Discharging disheveled patients from the hospital

Antikigirl, ASN, RN · Jun 1, 2005

I work in an acute care setting and have worked in LTC setting in the past. Have seen both sides. When we discharge to a LTC here, we have a discharge form that we fill out. It lists the dx, physician orders for meds, activity, diet, nebs, o2, foley(reason), allergies. Most of the orders still have to be called and verified by the LTC with a physician since they seldom sign them ahead of time for us. We are required to call a verbal report to the nurse at the recieving facility. We also have to copy all labs, imaging reports, procedure reports, consultations, h&p's and that days MAR to send back with pt. We send the original copy and keep the carbons, and usually fax the orders ahead of time so that they may have time to get ahead on getting meds ordered from the pharmacy. Had a problem awhile back with LTC facilities c/o not getting report, dressings not changed etc. So we now have a discharge checklist(yes more paperwork) that we go over. It list things like calls made to notify family or poa of transfer, iv dc'd, foley emptied, report called orders faxed, pt.'s cleaned prior to discharge, dressings changed, dated, timed and initialed, etc. It only takes a few minutes to complete and it has really helped. Our problems seemed to be narrowed down to a select few who weren't doing what they were suppose to.
My bigest c/o so far though has been that when we get direct admits from the LTC facilites we don't get a report, so I see where your coming from. It's very difficult to assess a demented, nonverbal, total care pt. who is a poor historian. I can usually find some info in old records, but it's nice to know things like level of activity, ambulation?, ability to feed self, inc/inv., able to swallow pills and we don't always have family to talk with. Can be very frustrating. I usually call the LTC facilty and speak with a nurse, who is usually not happy with me, as she is busy and doesn't have any more time to be on the phone then I do.
On the flipside I admitted a pt. whom I had sent to the nursing home 6 weeks prior with orders to change central line dressing q week. While doing my assessment found her to still have the dressing I had applied when I discharged her 6 weeks ago.

One of our hospitals does this too a T! AND I LOVE THEM! But sadly the nearest hospital does not follow up all the time if at all. I use to get RN to RN calls but for some reason those aren't coming in as much (must be a staffing thing). But I asked for the originals and a fax before discharge so we can get things rolling before the resident returns..but sadly I get to find the info from this hospital from the EMT's or w/c van at the door on carbon . But we do our best.

I too worked hospital, ER and Neurovasc...I know that end too (luckly I worked in the one that does communicate!).

We have brought up our greivences to the admin of the hospital in question, and encouraged other LTC's to do the same so we can all resume a teamwork atmosphere :).

But mainly I don't blame the nurses as much as the chicken scratch MD who is in a hurry to discharge between patients and sends me some cryptic message and no DX!

meownsmile, BSN, RN · Jun 1, 2005

I agree with mjlrn,, and hospitals have as many poorly kempt patients coming in from NH's as they do having them come back that way. I think its best to just accept the fact that sometimes things dont get done exactly the way WE would want them done and do what we can to make the situation right for the patient. It does absolutely no good to point fingers and lay blame. We have no idea what was on someone elses plate that day, so reserve judgement until you consistently never have days when some things get done halfway.

As far as shaving goes. Until hospitals let nurses use electric shavers like they do in NH's it will probly stay that way. Maybe LTC's should send the patients electric razor with them if they have to go to the hospital? Or is there a community shaver that gets used? Let's face it there are a lot of differences in the way LTC's are allowed to do things and the way hospitals have to.

CapeCodMermaid, RN · Jun 1, 2005

I agree with mjlrn,, and hospitals have as many poorly kempt patients coming in from NH's as they do having them come back that way. I think its best to just accept the fact that sometimes things dont get done exactly the way WE would want them done and do what we can to make the situation right for the patient. It does absolutely no good to point fingers and lay blame. We have no idea what was on someone elses plate that day, so reserve judgement until you consistently never have days when some things get done halfway.
As far as shaving goes. Until hospitals let nurses use electric shavers like they do in NH's it will probly stay that way. Maybe LTC's should send the patients electric razor with them if they have to go to the hospital? Or is there a community shaver that gets used? Let's face it there are a lot of differences in the way LTC's are allowed to do things and the way hospitals have to.

You're right. There are many differences..but I think you've got it backwards. Hospitals are allowed to give IM Haldol willy nilly...use any kind of restraint they see fit for "the patient's safety". We HAVE to have a restraint assessment and an MD order and a team meeting and a family consent before we use a restraint. They are allowed to put a restraint on anyone at anytime. We HAVE to do skin checks and turn every patient at least every two hours or get a citation from the DPH. They are allowed to send people back with all sorts of skin issues from stage 2's to stage 4's with no documentation and no no chance of reprisal.

Long Term Care Columnist / Guide · Jun 1, 2005

You're right. There are many differences..but I think you've got it backwards. Hospitals are allowed to give IM Haldol willy nilly...use any kind of restraint they see fit for "the patient's safety". We HAVE to have a restraint assessment and an MD order and a team meeting and a family consent before we use a restraint. They are allowed to put a restraint on anyone at anytime. We HAVE to do skin checks and turn every patient at least every two hours or get a citation from the DPH. They are allowed to send people back with all sorts of skin issues from stage 2's to stage 4's with no documentation and no no chance of reprisal.

Uh......I beg to differ! For one thing, I can't remember the last time we restrained a patient; we use CNAs as 'sitters' on a 1:1 or 1:2 basis. And when we DO apply restraints, we have to obtain an MD order within one hour, we have to use the least restrictive restraint possible, and we can't just 'give IM Haldol willy-nilly'---we don't even have it on the floor, we have to get it from pharmacy. In addition, we have to document our hind ends off as well---Q 15 min. assessment for acute restraint use (e.g. ETOH/meth withdrawal) and Q 1 hr. for medical-surgical restraints (pt. is picking at IVs/dressings or climbing OOB). We also have to release the restraints, offer food/fluids and toileting, do range-of-motion and turn them every 2 hours (try doing that with someone going through DTs or experiencing a psychotic break :stone ).

I don't know where you got your information, but it's certainly not that way where I work........and if we sent a pt. who came in with intact skin to a NH with a Stage II or worse, we'd hear about it for sure!

CapeCodMermaid, RN · Jun 1, 2005

Perhaps you work in a "better" hospital. I would say that more than 1/2 of the patients we get from the local hospital have been given Haldol sometime during their stay. Surely they can't all be psychotic....and at least 1/2 if not more of our patients who spend more than 3 days there come back with a stage 2 or worse.

And, oh yeah, the state surveyors don't see "climbing out of bed" as a good enough reason to restrain someone.

Long Term Care Columnist / Guide · Jun 1, 2005

Years ago, we used to use restraints and anti-psychotics a lot more than we do now. The federal Joint Commission, which surveys and accredits hospitals, has been tightening up on acute care facilities much like the States have with LTC, and evidently the hospital you describe either isn't accredited, or they just don't care.......I can't imagine half of any hospital's patients being given Haldol or being discharged with pressure ulcers they didn't come in with, JCAHO would yank their accreditation in a flash. Wow. :stone

meownsmile, BSN, RN · Jun 2, 2005

Thanks mjlrn,, i was going to post similar to yours. All joint commission standards are followed in my hospital also, and i think if capecod is getting less maybe they need to report to joint commission with documentation about the hospital this is coming out of.

I still hold to my thought that we see as much awful care coming from certain LTC as they do coming from certain hospitals. Lets face it,, in our own areas we know which LTC and hospitals are notorious for poor care. To presume all are in a blanket category is competely rediculous.

LPNVirgo · Jun 3, 2005

Thanks mjlrn,, i was going to post similar to yours. All joint commission standards are followed in my hospital also, and i think if capecod is getting less maybe they need to report to joint commission with documentation about the hospital this is coming out of.
I still hold to my thought that we see as much awful care coming from certain LTC as they do coming from certain hospitals. Lets face it,, in our own areas we know which LTC and hospitals are notorious for poor care. To presume all are in a blanket category is competely rediculous.

Where there is lack of proper staffing, lack of education and lack of follow through there will be lack of proper care. I get told that I am a nitpicker for wanting my residents to have proper AM and PM care. If I see someone left in poor hygienic condition I report it and clean them up. It's sad to see such apathy on the part of the people that are providing the bulk of the direct care. I make a point to educate and follow up with my nurses aides and my peers.

Cubby · Jun 4, 2005

And yet, LTC facilities are the ones with the bad reputation. I send one of my residents to the hospital with an acute process and when they return they have bedsores, and don't look (Or smell) like they have had a bath the whole time they were gone. But yet LTC nurses aren't 'Real Nurses' Makes my blood boil!

leslie :-D · Jun 4, 2005

You're right. There are many differences..but I think you've got it backwards. Hospitals are allowed to give IM Haldol willy nilly...use any kind of restraint they see fit for "the patient's safety". We HAVE to have a restraint assessment and an MD order and a team meeting and a family consent before we use a restraint. They are allowed to put a restraint on anyone at anytime. We HAVE to do skin checks and turn every patient at least every two hours or get a citation from the DPH. They are allowed to send people back with all sorts of skin issues from stage 2's to stage 4's with no documentation and no no chance of reprisal.

i've witnessed (too often) what you describe.

and the 3 hospitals i've dealt with are all jcaho accredited.

so maybe it's just in massachusetts that hospitals can randomly use restraints, chemical or otherwise?

and so many stage II's (minimum)....

yes, i acknowledge that it works both ways.

but all i'm saying is using restraints in a snf is a HUGE deal.

fortunately, the hospice unit i worked in (which was attached to a snf) was hypervigilant in preventing decubs and no restraints unless it was an emergent issue; and that order is good for only 24 hrs.

evidentally p&p's/regulations vary from state to state.

leslie

CapeCodMermaid, RN · Jun 4, 2005

Ah,yes...the lovely state of Massachusetts...the mecca of medicine where there are more regs for LTC than for the Nuclear Power Plant in Plymouth! At my 142 bed facility, we currently have only 8 restraints...3 of which are Merry Walkers (who came up with that name?!?). We only use restraints as a last resort after meeting with the team which includes nurses and the rehab people. We have a restraint meeting once a week and get rid of them as we can.

As far as pressure sores, the company just spent more than $100,000 buying new beds with pressure relieving mattresses. Everyone in the building now has an electric bed with a beautiful GeoMattess. Our rate of acquired pressure sores is extremely low...3 in the last quarter and we resolved 2 of them within 2 weeks. We do skin checks on everyone weekly, and have "skin rounds" once a week with the skin committee to monitor any wound in the building.

Long Term Care Columnist / Guide · Jun 4, 2005

Ah,yes...the lovely state of Massachusetts...the mecca of medicine where there are more regs for LTC than for the Nuclear Power Plant in Plymouth! At my 142 bed facility, we currently have only 8 restraints...3 of which are Merry Walkers (who came up with that name?!?). We only use restraints as a last resort after meeting with the team which includes nurses and the rehab people. We have a restraint meeting once a week and get rid of them as we can.
As far as pressure sores, the company just spent more than $100,000 buying new beds with pressure relieving mattresses. Everyone in the building now has an electric bed with a beautiful GeoMattess. Our rate of acquired pressure sores is extremely low...3 in the last quarter and we resolved 2 of them within 2 weeks. We do skin checks on everyone weekly, and have "skin rounds" once a week with the skin committee to monitor any wound in the building.

I hear what you're saying about the regulations in LTC.......I worked in the field for several years, as a charge nurse and then as a manager, and there were more rules than you could shake a stick at. However, it sounds like your facility is one of the better ones........regulations or no, a great many LTCs have neither the staffing nor the $$ to provide the kind of care you describe. Your residents are very fortunate; given the amount of money they (or the state) have to pay for their care, however, this level of service should be standard, not exceptional.......alas, in many NHs residents are lucky to be turned, toileted, and offered fluids half as often as their care plans call for. :stone