Refused admission

[savoytruffle, BSN, RN]

Hi there! I currently work as an executive director/ RN administrator at a dementia care adult home. It's not a skilled facility. We are considered more of an assisted living level. NY state regs are very specific about what kind of person I can retain. I have a resident that is exceeding my level of care and has a PRI that places her at a skilled level. (Not a real high skill level, but just outside my license allows). A SNF accepted her and we discharged her. When she arrived to the SNF she became very agitated and I received a call that they sent her to the ED for evaluation and are now refusing to admit her. After offering a bed and accepting a resident, do they have the right to refuse? I have discharged her! Her meds are gone and her apartment was cleaned out by family this morning. I can't knowingly re-admit a resident that has documentation stating she is outside my scope. Has anyone encountered this before?? It seems very unprofessional to me. Please help!!

[Silverdragon102, BSN]

If the person had been discharged and currently in Emerg then they need to get the SW involved as they are no longer your client or problem

[sallyrnrrt, ADN, RN]

it is on the hospital ER and their social worker, I have done similar I even called DADs sharing how I could not meet a certain resident's need......I was told by them, "you know you can not taker them back"

[tyvin, BSN, RN]

Why was she released to go to a SNF when she lived at your facility (what skilled her?); she should have been released to a LTC...SNF is not long term placement. Is that part of the problem? They probably realized that she wasn't skilled, therefore not going to get a skilled bed (which of course is for skilled patients only).

[savoytruffle, BSN, RN]

She was going to be placed on a long term care floor. They knew that she was adulatory and had dementia. They knew she was currently living in a secured adult home. The thing that moved her on- she was no longer appropriate for the adult home due to a worsening of her dementia. I do not employ CNAs, only personal care aides. We cannot give a bed bath, change a brief in bed, feed a resident, or provide any physical assist with transfers or ambulation. She was progressively getting more resistant to care, refusing medications, and loosing weight. She needed to be somewhere with more medical oversight. In my home, residents still see their Primary care docs. She would refuse to leave for appointments. We literally could not get her to go to the MD. Her resistance to personal care made her more susceptible to UTIs, which we had a hard time treating because she wouldn't give a urine sample or go to the MD. A few times she ended up in the ER from them. We just couldn't carry on like that anymore. The nursing home evaluated her and accepted her, then twenty minutes after she arrived, dumped her at the ER and abandoned her. It's a very sad situation. Her family is distraught.

[tnmarie]

Many nursing homes will not accept or keep residents with certain behaviors. I work at one that accepts EVERYTHING, but some nursing homes do not accept yellers, overly combative people etc. If they do get them, they ship them out pretty quickly. That may be what happened here. Since she is discharged from your facility, you really can't do too much. It does really stink for her and her family. They will now have to find another place that WILL accept her.

Several of our residents have been kicked out of every nursing home in the area before coming to us, so depending on her behaviors, it could take them a while to find a permanent place for her.

[lifelearningrn, BSN, RN]

She was going to be placed on a long term care floor. They knew that she was adulatory and had dementia. They knew she was currently living in a secured adult home. The thing that moved her on- she was no longer appropriate for the adult home due to a worsening of her dementia. I do not employ CNAs, only personal care aides. We cannot give a bed bath, change a brief in bed, feed a resident, or provide any physical assist with transfers or ambulation. She was progressively getting more resistant to care, refusing medications, and loosing weight. She needed to be somewhere with more medical oversight. In my home, residents still see their Primary care docs. She would refuse to leave for appointments. We literally could not get her to go to the MD. Her resistance to personal care made her more susceptible to UTIs, which we had a hard time treating because she wouldn't give a urine sample or go to the MD. A few times she ended up in the ER from them. We just couldn't carry on like that anymore. The nursing home evaluated her and accepted her, then twenty minutes after she arrived, dumped her at the ER and abandoned her. It's a very sad situation. Her family is distraught.

It sounds like you did everything right, as you can no longer care for this patient at the level of care she requires. On what grounds are they refusing to admit her back, I wonder? Can they send a patient to the ER and then refuse to readmit like that? I'm curious what her behaviors were that they are flat out refusing to take her back? I hope the family can get her placed soon, and with a facility that is prepared to help patients like her transition. This must be very distressful and confusing for her.

Stories like this, and in my (albeit limited) experience in geriatrics, there is a huge gap that needs to be filled when it comes to dementia patients. Assisted living facilities sell the 'aging in place' philosophy, but in the real world, that is not realistic for dementia patients unless these facilities start actively preparing their facilities (including proper licensing and staffing) to meet the needs of these patients as the disease progresses.

The sad fact is, as a society, we are not prepared to care for the realities of our aging population, particularly, those with dementia.

[melizerd, ASN, RN]

We frequently have patients like this on my floor, they may need med adjustment or just in need of placement due to change in behavior. So the SW works with other facilities to find one appropriate for placement. They wouldn't go back to a place they skilled out of, but stay in the hospital wi us until a new placement can be arranged.

[vintagemother, BSN, CNA, LVN, RN]

If they admitted her, then sent her to the ER then she was their pt, not yours.

If she was never admitted at the new facility, I guess the hospital could try to send her back to you, but you have to refuse.

Some people are hard to place. She sounds like one of those. But it's not your problem, anymore. I hope it all works out for the pt and she gets the care she needs at an appropriate placement.

PS yes they can send some one to the ER and refuse to take them back. Some people call it "dumping" but it's sometimes the only way to get a pt transferred to a more appropriate level of care. Sad system. But that is the system.

[NICUmiiki, DNP, NP]

We get patients like this in our ED whose home won't take them back. It's a shame that they get dumped into the ED like that. It not really our place to find them somewhere to live. We have psychiatric social workers, but they don't place people into long term care. They end up getting admitted to a medicine floor with a sitter until the medical social workers can find them somewhere appropriate to go.

[lifelearningrn, BSN, RN]

I guess I thought LTC facilities were required to accept residents back once they were sent out? Especially since they had evaluated her and accepted her into their facility. Why did they send her to the ER? Agitation? Would she not allow the admitting nurse to do an assessment? (I'm guessing that was probably the case), but still, is agitation upon admission that unheard of and troublesome that they wont take the patient back? Is this patient a Geri-psychiatric candidate? I've heard those can be pretty bad places for dementia patients. :/

[savoytruffle, BSN, RN]

I got a call that she saw her name on the outside of the room and got upset. She would not allow the nurses to assess her. She was able to over turn a med cart. She went straight out to the ER to be evaluated for the psych emergency center, but being that she has dementia and not a true psych disorder they would not accept her either.