1. Running Head: CASE STUDY PROJECT: A CASE OF ABANDONMENT 1
Case Study Project: A Case of Abandonment
Meghan M. Brill
Binghamton University

2. CASE STUDY PROJECT: A CASE OF ABANDONMENT 2
Case Study Project: A Case of Abandonment
Case management is an essential nursing function that involves the development,
implementation, and evaluation of an integrated plan of care (Decker, 2015). Case managers
work closely with patients and their families, as well as other providers and financing, to create
the best possible patient outcomes. The task of a case manager is often a delicate balancing act
between patient advocacy and hospital constraints, both of which need to be considered
throughout.
Client/Family Introduction
A female patient in her mid-sixties arrived in the emergency department after a home
health care nurse placed a call to an ambulance company. The patient was found in her home,
alone, not moved or cared for since the home health nurse left the patient seventy two hours
prior. The home health nurse was scheduled to visit in order to assess and care for a pressure
ulcer wound. The patient’s primary caregiver was her adult son, who was responsible for
helping with performing her activities of daily living. The family has close ties to relatives in
Iran, frequently visiting and maintaining Iranian custom and culture. Women are traditionally
seen as subservient to men in Iranian culture, and are expected to act modestly and deferentially
to their male counterparts (Povey, 2012). Due to the patient’s deterioration, related to issues
with skin integrity and multiple cardiac complications, she was unable to act in such a way to
satisfy this cultural norm.
According to the patient, her son had decided to go out of the country to Iran, and left a
friend in charge of her caregiving. However, the friend had not come by to help with the care of
the patient. The main problem was that the patient was completely unable to care for herself,
and had not eaten or cleaned herself up since the nurse had left her seventy two hours prior.

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Upon the patient’s arrival to the emergency department, she had was very malodorous. The
nursing staff initially attributed this to the patient’s open wounds, now located on all extremities,
but eventually concluded that the odor was coming from the patient’s indwelling catheter. After
removing the over-filled catheter, a significant amount of foul-smelling pus came out of the
patient. The patient was thereafter cleaned and wounds dressed. This was not the first time the
patient had arrived with apparent neglect by the family. Adult protective services was contacted
and a report made. The patient was unable to care for herself, and the family was unable to
provide adequate care. Additionally, the family was unwilling to pay for assistance in the
patient’s care in the home, and the family refused to place the patient in a nursing home or
skilled nursing. Ideally, the optimal situation would have included the patient being well cared
for by her family, or placed under professional care. The patient was admitted to the hospital,
mostly as a social admit, but also to monitor for infections from the catheter. Security was
notified of the situation, and was instructed to not allow the son to discharge his mother against
medical advice, as he had in the past.
Management/Leadership Issues
According to Louis Pondy’s Conflict Theory, there are five stages of conflict: latent
conflict, perceived conflict, felt conflict, manifest conflict, then conflict aftermath (Williams,
2011). The conflict in this situation stemmed from between the hospital staff, including nurses,
administration, and physicians; and the patient’s son. After the patient was admitted to the
hospital, and adult protective services had come, the son suddenly reappeared locally. This is an
example of latent conflict, as factors existed which could create conflict at any time. The staff
was aware that there could be an issue with the son trying to visit the hospital, and eventually try
to discharge his mother. The son called the emergency department, asking for his mother’s

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location, which was disclosed to him through communication with the security offices, whom
explained the severity of the situation. This brought the situation to the perceived conflict stage,
as both the hospital staff and patient’s son were aware that a problem existed, and the son was
frustrated with the hospital’s and adult protective service’s decisions. The son was not aware of
this situation prior, so it was the acknowledgment of the situation. The felt conflict came into
place upon talking with the nursing staff, who were experiencing anxiety about the patient’s son
coming into the hospital, and were becoming nervous about the situation that may occur. The
patient’s son was very hostile on the phone, and arrived at the hospital in a similar state.
Manifest conflict was apparent when the patient’s son arrived at the hospital, and began yelling
at the nurses on the floor, demanding the patient’s release from the hospital. The patient needed
to be escorted out by security, and very openly displayed his dissatisfaction with the situation. In
the conflict aftermath, the nursing staff talked amongst themselves about how to prevent the
situation from happening again, both the son arriving and the patient from being readmitted. The
patient’s son was not seen again throughout the shift. However, there was still some latent
conflict possible, as the son was not happy upon being removed from the hospital.
There were multiple case management strategies utilized. The case manager identified
the issue, which was one of neglect by the patient’s son; and the possibility that he would want to
come and release the patient from the hospital. She then tried to understand each party’s issue.
The nursing staff did not want the patient’s son in the room, because they were anxious about the
son becoming destructive. The patient wanted to see her son, because she loved him and did not
comprehend that he was the reason she was in the hospital. The patient’s son wanted the patient
out of the hospital because he did not believe that the staff could do anything for his mother.
Adult protective services wanted to keep the patient safe and away from the son. The case

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manager determined that the best solution was to allow the son to visit his mother, but to not
allow him to make any decisions about the patient’s care. This led to the argument and the son
being escorted out of the hospital, disrupting the quietness of the floor for the other patients.
There were several other options the nurse case manager had in this situation. The first
option would have been to not contact the son upon the patient’s arrival to the hospital. This
could have been done by not calling the contact phone number for the ‘responsible’ friend. This
option would have allowed the patient to heal, and assess for infection, prior to allowing the
patient to make decisions. If the patient was found to have an infection, this could impact her
thought processes. Another option would have been to request adult protective services work
with the local police department, and assess if there were grounds for abuse by the son, and have
him arrested. This would have prevented the son from entering the patient’s room, but would
have upset and confused the patient as to why the son was not there. The situation and the
criteria for the son to see his mother could have been made clearer, and his limit of control on the
situation explained more thoroughly. The case manager could have also called in the social
worker once the son was on premises, in order to discuss options while he was with his mother.
This may have prevented the loud and argumentative situation, after the son tried to discharge his
mother.
Legal and ethical issues were present throughout this case in regards to the quality of care
and cost-containment. The first ethical issue relates to treating the patient. As she had been
admitted in the last thirty days, the hospital would not be receiving any payment for this visit.
While the patient was in need of care due to her wounds and catheter, this could have been
prevented if she had been taken care of properly by the son, and if the home health nurse had
known that the son would be out of town and unable to care for the patient. This “readmission”

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was no fault of the hospitals, but they would have to absorb the costs. Another ethical issue
stems from allowing the son to visit the patient. It was due to the son’s actions that the patient
was in the hospital. Because adult protective services allowed the son to see the mother, the
hospital staff decided to as well. Another ethically questionable situation was allowing the son
into the room, even when the staff predicted there would be an argument after. To allow the son
in, and to have him talk with the patient, making her upset, was a difficult choice. After the son
left, the patient was distraught, and wanted to leave herself to be with him and comfort him. The
legal issues lie with the son living with the mother in the future, and what should be done about
the patient’s home situation. The debate of if the son should be arrested is also to be considered,
and how it will affect the patient’s wellbeing if he is her caregiver.
Two leadership roles that were present throughout the situation were coordination and
collaboration. Coordination is especially important in the emergency department, where the
“coordination of quality healthcare services to meet an individual’s specific healthcare needs in a
cost-effective manner to promote positive outcomes” is essential (Howenstein & Sandy, 2012).
The case manager was responsible for contacting multiple departments to ensure the best
possible patient outcomes. The case manager coordinated with the floor the patient was admitted
to, as well as security, about the situation at hand with the son, and preventing him from
discharging her against medical advice. The case manager coordinated with the hospitalist and
emergency room physician what the best plan of care was for the patient, in regards to admission
or discharge to a skilled nursing facility. Collaboration was also present throughout this
situation. Collaboration occurs when multiple parties work together towards a common goal,
especially with health and social care (Forbes, 2008). The case manager collaborated with the
nursing staff, as well as the social worker, before deciding to admit the patient to the hospital. In

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discussion, the social worker was also able to direct the nursing staff to facilities that would work
for the patient after discharge. The team in the emergency department also collaborated in their
care of the patient upon admission to a room. The nurses and nurses’ aides collaborated and
worked together to find the best way to get the patient cleaned up quickly without upsetting any
of the other patients with the smell exuding from the patient. An emergency department case
manager is “an asset with the goal of improving operations, promoting quality care, improving
patient and financial outcomes and increasing staff satisfaction in the ED” (Walsh & Zander,
2007). The case manager is essential in the emergency department, and also throughout the
hospital.
Summary/Conclusion
The current integrated plan of care present was to keep the patient in the hospital to
observe for infection, as well as socially admit her until the situation stabilizes. Part of the plan
of care should include the son meeting with a psychologist and social work, to find out why the
mother was left alone, and to determine if this issue will happen again. The patient should also
speak with a mental health professional, to determine the effects of being left for three days
completely unattended has done, and how she feels about her relationship with her son. The
integrated plan of care should also include establishing if there are any other caretakers or family
members in the area, or if the patient should be placed into a nursing home or other skilled care
facility. Nursing interventions should include assessing the patient for signs of infections
throughout her stay. The nursing staff will also monitor the patient for any psychological
problems, and call the appropriate mental health services if applicable. Nurses should also
monitor patient for skin integrity, ensuring to turn and position the patient at least every two
hours. The wound care nurse should also assess the patient’s wounds and stage them. The

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nursing staff should also monitor the patency of the patient’s indwelling catheter to prevent
infection. The drainage from the catheter should also be monitored, ensuring that there is no
purulent discharge present.
This case helped demonstrate the essential role of the case manager. The case manager is
responsible for coordinating care of the patient in a cost effective manner while maintaining a
high quality of care. Without a case manager present, nursing staff would have to dedicate a
significant amount of time to case management, taking time away from physical care of other
patients. Case management is a careful balance of the patient’s and hospital’s needs, where legal
and ethical considerations must be made.

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References
Decker, M. (2015). Case Study Assignment [Class handout]. Binghamton University,
Binghamton, NY.
Forbes T. The case for interprofessional collaboration. Journal of Nursing Management [serial
online]. April 2008;16(3):382-383. Available from: CINAHL Complete, Ipswich, MA.
Accessed March 4, 2015
Howenstein, J., & Sandy, L. (2012). Case Management and the Expanded Role of the
Emergency Nurse. Journal of Emergency Nursing, 38(5), 454-459.
Povey, T. (2012). Women, power and politics in 21st century Iran. Farnham, Surrey, England:
Ashgate.
Walsh, K., & Zander, K. (2007). Emergency department case management: Strategies for
creating and sustaining a successful program (1st ed., p. 15). Marblehead, MA: HCPro.
Williams, F. (2011). Interpersonal Conflict: The Importance of Clarifying Manifest Conflict
Behavior. International Journal of Business, Humanities and Technology, 1(3), 148-160.