Edward Hearon Service Plan Notes

Service Initiation Date: April 26th, 2018

NO DNR ON FILE

Home Health: Omnix Home Health

Summary: In March, Mr. Hearon was schedule to get a pacemaker when he became disorientated in the hospital.  Since then he has experienced hallucinations and restlessness.  His wife stayed by his side for over a month, only leaving twice.  Doctors cannot identify the cause of his disorientation and recommended he be discharged to recover at home.  We are there to provide 24-hour personal care and keep him safe when he's disoriented.  We also provide respite to his wife and family.  He lives with his wife, Dorothy, in Crosby.  His daughter and son-in-law are Tish and Russel Humphrey and live in Tomball.

Stated Medical Condition

  • Disorientation

  • Restlessness

  • Hallucinations

  • Cyst on back. Covered with bandage.

Personal Care

  • See Service Plan and detailed list of ADL’s in the blue folder.

  • Bed bound

  • Total care

  • Turn in bed every 2 hours

  • Keep hydrated

  • Measure and document urine output

Personal Services

  • See detailed list of cleaning tasks on Page 2 and 3 of Service Plan in the blue folder.

  • Living area and kitchen cleaning

Likes and Dislikes

  • See Getting to Know You document in the blue folder.

  • Holding his hand calms him.

Notes

  • Emergency Contact Information found in the blue folder.

  • Mr. Hearon is approximately 180lbs. He will help you turning in the bed.

  • Mr. Hearon has very strong hands so be careful when he is reaching.

  • Please document any requested tasks by the home health nurse. Please notify your supervisor so that we can update the service plan notes and communicate to other caregivers.

Updates:

  • 04/26/2018 - Services started at Kindred Hospital Medical Center. Night shifts to give respite to wife.

  • 05/03/2018 - Transferred home. 24-hour services started.

  • 05/09/2018 - Mr. Hearon was transported by ambulance to hospital after the home health nurse discovered his blood pressure at a dangerously low level. It was discovered he was also dehydrated and vitamin deficient.

  • 05/17/2018 - Mr. Hearon's daughter reported that the home health nurse asked us to measure his urine output. A note was written in the care notes but not followed by other caregivers. Be sure to read the caregiver notes and service plan notes before each shift.

  • 05/17/2018 - Received notification that Mr. Hearon will be discharged on Saturday, May 19th. We will restart 24 services at his home.

  • 05/21/2018 - Reminder to mea sure and document urine output.

  • 05/27/2018 - Caregiver reported Mr. Hearon tried to hit her and twist her arm.

  • 05/29/2018 - The home health company said to leave his diaper OFF. The rash on one of his testicles needs time to heal.

  • 06/22/2018 - Blood pressure reminder 3 times per day. BP log in blue folder.

  • 06/24/2018 - There have been two reported incidents over the past few days regarding Edward's son-in-law, Russell. On two separate occasions, it was reported that Russell was rough in handling Edward. He was reported to have forced a pill into Edwards mouth. Russell and the family say that Edward was the one who bit Russell and that was the reason for the incident. Another situation involved Russell pulling Edward from the bed to wheelchair using too much force. Russell and family said it was necessary since Edward's resistance was causing both people to fall to the ground. I've interviewed the family and reported the situation to Adult Protective Services. If you see anything that should be reported, you must let me know within 1 hour of witnessing the incident.

  • 06/27/2018 - Edward took a late-night trip to the ER to have his catheter reinserted. The family returned home at 4am.

  • 06/29/2018 - The family requested the following:

    • Please sit close to Edward to make sure he does not pull his catheter out. It was reported that some of our employees are sitting at the bar to use their phone while it is charging. The family is OK with the caregivers using their phone during down time. Dorothy has provided an extension cord so you can still be on your phone and stay close to Edward.

    • Be sure to clean the area around Edward's catheter daily.

  • 07/02/2018 - Reported that Edward balled his fist at Dorothy. Be careful if he gets agitated.

  • 07/18/2018 - Services restarted after client was admitted to the hospital. Edward has had complications with his catheter and bladder. His hands are restrained because he continues to try and pull out his catheter. The family stressed that all of our caregivers must be alert at all times to make sure he does not bother his catheter. He is currently at Kindred Hospital-Bay Area in Pasadena, Room 212.

  • 07/19/2018 - Notified that catheter was removed on 07/18/2018.

  • 07/21/2018 - Edward is now a sitter job in the hospital. Personal care to be performed by hospital staff.

  • 07/23/2018 - Family requested all caregivers know the following:

    • Please read the yellow note in his hospital room left by the family titled: "Sitters Read"

      • Make sure Edward's hearing aid is in his left ear. If it's not there, please locate it. His lack of hearing causes agitation. His right ear hearing aid was damaged.

      • No psychotic drugs. When the staff gives him medication, ask is they are psychotic drugs, drugs that deal with panic or anxiety or drugs for sedation. If they are, please ask them to contact the family.

      • Don't leave him unattended. If you need to leave the room, make sure someone is there. Ask the staff nicely.

      • Our caregivers should be feeding him, not the nursing staff. He closes his eyes but will be awake. You can stimulate his drinking by using a straw filled with fluid and slowing giving him liquids. Make sure he swallows. His wife says you don't need to ask him if he wants to eat. He has a good appetite and eats almost anything.

    • Keep giving him liquids. The doctor said he needed more. Use the filled straw to drop water into his mouth. Make sure he swallows.

    • Do not put on his diaper. He sits on a diaper and pad but the diaper should remain open. Watch him to see if he looks like he needs to urinate and use hand held the urinal.

    • Do not let the staff restrain his arms. They restrained him in the past because of the IV's and catheter but it is not needed anymore. The wound nurse may use them temporarily while they care for him. They should not be left on.

    • We are not to do personal care at the hospital. We must call the care associate of the hospital.

    • The family suggested you take your time getting him to do things. He gets agitated when forced so if he refuses something, come back and try again in a few minutes.

    • At the end of each shift, please call Tish at 936-577-2004 to discuss his condition if the family is not there. Here phone number should be written down there at the hospital room.

    • Any new information regarding Edwards care given by the family must be reported to Eric so he can update the care plan notes.

  • 07/25/2018 - Caregivers are recommended to limit engagement and conversations with Edward. He is not of sound mind to process normal conversations and doing so could lead to increased aggravation. Limit stimulation when possible.

  • 07/25/2018 - If Edward is aggravated he will call out to his wife, Dorothy. You are able to calm him taking his had and soothing him as if you were Dorothy. He normally does not know you are not his wife.

  • 07/26/2018 - Please document in the notes every time the doctor comes into the room, therapy is conducted or any procedure is performed. The family wants to know what is being done and said when they are not there.

  • 07/27/2018 - Edward currently has an IV. The family said if it comes out and they want to put another one in, call the family first.

  • 07/28/2018 - Dorothy asked us document and let them know every time he has a BM. The blue folder is there so you can note it in the caregiving notes pages.

  • 07/28/2018 - Updates from the family:

    • Make sure we know where his left hearing aid is at all times. We CANNOT lose it.

    • Dorothy told the doctor to stop IV meds so make sure they don't give him anymore IV antibiotics.

  • 07/30/2018 - Last day of services. Edward was transferred to Avalon Memory Care.

  • 09/18/2018 - Family requested a sitter from 8a-8p at Avalon Memory Care in Atascocita. Edward can be loud and having someone with him helps manage his disorientation. Personal care task will be handled by the facility.

    • Limit stimulation: Edward experiences hallucinations. Do not attempt to verbally respond to everything he says. This leads to confusion.

    • Keep his hearing aid in his ear. He is less confused when he can hear properly.

    • If he calls out for Dorothy, you can respond a speak to him as if you were his wife.

    • Hold his hand and talk to him to calm him down. Be careful. He has a strong grip.

  • 09/29/2018 - Ants found near and on Edward’s bed. Please be aware and report to staff if seen.

  • 09/29/2018 - I spoke with the director who said the main purpose of us being there is to keep Edward safe and control his yelling. If he starts yelling out, please do your best to calm him. If he cannot be easily calmed, please go with him to his room.

  • 09/30/2018 - Family reported Edward had very low blood pressure is not conscious. The family asked that we stay with him at night to monitor him and report if his condition gets worse.