Duty to Report: What My First APS Call Taught Me

Note: This story is a composite drawn from more than one patient encounter early in my career. Details have been changed to protect patient privacy.

I've seen people at their worst in the hospital. Overgrown nails, wounds and pressure sores, malnourished and unwashed... Usually there's an acute or chronic illness behind it, something explainable. But one patient stuck with me differently, because from the moment I got report, something felt off.

In report, I learned he had no advanced directive, minimal social support, and a medical history that painted a hard picture. He also had a complicated relationship with a family member who called often for updates, enough back-and-forth that my first read was that this person wasn't very involved in his care day-to-day. One night, that family member called asking questions that surprised me, about feeding, medications, hydration, questions someone closely involved would usually already know the answers to. When I asked who was actually making care decisions for him, she said it was her. I wasn't sure that was accurate, so I told her we'd loop the doctors in the next day, and after hanging up, I decided to look closer at his chart myself.

Going back to his admission note, I found more than what report had covered. He'd had a fall at home and couldn't get up; so had the person he lived with. Neither could reach the other for help, and by the time EMS was called, real time had passed. Other notes hinted at a pattern of self-neglect. I started to worry his home situation wasn't safe to discharge him back into, so I went and talked to him myself.

What I learned concerned me more. He'd struggled to afford food, couldn't reliably get to medical appointments, and had recently lost stable housing. The person he lived with cared about him but had real limitations of his own, not much capacity to look after either of them. There was no other support close by. For the first time in my career, I started seriously considering calling Adult Protective Services.

At first I talked myself out of it. I pictured APS as something for cases of clear abuse, and this didn't look like that to me. I could tell the people around him cared. But the feeling didn't go away, so I looked into what APS actually investigates, and found that chronic self-neglect is well within their scope. I ran it by a charge nurse I trusted, and she agreed with my read. Since nurses are mandated reporters regardless, I made the call.

I hesitated for a while before I did, afraid of getting someone in trouble who didn't deserve it, afraid of overreacting, afraid of being wrong. But in the end, trusting that instinct was the right move. It reminded me that "duty to report" isn't about having certainty or proof. It's about not staying quiet when something doesn't sit right.

I learned a lot from this experience, but most importantly I was reminded how critical it is for nurses to look for the warning signs and be brave in advocating for patients who are in potentially unsafe situations rather than to just leave it for the next nurse or assume someone else will take care of it. Sometimes only one person takes the step, and without that one person, no one takes the step.

• Bella, RN