[CaretakerNurse]

Had to put my Dad in the hospital under "mental status change" because he could no longer walk and couldn't take care of him at home. Needed to find a Nursing Home for him to go to and NH's take patients directly from hospitals first, from home second. In the interrum while in the hospital, they found and corrected a PE, adjusted some meds and began PT which qualified him for skilled at least for a short time in the NH. He was sent back to the hospital twice from the NH for "mental status change" when had problems swallowing. Sometimes I think that is a convenient diagnosis (a catch-all) but it seems to help with Medicare requirements.

He was very irritable in the morning times, and when I went to see him, wasn't given or offered liquid or food until later then 10:30A and was very thirsty and hungry, if offered them earlier, wasn't irritable anymore. The CNA had 17 patients usually and no way could get to all in a reasonable length of time. I arranged to be there or have someone else there in the morning times for him. I HAVE heard of NH refusing some patients/asking them to leave due to history of violence, sometimes the psych approach, may be a last resort for some people?

[Mister Chris]

Yes, "Granny Dumping" is, as pointed out previously, where the relatives literally leave the "gran" or "grandad", or any other "old relative" with a nursing facility as they cannot handle them, care for them adequately, or just find it an inconvenience. And yes this does frequently happen just before holidays! They somehow just happen to contract "something" and need care from a nursing/hospital facility. (Not always a genuine case of respite for their carers.)

It is sad but true. Having experienced many cases when I worked in a casualty unit in London and also Australia. "gran" just happened to get a bad 'turn' or a chest cold just before the Christmas, Easter, School or family holidays. They get admitted and in some cases no one ever comes to see them. In a few cases I have known there has been an application already filed for them to be admitted to an aged care facility! The whole thing was carefully planned, but still "dumping". In one case I experienced no one ever came to see them or make claim for them and the state had to take over their care and find somewhere for them to go once the hospital could do no more to improve their physical status. The only relatives had moved away!

The other side to this whole aged care problem is now in Australia, that there are no beds for any psychiatrically ill or dementure specific clients if they are over 60 to 65 years old. Psychiatric Units no longer cater for the elderly!
In the wisdom of the 'powers to be' once you get to that age you no longer have a psychiatric illness merely dementia and must be cared for in an old persons home. I was working in a psychiatric hospital specialising in psychogeriatrics when this situation arose and had to assist in sending all our elderly institutionalised (psycho)geriatrics to local, and some distant old peoples homes. It was heartbreaking to see these people who already had problems, moving to a strange environment after spending many years in an institution where they had security, space and familiar things all around them for many years.

Anyway (getting down off my soapbox!), dumping still goes on and will continue probably forever. Or until they bring in siome other way for people to 'dispose' of their elderly, debilitating parents, aunts, uncles, grandparents etc. etc.

Still love nursing even so.
God bless all you nurses.
Mister Chris

[Blackcat99]

My mother has Alzheimer's and I am going out of state for one week next Tuesday. It is costing me a fortune to hire good in-home care for my mother.
Just think of the money I could have saved if I would have just dropped off Mom at the ER? No seriously, I really don't understand how people can just dump off their elderly relatives at the ER and take off. It's a disgrace.

[elkpark]

I've been a psych nurse for a v. long time, and must say that I've seen plenty of "dumping" by LTC facilities. With some facilities, it seemed like anytime a resident raised her/his voice they would ship the person off to the local psych unit, and pop a new person in the bed immediately (often even before the person actually arrived on our unit) and it would then be our job to find a new placement when it turned out there was nothing psychiatrically wrong with the person and no reason for her/him to be on an acute psych unit. This often appeared to be just a way of getting rid of an unpopular resident (someone who complained a lot, or whose family complained).

I remember one woman in particular, who was admitted to us with dire accounts from the NH about how she had abruptly and dramatically declined, the main, specific symptom being that she had suddenly stopped eating ... When she arrived on the unit, she was A&O, v. pleasant and cooperative with us (although I gathered that she had not been so at the NH), and was able to explain to me coherently in the admission assessment that the reason she had quit eating was that she didn't like the food at the NH -- they deep-fried nearly everything, which she didn't care for, and refused to serve her anything else, so she was just eating what appealed to her on the trays (which wasn't much) and leaving the rest. This is a reason for an acute psych admission?? She ate fine for us, and our psychiatrist couldn't find anything else wrong with her, but when we called the NH the next day (needless to say, the admission took place after hours -- otherwise, we might have headed it off in the first place ... ), they admitted that was she told us was basically the truth but they had already put someone else in her bed, so it was now up to us to find her another placement. I have seen more situations like this than I could possibly count, and have worked on psych units where they finally made it a policy that we wouldn't take clients from NHs unless the facility promised to hold the bed and take the person back at discharge -- but the facilities would say whatever we wanted them to in order to get someone admitted, and then turn around and give away the bed ...

The other problem I have seen is psychiatrists "trolling" for patients in nursing homes -- they make monthly visits and encourage the staff to share any concerns they are having about any residents, and then suggest that an acute psych admission (by them, to the unit they have privileges on, of course) might help. Even if residents are being aggressive and/or disruptive in the NH, that doesn't necessarily mean there is anything acutely psychiatrically wrong with them (believe me -- if we (the psych community) could fix dementia, we would!) The person is admitted to the psych unit, and spends a week or two there, during which time the doc tinkers a little with her/his medications; it's never really clear exatly why the person was admitted to the unit and it's certainly not clear how s/he is improved at discharge, or how the decision was made that s/he is "ready" for discharge; the doc makes lots of money off each of these admissions (Medicare -- our tax dollars at work ); so does the hospital; and nothing has really been done for the person that couldn't have been done at the NH (a little med titration). IMHO, it's borderline Medicare fraud ...

I'm not criticizing any individual LTC staff for this problem -- I understand v. well that they have their own set of problems and pressures. But, honestly, nearly all the psych admits from LTCs that I've seen over the course of my career have been inappropriate/unnecessary (psychiatrically) ... There's got to be a better way; acute psych units are not appropriate or therapeutic places to dump DLOPs (the acronym we came up with at one place I worked for "demented little old people") or other varieties of "problem" residents.

[boulergirl]

A while back my boss had one of our residents admitted to the ER at a local hospital in order to get her a psych evaluation. She had been very disruptive on the Alzheimer's wing (and my boss had recently been attacked by a male resident), so she panicked and had her sent out. I was given orders not to allow the hospital to send her back to us until she had been thoroughly evaluated. That night I got a call from the hospital saying that the resident was not observed to be a threat to herself or others and was talking with the staff, so she was coming back. I called my boss, who said she wanted them to keep her until she'd been through a complete psych evalution. (There is a hospital in the area that does the type of evaluation--7 to 10 days--that she was looking for. Why didn't she send her there?) So I ended up talking to the charge nurse and then the doctor, who threatened us with a COBRA violation if we didn't take her back. (I'm a nurse's aide and don't know what that means. MY boss is an LPN.) I called my boss about this and she said, "NO!! They can't do that!" So I let her hash it out with the hospital, her boss, corporate office, whoever--this was her decision, her battle, and I didn't want to be caught in the middle of it. That night, the resident went to her daughter's house (and I think there was a court order prohibiting this). Believe me, it was no fun being threatened over the phone by a doctor and not knowing what to say to them. I hope I'm never forced into a similar situation again.

BTW, she's back with us now and is doing fine.

[Town & Country]

I've been a psych nurse for a v. long time, and must say that I've seen plenty of "dumping" by LTC facilities. With some facilities, it seemed like anytime a resident raised her/his voice they would ship the person off to the local psych unit, and pop a new person in the bed immediately (often even before the person actually arrived on our unit) and it would then be our job to find a new placement when it turned out there was nothing psychiatrically wrong with the person and no reason for her/him to be on an acute psych unit. This often appeared to be just a way of getting rid of an unpopular resident (someone who complained a lot, or whose family complained).

This is what happened ~ we got a little old lady from a NH; she wasn't even demented. She was sharp as a tack.
Evidently, she had been upset about her family's lack of attention at the NH.
Seems like these old people "fall thru the cracks" ~ NH can't/won't handle their "behaviors" and the psyche unit isn't the place for them.

It's a need waiting to be filled. Inservices to NH on how to better deal with "high-maintenance" residents? Something like that.........

[noclpn]

[quote]

I remember one woman in particular, who was admitted to us with dire accounts from the NH about how she had abruptly and dramatically declined, the main, specific symptom being that she had suddenly stopped eating ... When she arrived on the unit, she was A&O, v. pleasant and cooperative with us (although I gathered that she had not been so at the NH), and was able to explain to me coherently in the admission assessment that the reason she had quit eating was that she didn't like the food at the NH -- they deep-fried nearly everything, which she didn't care for, and refused to serve her anything else, so she was just eating what appealed to her on the trays (which wasn't much) and leaving the rest. This is a reason for an acute psych admission?? She ate fine for us, and our psychiatrist couldn't find anything else wrong with her, but when we called the NH the next day (needless to say, the admission took place after hours -- otherwise, we might have headed it off in the first place ... ), they admitted that was she told us was basically the truth but they had already put someone else in her bed, so it was now up to us to find her another placement. I have seen more situations like this than I could possibly count, and have worked on psych units where they finally made it a policy that we wouldn't take clients from NHs unless the facility promised to hold the bed and take the person back at discharge -- but the facilities would say whatever we wanted them to in order to get someone admitted, and then turn around and give away the bed ...







In most states, beds (by law) can not be filled for at least 24 hours after a transfer to another facility for evaluation. At our facility, it is 72 hours by law. Also, residents act one way at LTC and then do a 180 for ER or other facility. I have never heard of a LTC facility that deep fried everything. LTC facilities are under strict regulations regarding nutrition. In my LTC, we offer alternatives to every meal (state mandated) and offer snacks throughout the day (state also checks and verifies that this is done). I have had a 1:40 patient ratio at an acute skilled care facility, so you can imagine how hectic and busy we are. Even there, simple questions like UTI? or Nutrition? would be assessed for mental status change. It also worries me that other psych nurses may feel the way that you do and are downplaying s/s reported from the nursing home. Psych is a big problem in LTC, docs want to give meds to easily without even attempting to find the real cause of the problem. Some LTC nurses fight for the res to get screened by psych. Although they might be A&O for you, they might have been a different person 24 hours ago. Just remember that!!! Also, I would be more worried about sending the pt back to the NH that was not providing proper nutrition than being put out by finding them a new placement.

[elkpark]

It's a need waiting to be filled. Inservices to NH on how to better deal with "high-maintenance" residents? Something like that.........

They know how to "better deal with 'high-maintenance' residents" -- better staffing, better programming, etc. -- but that would cost money and eat into their profits (can't have that, now, can we? )

(Again, I'm not criticizing the individual, direct care staff, but the administrative people who are making the big financial decisions.)

In most states, beds (by law) can not be filled for at least 24 hours after a transfer to another facility for evaluation. At our facility, it is 72 hours by law. Also, residents act one way at LTC and then do a 180 for ER or other facility. I have never heard of a LTC facility that deep fried everything. LTC facilities are under strict regulations regarding nutrition. In my LTC, we offer alternatives to every meal (state mandated) and offer snacks throughout the day (state also checks and verifies that this is done). I have had a 1:40 patient ratio at an acute skilled care facility, so you can imagine how hectic and busy we are. Even there, simple questions like UTI? or Nutrition? would be assessed for mental status change. It also worries me that other psych nurses may feel the way that you do and are downplaying s/s reported from the nursing home. Psych is a big problem in LTC, docs want to give meds to easily without even attempting to find the real cause of the problem. Some LTC nurses fight for the res to get screened by psych. Although they might be A&O for you, they might have been a different person 24 hours ago. Just remember that!!! Also, I would be more worried about sending the pt back to the NH that was not providing proper nutrition than being put out by finding them a new placement.

That particular example is quite old, so I would hope that the NH rules regarding nutrition and dumping have been improved since then (because of examples like that). It was in a very rural part of Appalachia, and, heck, the hospital kitchen deep-fried nearly everything (although they did always have alternative choices), so I don't doubt the NH kitchen did. When we confronted them the next day, they basically conceded that the entire episode was because this woman was giving them a hard time about the food.

I agree that psych is a big issue in LTC, and, probably, the residents who might most benefit from a psych eval don't get them. However, there is no reason a psych eval can't be done at the NH -- in fact, the results of the eval would be more valid if done in the resident's "natural habitat" instead of in a new, unfamiliar environment. That's no real reason to admit someone to an acute psychiatric unit, and it's certainly no excuse for dumping residents.

And I don't "downplay" s/s -- I'm merely commenting on how often it was the case, in my own experience, that the NH would report symptoms and we would be unable to find any evidence of the symptoms ourselves. You cannot keep people on a psych unit because someone else (even NH staff) said they were exhibiting symptoms when you can't find any evidence of an acute problem ...

[dutchgirl]

looks like geriatric psyche care units will be necessary - hope they get some before I need it...

[Nascar nurse]

Wow - this LTC nurse feels beat up on in here. OK - put the shoe on the other foot for a moment. You have a parent in LTC facility. How do you feel about your Mom/Dad being in the same facility where another resident just down the hall is hitting, swearing, sexually abusing, etc.. etc, other residents. You would be screaming "Lawsuit" so dang fast it wouldn't be funny if it was your parent that got hurt. No we can't just restrain them - that is highly against our regulations and we can't just chemically restrain them (ie: snow them) either - Also against regulations. Other LTC nurses posts are correct, we do try to eliminate other possiblilties, ie UTI, Resp, infect and the like. We also try to adjust psych meds at a slow pace, but this all takes time and in the mean time - IT'S YOUR MOM THAT MAY GET HURT. We have an obligation to provide the best care to all residents not just one. One of the first posts indicated that we didn't WANT to provide 1:1 care to problem residents. Have your ever been in LTC - please!!! If I provide 1:1 for even 1 hour - thay may be AT LEAST 20 residents not getting any attention for one full hour - AGAIN THIS COULD BE YOUR MOTHER UNATTENDED WHILE I HANDLE THE OTHER PROBLEM. As for education - in my state we are required to have an annual inservice (plus upon hire) regarding the care of specialized/dementia residents. We preach over and over about the correct way to approach a confused person, etc, etc. But we are not the only ones they come in contact with - ie: lots of times another resident purposely or inadvertently gets them wound up, heck I've even heard residents go balistic when the church group was singing X-Mas songs in the hall. And last but not least - we have received plenty of admissions from the hospital that told us what a "sweet LOL" so and so, only to find out from family later that the hospital had had a bunch of problems with them too. Sorry for the long rant, but it is very unkind to just blame the LTC industry for this problem. I understand your feelings too. I think the system is just broke and these poor folks fall through the cracks. I hear in ILL. they are thinking of passing a bill regarding criminal background checks on all pre-admit LTC residents to prevent convicted sex offenders from being admitted. Just goes to show, this whole dilemma will not end any time soon.