Do Not Send to Hospital From Nursing Home

[toughjob,nurse]

Is a do not send to hospital order valid? Is it valid in all situations? I had a DNRCC patient have a heart attack and was in a great deal of pain. He had a PRN order for nitro and it was given as directed with no relief. Followed directions that stated call dr. for further instructions with no relief from pain. Called dr. and advised as to situation, including DNRCC directive. He asked if the patient had orders for morphine, which the patient had no orders and was not a hospice patient. I also advised dr. that he could order the morphine, however in our rural setting the morphine would be difficult to obtain in a short period of time. It would take hours to get the needed pain medication. The doctor ordered the patient to go to the hospital to eval and treat for pain.

This is the 3rd shift and I am the only nurse. When the DON arrived in the morning, I was given the "what for" for sending this completely lucid patient to the hospital for pain management. The lucid patient was asking me for help and asking for something to make him feel better. I could not comply with anything other than Tylenol. The DON stated this patient has a do not send to the hospital order. I asked to see that order. It was nowhere to be found in the chart.

By the way, this patient came back from the hospital on round the clock morphine and ativan and on hospice. I am thinking this is exactly what I wanted to accomplish in the first place. How could I have handled this differently? What would you have done? My impression is that DNR CC specifically states that he is to get comfort care that I could not provide. Now I can provide this. Answers and advice please?!?!?!?!?! I will also be asking my DON for answers and advise. My impression was that I was to wait hours for the morphine, but I will assume nothing for the future.

[dudette10, MSN, RN]

Seems that there may be some policy and procedure issues that need to be addressed, if there is such a huge problem with what I did. What can I suggest to solve the problem? I want to be part of the solution for all and not a whining and complaining employee. Just had to get past the "what did I do wrong feelings"?

Correct me if I'm wrong, but the reason you had to send him out was because you didn't have the necessary drugs on hand for comfort care. What about suggesting that an emergency supply be kept at the facility for these types of situations?

[BuckyBadgerRN, ASN, RN]

I would like to add to this. . .

Midnight census is important in LTC facilities due to the monetary aspects. If the resident is not physically present in the LTC facility at midnight due to taking up a bed at a local ER, the LTC facility cannot charge the resident for that day even though their nursing home bed is being held in anticipation of a return (a.k.a. bed hold).

Your DON possibly has money on her mind, which is probably why she is upset over the transport to the hospital. However, I'll reiterate that you did the right thing for your resident.

Ding, ding, ding!!!! I learned that long ago while working as an EMT---Medicare reimbursements for SNF are based on "who's in their bed at midnight"

That said, I totally think you were in the right to send your patient. If $$ is the priority over patient care/comfort with your DON, I pity every client that calls your facility home...

[toughjob,nurse]

You are partially correct. I did not have access to the needed medication. We do have a C box with narcs in it, however it is a long process to be allowed to open that box. Remember, this is third shift. Here's is a basic idea of that process:

1.) Call doc and get the order

2.) Fill out the PO

3.) Fill out special form for narcotics

4.) Fax that form to dr. (at 3 in the morning?)

5.) The pharmacy will not allow the narc C box to be opened without the dr. signature and DEA number. Which only he can give. The c-box is sealed with ties that have numbers on them. No change of numbers without following these steps.

6.) Then, fax the "special" narc order form to pharmacy

7.) Wait for pharmacy reply and permission to open sealed narc C-box

8.) Open c-box

I have seen this process take a couple hours in the daytime, let alone at 3am. Hence, the reason to tell on call doc, I can take your morphine order, but who knows when the patient will get it!

[sapphire18]

I agree with dudette. That's kind of ridiculous that a pt needs to be sent to the ER/ICU for necessary pain medicine...not saying it's your fault in any way but a faulty system. If a pt is "comfort care," is that not the same thing as "hospice"?? Without necessarily the 6-month life expectancy aspect. Sounds like you def did the right thing though- I would def never let my pt sit in pain for hours on end; how long has it been since the DON did bedside nursing??

[leslie :-D]

This is the 3rd shift and I am the only nurse. When the DON arrived in the morning, I was given the "what for" for sending this completely lucid patient to the hospital for pain management. The lucid patient was asking me for help and asking for something to make him feel better. I could not comply with anything other than Tylenol. The DON stated this patient has a do not send to the hospital order. I asked to see that order. It was nowhere to be found in the chart.

how were you supposed to know pt was dnh, when order wasn't even in chart?

only thing i might have done differently, is obtain order/fax from dr (for narc kit) while you had him on phone.

then pt could have gotten ativan and morphine that he needed.

who determines policy of opening narc kit?

the brief time i did in ltc, we could just open it with dr's order.

after we opened it, we would immediately have to call pharmacy, letting them know what we took and for who.

that's it.

bottom line: you advocated for pt's pain...so yes, you did wonderfully.

leslie

[SuesquatchRN, BSN, RN]

I would ask that the DON clarify situations in which a DNH patient may and SHOULD be sent to the ED.

[CrunchRN, ADN, RN]

Thank god for nurses like you! You definitely did the right thing. No one should make a patient wait unduly for pain relief.

Now, it is important to meet with your DNS and work on a plan for this type of emergency. One that allows pain control without requiring a hospital visit......

Perhaps she will be willing to drive to the hospital pharmacy at 0300 and retrieve the needed medication?:smokin::smokin::smokin:

[StrwbryblndRN]

If money was an issue then whoever thought up the process to get into the c-box must have never had to worry about money.

Sad that sending the pt to the hospital gave him quicker relief then opening up the box. I would have thought that opening up the box would be first line of defense and financially smarter. Then if no resolution send the pt to the hospital.

Processes can be so backwards.

[xtxrn, ASN, RN]

Medicare will pay for transport TO the hospital, but not BACK to the LTC...so there is a loss from the patient not being in the bed at midnight (is this a Medicare patient or 'lifer'?) and the cost of the return trip- which in a great world wouldn't be more important than patient care...

I can guarantee you that the DON was asked why all of this occurred in any morning meeting with the Admin. She probably grilled you so she knew the answers for the administrator, who gets chewed by corporate-especially if this is a FOR profit outfit.

You did the right thing. The facility needs a better emergency kit. AND clarification about dealing with someone who is pulseless, vs someone with an acute, treatable condition.

[NocturneNrse]

Good job sending this patient out.! What a great advocate you are for this patient. I'm sure he/she thanks you completely!!! :redbeathe

[nerdtonurse?, BSN, RN]

I think everyone who's in long term care needs to have a hospice eval at least once a year...they might not want it, or need it, but they need to know it's there when it's time. You've got docs out there who wouldn't write a DNR on someone who's been dead a week.

[nurseprnRN, BSN, RN]

there is no excuse for such a convoluted, lengthy procedure to obtain pain relief as you describe. i am sure there's no state or other regulation which mandates this, and leaving someone in pain for hours is completely unacceptable in many ways, not least of which is that the regulatory agencies really hate it and will scrutinize any complaint of lack of pain management.

in my opinion, the first thing you do is write a reasonable pain management protocol :idea:which says something like, we will have adequate medication on hand in a locked container, the contents of which will be counted by ongoing and reporting rn q shift and both will sign for the count; upon rn receipt of a valid verbal order for opioids, we have access to it and will give it; it will be replaced by the pharmacy (specify billing procedures or whatever is needed ...); the physician or anp giving the order will sign the verbal order within 24 hours. you present it to the don and s/he gets it passed by the powers that be, and you institute it stat.

obviously, in this particular individual's case, there was no "do not hospitalize" order written, which, if it was the patient's/family's/hcp's wish, was an oversight. even if so, the patient/family/hcp is allowed to override it if he changes his mind; to refuse that would be actionable (think: this is not jail, the patient has rights). that will cost a lot more than an ambulance ride and a day or three of reimbursement.

i'm with the posters who say your don isn't mad about anything, really, except the money; you just happen to be a nearby easy target and that will pass as the issue becomes clearer. you absolutely did the right thing.