Discharging disheveled patients from the hospital

mattsmom81 · May 30, 2005

I agree with Tweety and Judee. Sadly enough, the push and shoving in our revolving door hospitals today sometimes leads to patients getting shafted on basic cares. The ER is backed up and pressure is on to discharge so we can admit. Sometimes the basics are secondary to more critical needs as well.

Its no excuse; just some info on today's hospitals and how pressured the nursing staff can be. :)

Rio, ASN, RN · May 30, 2005

Presuming that this "comatose" patient had returned to your facility without mouth care. What did you do about it ? Did you fill out an Incident Report and forward it to your manager and Quality Assurance Department ? Did you follow up personally with your manager making it clear your expectations?

Upon receiving this patient did you immediately notify your facility supervisor ? If you are the supervisor did you contact the Charge Nurse at the sending facility and make them aware of your concern ? If you did not obtain a satisfactory answer, did you then ask to speak with the sending facility's House Supervisor ? Did you follow any Chain of Command ?

Is this a trend from one facility or an anectodal observation that has lead to a generalization ?

We all have the opportunity to effect change or at least affect change, the variability is the courage of the individual.

worldsoulrn · May 30, 2005

. . ." It's bad enough that 3/4 of the people we send to the hospital come back with pressure sores, but to send someone who has dried food in his mouth is too much."

Hi CapeCodMermaid,

We too wondered why our residents returned from the hospital with pressure sores. Our wound care specialist advised we give the hospital as much information as possible upon admission to help prevent them. If the resident is on an air mattress in the LTC facility, ask that they order one in the hospital. If they are prone to heel breakdown, yeast infections, sensitivities to products, . . .whatever; send them a red flag. If they have existing skin issues, you might want to request an evalution in the hospital by the wound care specialist. Working closely with the hospital staff has made a big difference for our residents going out.

I don't know what to think about the oral care. We still haven't come up with an effective system at our facility for good consistent oral care. If anyone out there has some advise, it would be appreciated!

_________________________________________________________________

"The Journey Is The Reward"

NancyJo · May 31, 2005

Now, we have that probelm too, but it isn't as bad as the fact the majority of our residents come home with NO information on what was done, what their Dx is, or even post treatment!!!! We just get some scribbled discharge orders on...I swear..the third sheet of carbon so you can't read it...and we get to call the MD and ask and hope they don't give us a confindentiality speach!!!

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.

CapeCodMermaid, RN · May 31, 2005

When we send anyone to the hospital, we always call in a report to the ER nurse. We give the ambulance attendants a current med list, a list of any treatments, other than the usual A+D, a verbal report of what the patient's history is and why we called rescue. We give a written report for them to give to the ER staff as well. More often than not, I get an attitude from the ER nurse. One actually said "Oh don't worry...we'll figure it out when she gets here." And it does no good to report bad care. We've done that in the past and it gets us no where. On the flip side--I worked with one CNA who refused to send anyone out to the hospital "looking bad". I kid you not...even if we had just called rescue, she'd go in and give 'em a shave....I'd love to clone that woman!

flashpoint · May 31, 2005

I appreciate the fact that a CNA wouldn't want to send a resident out looking bad, but is it really a priority? It just infuriates me to be called to an LTC and to have nurses tell me we need to wait to transport until the resident is shaved, their daughter shows up, their brief is changed, etc...and yes, it does happen. You call 911 because something emergent is happening...something that for whatever reason cannot be handled within the facility..."looking good" is the last thing anyone in the ER is going to care about.

When I worked in LTC, we did our best to keep the residents looking good all of the time...men were shaved daily, women had their whiskers trimmed as needed, and nails were done weekly. Everyone who needed it go their hands and faces washed as needed and oral care was done at least twice daily. We KEPT our residents looking good so there was never a scramble to do it before they needed transport.

There is a huge difference between an LTC and a hospital. In the hospital, we deal with more acute problems and unfortunately, sometimes things like shaving need to take second place. Most of the time I am more concerned with maintaining my patient's airway and titrating drips than shaving.

Thunderwolf, MSN, RN · May 31, 2005

Tacky and a poor reflection of that hospital.

Long Term Care Columnist / Guide · May 31, 2005

I think we are all sort of missing the point here.

The point is not that one type of facility is inferior to another (hospital vs. LTC) or that staff at one type are slackers and those at the other are hard-working. The real issue is that human beings are not receiving the care they deserve, and that time constraints imposed by the nature of our work (and the rush-rush atmosphere that took over when health care became a business rather than a service to humanity) make it difficult, if not impossible, to provide that care on a consistent basis throughout the care continuum.

Yes, there are bad caregivers in all areas of the profession. Yes, it is shameful that people are sent to/from hospitals with pressure sores and urine rings on their linens and days-old crud in their mouths. But let's tackle this problem at its source---which is the ever-increasing workload in health care created in no small part by profit-driven CEOs and the insurance industry---rather than attack each other. That has NEVER worked, and it never will........all it does is distract us from the real issues that make our jobs harder than they have to be, and leave us without the energy needed to change the way health care is delivered. And sadly, until we figure that out, patients will continue to suffer. :stone

Judee Smudee, ADN, RN · May 31, 2005

I think we are all sort of missing the point here.
The point is not that one type of facility is inferior to another (hospital vs. LTC) or that staff at one type are slackers and those at the other are hard-working. The real issue is that human beings are not receiving the care they deserve, and that time constraints imposed by the nature of our work (and the rush-rush atmosphere that took over when health care became a business rather than a service to humanity) make it difficult, if not impossible, to provide that care on a consistent basis throughout the care continuum.
Yes, there are bad caregivers in all areas of the profession. Yes, it is shameful that people are sent to/from hospitals with pressure sores and urine rings on their linens and days-old crud in their mouths. But let's tackle this problem at its source---which is the ever-increasing workload in health care created in no small part by profit-driven CEOs and the insurance industry---rather than attack each other. That has NEVER worked, and it never will........all it does is distract us from the real issues that make our jobs harder than they have to be, and leave us without the energy needed to change the way health care is delivered. And sadly, until we figure that out, patients will continue to suffer. :stone

This is what I was trying to say in earlier post but I am not as eloquent as you. There is a point at which staffing is so inadequate that it becomes impossible to give good care. There are actually people here who say that bad staffing is no excuse for poor care. Take it from one who just exited a institution where it did become impossible to give good care, it does happen. It does not rule out the possiblility that laxity produced the described situation but it is more likely that over work caused the deplorable conditions.

CoffeeRTC, BSN, RN · May 31, 2005

I think we are all sort of missing the point here.
The point is not that one type of facility is inferior to another (hospital vs. LTC) or that staff at one type are slackers and those at the other are hard-working. The real issue is that human beings are not receiving the care they deserve, and that time constraints imposed by the nature of our work (and the rush-rush atmosphere that took over when health care became a business rather than a service to humanity) make it difficult, if not impossible, to provide that care on a consistent basis throughout the care continuum.
Yes, there are bad caregivers in all areas of the profession. Yes, it is shameful that people are sent to/from hospitals with pressure sores and urine rings on their linens and days-old crud in their mouths. But let's tackle this problem at its source---which is the ever-increasing workload in health care created in no small part by profit-driven CEOs and the insurance industry---rather than attack each other. That has NEVER worked, and it never will........all it does is distract us from the real issues that make our jobs harder than they have to be, and leave us without the energy needed to change the way health care is delivered. And sadly, until we figure that out, patients will continue to suffer. :stone

Right on!

CHATSDALE · May 31, 2005

I, too, have worked both sides of the aisle patients in our facility are for the most part ambulatory and we have very few bed sores...but in the last month we had a resident who had a decub on side of foot...aides told nurse about it during whirlpool they told the floor nurse and they told the tx nurse..nothing was done...when i came in on weekend it was bad i called on-call md about a tx for it and he became very nasty said that why was he being called on w-e for what was not an emergency . i told him the pt needed care and that i only worked on weekend and that i didn't like it dumped on me anymore than he did

but we have also gotten pts back from hospital that it was apparent that they had not been turned on any kind of schedule...don says just report that they came back to us in that condition so that state would not charge us with condition...that does very little good to pt

i know that a lot of people are overworked..don't know what happens to the classes of rns and lpns that are graduated each year..

we need to pay a living wage to cnas

hire more nuses so that those who are at work do not feel overwhelmed

remember that these pts are humans and would we like to be treated like this

CapeCodMermaid, RN · May 31, 2005

I appreciate the fact that a CNA wouldn't want to send a resident out looking bad, but is it really a priority? It just infuriates me to be called to an LTC and to have nurses tell me we need to wait to transport until the resident is shaved, their daughter shows up, their brief is changed, etc...and yes, it does happen. You call 911 because something emergent is happening...something that for whatever reason cannot be handled within the facility..."looking good" is the last thing anyone in the ER is going to care about.
When I worked in LTC, we did our best to keep the residents looking good all of the time...men were shaved daily, women had their whiskers trimmed as needed, and nails were done weekly. Everyone who needed it go their hands and faces washed as needed and oral care was done at least twice daily. We KEPT our residents looking good so there was never a scramble to do it before they needed transport.
There is a huge difference between an LTC and a hospital. In the hospital, we deal with more acute problems and unfortunately, sometimes things like shaving need to take second place. Most of the time I am more concerned with maintaining my patient's airway and titrating drips than shaving.

well...DUH...we didn't keep transport/rescue waiting and the patients got shaved every day. My point was some people care and others claim they are too busy. Plus...if someone is stable enough to be discharged to a skilled facility, they must be maintaining their own airway.