How should I have handled this?

[ShayRN]

I know what I did, but want some opinions on how you would have handled this situation:

Man in his 50's with an extensive drug/alcohol abuse history admitted to hospice inpatient. 18 monthes ago, he had CVAx3 and MIx2, was admitted to LTC. His young son (20 ish) was making all healthcare decisions. When he got to me, he was completely contracted on his lt side. I documented no less than 10 bedsores, one of which was Stage 3 on his coccyx and the rest were at least a stage 2 in various stages of healing. When I asked him if he was in pain, he started whimpering. Looking back in the progress notes, I saw that the only medication ordered for pain was 2mg IV MS for the transfer. So, basically, he was left laying in a bed without pain medicine, contracted and obtaining one bedsore after another for 18 months. When our social worker called the ECF, they refused to take him back siting 70,000 in back bills.

So, What would you do?

[fultzymom]

I think that I would have reported the situation to the appropriate people. Makes you wonder about the people who were taking care of him. Were they not taking care of him due to the back bills?!?!?!

[Daytonite, BSN, RN]

I would have called the doctor and reported all his conditions and asked for pain medication and treatment orders. I'm not clear as to why transfer back to the ECF is an issue. If your inpatient hospice doesn't take patients for long term care, then the social worker needs to start working on getting a placement for this man. If it can't be found then your facility will need to discuss this with the son (assuming he has POA) and/or approach the local courts or state health department about taking over guardianship of this man.

[Altra, BSN, RN]

Are you able to clarify a few things?

1) Is there a diagnosis appropriate for hospice admission vs. LTC? If so, why was your social worker attempting to have the patient transferred back to the LTC?

2) Have you really been able to read through 18 months of documentation to state that he had had no pain meds for 18 months? Is there documentation of decubitii and/or contractures? Decubitii and contractures can occur even with excellent care.

3) I'm not sure of the legalities of discharging an LTC patient due to non-payment, but there probably are ways to do so, and the facility is probably within its rights not to accept the patient back.

4) I'm not entirely sure I understand your question, "How would you have handled this?" IMO, I can't really do anything about poor care my patient received at another facility. However, if you see evidence that crosses the line from poor care to neglect or malpractice, that is another matter, and my first call would be to the patient's primary physician. Is that what you're asking?

[Noryn]

The first thing of course is to take care of the patient, obtain proper pain management etc. Second I am unsure why you would send him back to the extended care facility especially since he had been neglected at this facility. I would report them to adult protective services and let it go from there. Why did your facility accept him then want to discharge him back? That confuses me.

[ShayRN]

Ok, sorry, I guess I should have clarified. I did notify our medical director. Discharge planning was initiated because that is what our SW normally does when people we think will be able to leave does on the first or second day of admission. Doesn't matter now, he did die a couple of days ago. However, I believe in my heart this man was neglected in the ECF. As far as pain, I don't doubt it wasn't treated because of his drug abuse history. I started morphine at 1mg subq and titrated to 6mg before I left, that held his pain. I also gave a whirlpool bath, which he found soothing. By the time I left, he grabbed my arm and thanked me, I cried that night.