Discharged - RN doubts

[Nurse SMS, MSN, RN]

What do you do when you have a patient who is being discharged to home, lives alone and it is just kind of obvious that patient should NOT be living alone anymore or at least for a while due to mobility issues and two falls in the last two months? Family was on scene, involved and concerned but not able to provide the needed assistance and not yet there yet in terms of accepting this person probably needs more help than they are getting and probably on a permanent basis. The patient could barely move from the wheelchair to the car. I just had a bad bad feeling about sending this person home. Is this something I just have to get used to or was there something that should have been done? Who makes that call and who talks to the family about it?

Postscript: I am a new grad and working with a preceptor. Just had my sixth shift on the floor.

[Altra, BSN, RN]

This is tough to see.

But relinquishing independence in the name of safety is not something that all seniors agree to readily, and it's understandable. If you've had the most frank discussion you can with the patient and family, and discussed specific possible "worst case scenarios" ... you've done what is needed. Educate the patient and family to look at the home with a fresh eye from a safety perspective, and see if there are small changes in routine that can benefit the patient. Are they perhaps eligible for some home health aid services for help with ADLs (but not skilled nursing)?

It is hard, I know. But human beings do not exist in the vacuum of the ultra-safe ideal care environment -- we all adapt and make our way as best we can.

[FancypantsRN]

I agree with above. Do you have a case manager on your unit? They have the resources to know what the pt qualifies for (insurance wise).

[Nurse SMS, MSN, RN]

We do, but they aren't there on the weekends. The patient came in Saturday and was d/c'd on Sunday late in the day. There were fracture concerns that turned out not to be fractures after all, so the patient was sent back home. The family visits twice a week and twice a week home health comes in and gives assistance with ADLs. The patient could not bend their knees or lift their legs for the most part.

[Twinmom06, ASN, APN]

in the hospitals where I've done my clinicals for med/surg they generally page an on call social worker prior to discharge in those scenarios...

[KelRN215, BSN, RN]

Perhaps this patient qualifies for more hours with his HHA after several falls. It sounds to me that he needs to be re-evaluated so whatever agency that provides his services should be contacted and they can take it from there. Basically all you can do is offer the services...whether or not the patient tries to take advantage of them is up to them. Is Assisted Living an option for this patient?

[nurseprnRN, BSN, RN]

i agree with altra. educate the family to the max. make sure the physician writing the discharge is in on those conversations, even try to get a signed ama (against medical advice) from them, which is sometimes enough to get a family's attention.

your hospital should have a case manager or social worker on call on off-shifts and weekends for these kinds of cases. if i were that person (and i have been) i would get her in a short-term rehab facility to work on her mobility and endurance, if her family does not provide her more care in the home. and if she flunks that and has to stay, or signs out ama, at least you know you didn't send her to an unsafe situation.

failing that, my rn license renewal form asks me to swear i will report elder abuse (among others). tell the family they can call the patient's town or state commission for the elderly, or whatever it's called, and ask for help from a case worker, and actually, you'll be happy to call them right now, you have the number right here in your pocket... .

i would hate to see what that family will do when you send her home (how? in a chair car?) on sunday afternoon and when they come to see her on tuesday night she's been on the floor since she went to throw a shoe at 60 minutes. they could make a case for inappropriate discharge, especially as her nursing assessments will say something (lots of things) like, "unable to toilet unassisted, cannot lift legs to get out of bed without assistance..."

[classicdame, MSN, EdD]

If you got Case manager involved and patient refused help there is not a lot you can do. If case mgr made suggestions, pt was silent on the matter and family is the one who refused, you might consider calling Health Dept regarding elder abuse.

[tokmom, BSN, RN]

If no on call discharge planner, then take to the MD to see if you can get another day so DP can get involved. If MD won't, document your butt off and also call DP (leave voicemail if you have to) and let them know so they can follow up on Monday.

Sadly, some insurances will not cover HH or some sort of outside help until the pt fails a number of times. Scary thought...

[Anna Flaxis, BSN, RN]

In my facility, discharge planners/case managers/social workers are not there on weekends, but you can make a referral for someone to contact the patient/family on Monday when the appropriate person comes in.

[DixieRedHead, ASN, RN]

Once, just once, in all my years of practice, I have had to discharge a patient to the street. It was in my first year at a hospital. I promised myself I would never do it again. Several times it took a long time and a lot of effort to find a shelter or family member who would help.

I don't know what I would do in your case. This has stuck with me for years. I can't forget it.

[Nurse SMS, MSN, RN]

Yeah, it really bugged me to send the patient home. The family was definitely not suspicious for elder abuse. They were very concerned, just kind of deer in headlights about it all. I wish social work/case mgmt had been there. If they are on call on weekends I wasn't informed of it. Certainly something I am going to be asking about and getting up to speed on. Thanks for all the feedback.