Anyone else think this is unsafe?

[hospicenurse]

Hi all-

Here in NJ we have residential facilities (not SNF's) where clients have their own apartments but have communal meals and a nurse who manages meds. The nurses are not there 24 hours, there are aides at night and a nurse on call.

Besides the obvious concern over how patients get PRN meds - which has worked out fairly well - the oncall nurse has actually come in to medicate them, my other concern is this: the facilities where I have hospice patients keep the patient room locked (the residents have their key - but most of my patients cannot use them as they decline) and refuse to allow side rails on hospital beds. They say this is a state law. I am really uncomfortable with this. What if there is a fire? What if the patient falls out of bed and nobody even knows for hours?

I always express my feelings to whatever family is available, which naturally irritates the management of the facility. Hoping not to make the facility look bad, but to inspire family to be there or hire 24 hr help.

Do any of you have similar situations, and if so, how do you handle them? I am thinking of looking into whatever regulatory agency covers these facilities, and at the very least register a complaint at these laws, if they exist.

Gail

[aimeee, BSN, RN]

Yes, it does sound unsafe IF the patient is unable to transfer themselves and do their own ADL's. I would apply the same judgement to this type of scenario that I would to a patient who is living alone with no caregiver. We have some of these senior living kind of places here too. We recently had to convince a family to move their loved one to another type of facility that provided actual care. There is very little regulation compared to what we are used to for nursing homes! As far as side rails go, I wouldn't fret about that too much. You can get special mattresses with sloped sides that will help keep the person from inadvertantly falling out of bed. A person who is confused and wants to climb out of bed will do so regardless of whether there are siderails or not and studies show they suffer greater rates of injury when siderails are in place due to entrapment or climbing over the top.

[CHPN1680]

There is no simple answer but I always put the patient wishes first. If they can understand the risks involved with remaining in a facility that may not be able to meet all of their needs as they decline, then they have the right to take the risk if they so choose. God help the person who tries to remove me from my home because I am at risk for falls and injury! I'll take the risk, thankyou very much! Home is home.

I think that our responsibility is to make sure that the patient is aware of the risks. Based on their choices, we as a hospice care team must do our best to work with the situation to provide the best possible support given the patient's living arrangements. Can the patient have a Lifeline necklace? Can they afford caregivers for certain key hours. Can we coordinate the team so that someone is there to check daily or twice per day? What can the volunteers and family members do?

Every situation is so different. Assisited Living Facilities do have regulations that they must follow which puts limitations on what they are allowed to do. I constantly make different decisions about care for patients with the same disease process but living in different environments. My advise is to always meet the patient "where they are". not necessarily where you think they should be.

[leslie :-D]

although i understand your trepidation re: the hospice patients falling out of bed, here in massachusetts side rails are considered a restraint. and aimee is right when she states that the confused are prone to more injury trying to climb over those side rails.

what i don't like the sounds of is the hospice pts getting minimal care and attn. an on-call nurse for all these residents is just not sufficient. that is an issue i would bring up to the powers that be. it sounds like they're left on their own a bit too much.

leslie