The Bruises and the Lancet in the Sofa
A home health physical therapist is treating Ms. Combs, age 79, for balance and weakness after a fall. Ms. Combs lives with her adult son, who is present for every visit and often answers questions for her. During the third visit, the PT notices bruises on both inner upper arms in different stages of healing, along with a fresh bruise on the left forearm. Ms. Combs says she “fell again,” but the pattern does not match a fall, and she looks toward her son before answering. The son says she is “getting clumsy” and asks the PT not to “make a big deal out of it.” While setting up the walker, the PT picks up a used glucose lancet that was left in the sofa cushion and sustains a needlestick through the glove. The son says the lancet is his and that he “forgot to cap it.”
1. What are the PT’s mandatory reporting obligations regarding Ms. Combs’s injuries, and what should the PT not do?
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The PT should report suspected elder abuse or neglect to the appropriate Kentucky adult protective services authority and, if there is immediate danger, to law enforcement. The bruises in protected areas, in different stages of healing, with an explanation that does not fit the pattern, and the patient’s deferential behavior toward her son are reasonable grounds for suspicion; the PT does not need proof or a confession. The PT should not investigate, confront the son, photograph the patient without proper authorization, or attempt to resolve the family situation personally. The PT should document objective findings in the patient’s own words, the son’s statements, the location and appearance of the injuries, and the report made, including the agency, date, time, and person contacted. HIPAA permits disclosures for abuse reporting as required by law. The PT should also ensure the patient is safe before leaving and should not let the son’s request to “not make a big deal” override the reporting duty. If the patient is in immediate danger, the PT should call 911.
2. What should the PT do immediately after the needlestick, and what follow-up is required?
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The PT should wash the wound with soap and water, allow it to bleed briefly, and avoid squeezing or using caustic agents. The PT should report the exposure immediately to the employer’s infection control or occupational health program and seek prompt evaluation for post-exposure prophylaxis, including HIV, hepatitis B, and hepatitis C assessment. The PT should document the device, the source, the depth of the injury, the gloves worn, and the time of exposure. The source person should be asked to consent to testing for bloodborne pathogens; if consent is refused or the source cannot be tested, the occupational health provider should follow the applicable protocols. The PT should not ignore the exposure because the lancet was small or because the son said he “forgot to cap it.” The PT should also address the unsafe condition in the home, including proper sharps disposal, and document the education provided. Follow-up testing and counseling should occur on the schedule set by occupational health.
3. How should the PT handle the tension between the son’s request for confidentiality and the duty to report and protect the patient?
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The PT should explain that the reporting duty is legal and cannot be waived by the son’s request. The PT should not promise confidentiality about suspected abuse, and should not argue with the son or disclose the report to him in a way that endangers the patient. The PT should focus on the patient: confirm her safety, give her contact information for protective services if appropriate, and document the son’s request and the PT’s response. The PT should share only the minimum necessary information with the agency and should not discuss the report with other family members. If the son becomes threatening or refuses to allow the PT to see the patient alone, the PT should leave, call for assistance if needed, and report the concerns. The PT should also notify the home health agency’s supervisor and follow its abuse-reporting policy. The patient’s right to privacy does not override the mandatory report, and the son’s preference does not change the PT’s professional obligation.