DNS overruled MD?!

bluegeegoo2, LPN · Jul 19, 2013

Earlier this year, (at a different job) we had a res that presented as acutely ill. The MD wanted him sent out, but the DON called him back and literally argued with him that "we can tx in house." The MD relented. The next day, the res was sent out 911 to the local hospital and was subsequently life-flighted to a bigger hospital d/t the seriousness of his illness. Turns out, the gentleman was in acute renal failure. Not the "flu" the DON had "diagnosed" him with. The res spent several wks in the hospital being tx'd before his return. At least he survived. Around the same time, another res had "the flu" as per our DON's "diagnosis" and she fought to keep him in the facility. Again, res sent out 911 after several days of delay and again, res dx: ARF. This one passed away unfortunately. (You see why I no longer work there?) Anyway, point being, if those gentlemen had been my residents I would have sent them out per MD order and regardless of what the DON wanted. She is not responsible for my license, I am. If I feel a resident needs to go, they need to go. The other bad part of the above situations is that we had a brand new nurse on the floor that the DON bullied into keeping those residents in the facility. Poor girl didn't know any better. Some of us more seasoned nurses tried to tell her to ship them, but she was scared of going against the DON. Last I heard she wised up and quit that facility as well.

mlbluvr · Jul 20, 2013

More often than not, elderly nursing home occupants come back from hospitals not only not better, but ever more confused, unkempt, with infections, pressure ulcers, ever more meds of questionable need, and etc. It also costs a lot of money, for everyone involved. And quite often, some doctors say 'send out' at the drop of a dime, and some nurses ASK to have them 'sent out', to make someone else deal with whatever the patient is presenting with. Sounds like this DON may have an issue with too many people being sent out without a real need for acute care (possibly as evidenced by the rate those people are sent back without having been admitted to the hospital), and has taken a firm stand against it. I've had several DONs that had to be called, at any hour, before any patient was 'sent out', unless it was a true 911 need. Fact is, a SNF can take care of a lot more medical issues than they used to be equipped for. It's a complex situation that affects census, quality indicators, facility finances, and all kinds of other factors. There are also new pushes to penalize providers that keep readmitting patients, because it really is out of control. I've yet to see a DON actually put a patient's health before keeping the census up, really.

fairyluv · Jul 22, 2013

I had sent a res out one night, and the DON had said to me.."i hope we get them back before midnight" this was 3 wks ago and last i heard the res was on the hospice unit in the hosp.

indiechic, LPN · Jul 22, 2013

I have dealt with administrators like this before... It's usually based on wanting to keep their census up and not lose money when the resident is out of facility. Very sad... It wouldn't hurt to call adult protective services. They keep your identity confidential, but will investigate situations like this.

mlbluvr · Jul 23, 2013

I had sent a res out one night, and the DON had said to me.."i hope we get them back before midnight" this was 3 wks ago and last i heard the res was on the hospice unit in the hosp.

To keep things in perspective, it's required to recognize that sick, old people are a gigantic financial commodity. It's not just nursing homes that are loathe the let go of patients- it's every area of health care. But just because a hospice intervened, and the patient was deemed 'terminal' and not returned to the nursing home, really doesn't mean much. A hospice wants patients, and can bend the rules a million ways to declare a patient 'terminal', and temp their families with the benefits available to hospice. I've been in countless care plan meetings with families that ask 'should we do it'? I've seen many hospices promise people the moon, and the stars, to get them to sign up. And? There seems to be a new hospice springing up like a weed about every other day, all over the country- you bet they're out fishing for 'terminally ill' patients. And like I said earlier, when old people leave the SNF to go acute, they normally come back worse for the wear. Yes, it's costly to lose a patient, but to claim nursing homes are all about the money is too simplistic- more so considering how many nursing home patients are total money losers.

ClearBlueOctoberSky · Jul 23, 2013

There are lots of medical issues we can treat in house. In my facility, we do. It is only when our acute interventions fail and they need additional diagnostic work up that our services can't provide, that we send them.

In reality, what services will the hospital provide a patient with ARF or sepsis, that we can't? Unless your patient absolutely needs interventions, such as acute dialysis, vent support, or surgery, that the facility is unable to provide, why cause your patient more distress and discomfort by sending them out to the hospital? Just because it is LTC, doesn't mean we aren't capable of providing subacute to limited acute care.

mlbluvr · Jul 23, 2013

Many people, even in health care, and even some doctors, are unaware of the expansive scope of the current 'nursing home'. In fact, often the only real difference between SNFs and hospitals is that instead of, for example, the imaging department being on a different floor of a hospital- the imaging department arrives at the SNF- in a van.

LockportRN · Jul 23, 2013

I don't know the DON's motivation for this action, but so many times, it is easier on nursing staff to just 'send out' a patient rather than treat them at the facility. It seems to me there are a few reasons for this, the first being that the docs are too busy to deal with them or don't want further phone calls during the night to check on the condition. Or it may be that either the doctor doesn't really trust or know the nurse calling in about the patient. In this case, he will often give orders to send them to the hospital for a better or more complete evaluation.

The OP didn't give all the specifics but it sounds like the DON in this case, needs to up her training of both staff and doctors. Setting up protocols for what information the nurse needs to give to the docs before calling (I know, I know, nursing 101 but you would be surprised how many nurses will call the doc and just say the patient 'doesn't look good' or 'is not themselves'). Giving the doc a full picture of the patient with vitals, breath sounds and what meds and current dx helps him get a better picture. Also, telling the doc what you did to intervene for the patient prior to calling him/her, as well as how the patient responded (or not) to those interventions will widen the picture for him/her even more in order to give a better picture of what is really going on with the patient.

Another thing that this DON may consider after setting protocols and meeting with the Medical Director in trying to keep patients in the facility (as another poster wrote, our elderly folks get more confused when they are out of their normal environments often leading to some type of OBS diagnosis with the addition of unnecessary psych meds, and being returned to the facility with some fairly nasty bed sores etc), would be to have the nurses 'suggestive sell' (for lack of a better phrase at the moment). By this, I mean that when calling the doc, after giving the stats, have the nurse ask possible treatments/labs and medications before sending them out. As we all know, often times the elderly don't react as we do with illnesses like UTI's and Pneumonia. Pain and fever are often absent. What is wrong with asking the doc for possibly getting a U/A C&S or CXR, followed a broad spectrum ABT until the results are returned? This type of early intervention is often life saving and will keep the patient in the facility preventing a costly hospital trip (and I don't just mean in terms of money).

This type of training of both the nurse and the docs fosters increased trust on both parts. It provides better care for the patients and gives the facility on the whole, a better reputation in the community.

wyogypsy, RN · Jul 23, 2013

Yes, we 'can' take care of more issues in-house, that doesn't mean we always should. There are many factors to look at before deciding to treat in house. What is the staffing like? What is the acuity like? Is it realistic that the nurse and CNA on that hall can actually give that resident the care and treatment that they need? Are your staff stretched to the limit already on what they can get done in a shift? If I have 31 residents, one CNA who is not only taking care of those 31 but an additional 12 because a CNA called in, or there aren't enough CNAs at the facility to cover all of the slots, then maybe it is not a good idea. 31 residents you say is manageable? Oh most definitely depending on the residents. But let's add in 5 of them to dialysis, 14 of them QID blood sugar checks, 8 of them scheduled insulin with each meal plus prn, 3 of them with involved would care each taking a minimum of 45 minutes each - then don't forget the easier wound care, 3 on q 8 hr IV antibiotics and 2 on q 12 hr IV antibiotics and 1 on q 24 hour antibiotics. Now let's draw the labs that are not drawn on the two scheduled lab draw days; call the pharmacy and receive calls from them re: med issues; take the calls from dialysis about the one or two residents they have concerns about or that the doctor wants to change orders on; remind a family that we only have one more day of meds left from the mail order meds that they bring in and that we have been reminding them for two weeks about; receive calls from the Infectious Disease group about the resident they just saw who will need to be on IV meds another 3 weeks and don't forget to continue to do the Vanc troughs; oh yes the resident in room 114 needs turned and happens to be soiled as well; and is one of the 45 minute dressing changes and oh goodie she is on isolation as well; and don't you know that the lady in room 120 just pulled her dressing off of her leg and picked at it and blood is going everywhere and remember she has MRSA in that wound; the couple in room 117 are wondering where their meds are and do not understand why they can't always get them at 9:00 like they take them at home, don't you know those eye drops have to be given at 9 as they have done that for years? Why are so many call lights on in your hall, we are doing an audit and the call light response time in your hall is not acceptable. Hey, your admit is here for room 101, do you have the oxygen, the air overlay, and the BSC set up? What do you mean nobody told you about the admit, admisssions and the DON knew about it yesterday! Hey, we are taking the resident from room 102B to therapy and he is refusing to go unless he gets his inhalers and his pain med before we go, I know you are dressed to go in the isolation room but can't you just please give them to him before you go in? It will only take a minute.

Where was I? Oh yes, please keep the frail little old lady with the temp of 101, respirations 24, breathing heavy and sats still in the high 80s on 2L here for me, I would love to come right on down, draw labs including blood cultures, and start an IV on her and get her the stat respiratory treatments. I will be there in about............

mlbluvr · Jul 23, 2013

Exactly- so what's another call to the doctor to request another CXR, STAT labs, then try to find the IV start kit (that has no needles or tubing in it), after you call 911 for the hip fracture in the dining room, then find a patient died right after you strapped a nebulizer mask over her face and left the room, then realized you forgot about the new admit that was brought in 4 hours ago? A day in the life. This ability for nursing home nurses to multitask is WHY more patients should be treated in house! :)~

wyogypsy, RN · Jul 24, 2013

Our residents deserve better than that. So the staff.