own eyeballs, I loudly proclaimed: "Take a damn picture, you pissant fish--- IT'LL LAST LONGER!"

And finally, to my satisfaction, the stupid fish left, swimming off to bother somebody else.

And, to my utter mortification, when I turned back around in triumph, I found that the charge nurse of the retirement home was standing right in front of me and Mr. Benson---and she was looking at me very oddly. I was utterly mortified that she had seen me talking to the fish......and then I was doubly mortified when Mr. Benson innocently piped up and said:

"She doesn't like that fish. It was staring her in the eyeballs."

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Oh yes, I almost forgot----here's the completed "Baby Biker Sweater" that I knitted for Jane-Anne's upcoming baby. Yes, I know I got the studs on rather crookedly---but that stupid "Bedazzler" thingy just wouldn't operate right. (And I figure the kid's only gonna wear it for a couple of months anyway.)

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