I agree with chrisrn24, many times when things don't "seem right" there is usually a back story somewhere. Often a younger person is unable to be compliant for a variety of reasons, oftentimes not their fault, and keeping them in a SNF for a short period of time is actually more therapeutic and less expensive then sending them home and then readmitting them back to the hospital when the wound gets infected or they become contracted or whatever.
I do know that hospice tries to make sure someone is with the patient if they are dying. It is usually the patient's choice where services are provided. Hospice can provide services anywhere - SNFs, ALFs, private homes, in-patient units, hospice houses, trailers, we have even done hospice visits in homeless camps because the patient was AO4 and wanted to stay in place. If you see a hospice patient in your facility that you feel is actively dying or is having new symptoms, you can request the hospice company to provide crisis care (a/k/a continuous care), which is short-term 24 hour care for the patient. Patients on crisis care have to be assessed by a hospice nurse daily to maintain their crisis care status. CMS has really been hitting hospices hard the last few years for giving crisis care that CMS feels is not warranted. If the patient receives crisis care and they are stable, then that is considered fraudulent billing, usually Medicare/Medicaid fraud, and with the tight federal budget, hospices all over the country are being audited for this. Under CMS regulations, "actively dying" is not
considered a valid reason for crisis care, it is considered the expected outcome.
Hey, I couldn't make this stuff up.
So if you see a patient on hospice that is declining, find a "new symptom", which could be anything - increased pain, confusion, anxiety, agitation, decreased LOC, N/V, dyspnea, respiratory distress, fever, diarrhea, constipation, etc, are all considered valid new symptoms that could trigger crisis care. Follow your facility protocol for contacting hospice and request an evaluation for CC. And your facility should have a hospice nurse that does at least weekly visits on each of their patients...make friends with her, she can be a valuable resource for you. There may even be several hospice companies coming to your facility, get to know them all.
Good luck in your nursing career! It sounds like you really care about your patients and are doing a wonderful job.