SNFs and ALFs passing the buck ?

[holistic1028]

What is it with these facilities expecting for hospice to act as a primary caregiver?! I have been in hospice for a little over 6 months now. I've worked in SNFs, rehabs and also a memory care unit before and I never passed the buck for someone else to do. Yes, I would call hospice and report changes in conditions but I would never sit on my butt behind a desk and call hospice when a caregiver reports a patient had a seizure or if a patient has hemorrhoids or is constipated and needs a suppository.

I currently have a patient on hospice in an Assisted Living Facility that has a licensed nurse on duty. My patient has been constipated several times and now has hemorrhoids, all the orders are there i.e. to give bisacodyl supp or hemorrhoidal supp PRN etc... Well this nurse told me "we don't give suppositories here" and they expect for hospice to come our daily to give them if thats what the patient needs. I explained to her the whole mission and goal of hospice and that we don't take over a patient's care but will ASSIST in providing symptom and pain management by teaching and providing medications if needed, etc. Am I missing something?????? Has someone been through this before? How did you resolve it or what did you say to explain what hospice is for without sounding like you didn't want to take the responsibility (which is not the case) because if Im there, I will give a supp if I am able to or assist the patient with whatever they may need during my time there. I need advice on how to deal with these type of situations

[lifelearningrn, BSN, RN]

The ALF I have worked with thus far do NOT administer suppositories. It's considered a 'skilled' or 'invasive' nursing intervention and ALF don't provide that level of care. If constipation is causing the need for suppository daily, perhaps you can schedule Senna-S bid or lactalose daily, as those are both medications ALF will administer. Constipation IS something that hospice manages, so I don't really see an issue with them calling on your for constipation issues, but suppository daily is unreasonable. Find something ORAL that works.

I agree that we are not (and can not be) full time caregivers and our job is to educate. With facilities, we need to work hand in hand with the facilities to meet the patient's needs. It sounds like your facilities needs some extra "tucking in".

[holistic1028]

I was using that only as an example regarding giving a PRN suppository. This particular patient is already on a bowel regimen of senna BID. But let's say the patient has hemorrhoids and is in pain from it, and there is an order for PRN hemorrhoid supp such as prep H in place, is it hospice responsibility to come out daily to administer a suppository PRN because this facility licensed nurse refuses to do so? From my understanding it is not. But like I said, when I am there during my visit I will definitely give whatever the patient may need since nothing is done by facility nurse. But we are not there daily, so is it fair the patient is in pain from hemorrhoids AND there is an order in place to give PRN medication but it isn't being given because hospice is expected to do it? Just like if this was a patient at home, that is not something hospice would do. We wouldn't up our visits to daily to do wound care, give suppositories or check vital signs for example. Thats home health care. We can TEACH the primary care giver on how to do those and assist in managing symptoms for the patient. Unless my understanding and what I was taught wrong about hospice? I understand that an ALF is not a SNF and the care they can provide is very limited, but it would be easier for me to understand if they did not have a LVN on duty. What is the purpose of a licensed nurse working in a facility if they're not going to do anything clinically or any interventions with a patient? I don't get it. We will get called over the weekend to make a visit because the patient has an intact blister.. WTH?

[vintagemother, BSN, CNA, LVN, RN]

I think that the problem has to do with the facility's level of care. From what I understand, after working in LTC ALF and LTC psych, we are simply not allowed to do certain procdures because of the facilities licensure.

As an lvn I can do certain procedures, but my "facilities non medical licensure" restricts my scope further.

[holistic1028]

Oh I see, so that facility hiring a licensed nurse is more for sales or for glory? Because from what I've noticed the LVN at this particular ALF sits in an office as the "director of resident services". It seems more as an office administrative position rather than a nursing position. I guess I'm having a hard time understanding because when I was a LVN I also used to work in an ALF and we passed all meds and administered all within scope of LVN as needed and assessed patients as needed. I've already spoken to family about transferring to a LTC because pt is total care and this facility is not able to provide the care the patient needs but they are not able to afford it so the facility just passes the buck to hospice to care for patient. I've already changed frequency to 5x week, I as RN case manager visit 2x week and LVN visits 3xweek but they also call on weekends for on call weekend nurse to visit for petty issues (something that could be handled by nurse there or instructions given over phone). This patient is not actively dying. Something has to change! Its ridiculous.

[lifelearningrn, BSN, RN]

It is more of an administration position rather than a position where the nurse performs skilled nursing. The nurse is on staff because medications are being ordered and administered, and she is there to oversee the caregivers and medication techs, implement "wellness" programs, and keep the facility in compliance.

Senna BID is not working for this patient. It's up to you as the care manager (which you are for this patient) to work with the doctor and find a solution to the chronic constipation. Senna-S 3x daily, lactalose bid, mirilax daily, or a combination of these. Care givers can apply prep-h ointment q2hrs if ordered, right? So rather than orders for suppository, perhaps your doc can order that instead.

A total care patient does not belong in an ALF, period. I'm having a hard time understanding how a SNF is more expensive than the ALF?? If the ALF can not meet the BASIC care needs of the patient, he has to be moved, period. Get the social worker on this asap.

[toomuchbaloney]

SNF beds are in very short supply in some areas of the country. Fairbanks Alaska for example (3rd largest city in AK), a community of more than 35k people has ONE SNF with 90 beds for both Skilled and Rehab care. All other patients requiring care are in ALFs or group homes and that includes folks who are total care.

These sort of issues generally require a team meeting with the facility, the family, and the hospice team to collaborate on the POC which will meet the needs of the patient within the confines of ability and capacity of all involved parties.

Good luck.