In nursing home against will?!

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sorry to use the forums like this, but i'm so far from my specialties, i don't know where to start. can someone point me in the right direction?

a friend has asked for some help and advice regarding her father in law. he is very elderly but a&o, lives independently, drives, enjoys visiting friends and still actively farms. recently, at home he stepped on and fell over his rocking chair rocker, falling on his l side and bruising himself. concerned if he might have fractured a rib, he called his fam doc practice (does not have a strong relationship with the doc that took over when his retired) who sent him to the hospital. he was admitted and many tests were done. hops staff insists that he probably does not remember the accident, probably blacked out first then fell, and probably landed on right side since he's right handed (?! hello? bruises on the left?) he had not named any of his 6, involved children as poa, afraid to pick a "favorite" and not feeling he needed one. so now the county(?) has taken over. he is assumed incompetent to make decisions or name a poa. he was admitted to a local nursing home ("he can't live by himself") for "rehab" several days into admission he has yet to see the pt (online search tells me the facility has only part time pt and ot) "he needs to rest before he can start therapy" (?? open heart pts are oob next day, i think this man can handle it!) he has been confined to a wc with seat belt. yes, it's not a restraint since he can open it, but he's been scolded for doing so. waited three hours after telling staff he needed to use rest room before he couldn't hold it any longer, now they make him wear a brief!! oh and a social worker told him he would enjoy this facility since he likes to play cards and so do some other residents. he has yet to see another a&o person there! (btw i work in peds and i know better than to tell a kid, "you'll like it, they have a tv" or whatever. c'mon even a kid can prioritize, how condescending!)

so, what can his family do? they are involved (or at least trying) he also lives near a local religious community where he has many friends who visit daily and bring meals, homemade bread, etc.

why can't he at least choose his own facility- "they" said no to his two choices, including one that has onsite assisted living and apartments as well as full time pt and ot. (does he really need pt? i don't know, but he will soon! how much has he already atrophied after a week in his wc?)

i have numbers to pass on for the county ombudsman, but does that help coming from the same ageing agency that has created this mess in the first place!?)

how is competence/ incompetence decided? they said he needs a ct to prove he's competent (perfusion, i guess?) i thought a mini mental or the like would be enough? of course, ins won't pay for the ct, and now he needs transportation back to the hospital, too!

thanks for any tips you can give me before he looses another muscle fiber or actually does loose mental function from boredom or humiliation!!

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Specializes in Education, Acute, Med/Surg, Tele, etc.

I see this all the time, but I work in an assisted living facility where more 'independant' residents live on one side of our facility unless they need nursing care, then they live on my side. However, there are times when in my community these folks have lived independantly in their family century farms for generations..and it kills their spirits to be taken their prematurely!

Talking to an ombudsman helps in picking a right facility or services he may need in the future. They can't say yea or nea on the medical aspects for reasons why since they are not medics. So they will totally be a reference to services and facilties to fit him best.

His MD is the one that has the power to discharge to home or facility, and if he has to go through the county...well then I would advocate for this if this is the right thing to do.

I am suprised someone that didn't break a hip or suffer a larger injury is in this situation! Was the family involved and advocating from the start??? (if things were clear from the get go that he is independant then it may have changed the tides...a MD that doesn't know him well, or RN's that don't...have to assume on the side of caution in all cases).

Looks like the family is going to have to get advocating the MD for a discharge to home, and getting the needed proof from the PT/OT that he indeed can! Ask the RN's too to make sure they are documenting well about his abilities...that will help tons! And a mini geriatric depression test will be good against any probelms emotionally he is having being at a facility with the fear of never going home (because if he is undoing his seatbelt, or acting out in any way percieved by the RN's...well...going to have to prove it is because of the situation not a mental probelm like dementia or severe chronic depression putting him at risk of hurting himself).

Hope this helps...but the family must get involved and involved very strongly!!!! Sadly they are not going to listen to him much, so it is time for the family to stand up!

Good luck, and if he truely is independant...well I hope he gets to go home with services to aide him!

OH OH OH ...ask his church or church groups nearby if they have a parish nurse to help...they know of many services available for their parisheners to avoid premature facility placements! Or simply ask them for help as well!

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Specializes in ER.

Is he clear headed? It sounds like he is. He has every right to walk out, and his family can pick him up and take him home. Or they can make his arrangements for assisted living etc.

I don't see him being a ward of the state if he has interested family or he can make his own decisions.

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Well if he is indeed incompetent to make decisions, then one of his children can be his spokesperson or even his next of kin. All his children should get together and agree on which one will be the spokesperson/next of kin and that person CAN make decisions for him in regard to whether or not he needs to stay there. This spokesperson can agree to take him home with them to care for him. I would think that if he has family willing to make decisions for him, that there is no need for him to be controlled by the county. Did they confirm that he fractured his ribs, hip or any bones? Does he really need rehab? He may need it if they keep him in a wheel chair unable to get up and move around like he needs to. What a disaster. What is it that determined he was not mentally able to make decisions? Is he forgetful all the time? Is he confused? What is his Glascow Coma Scale? Is hie alert and oriented to person, place and time?

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Specializes in Education, Acute, Med/Surg, Tele, etc.

If he goes out voluntarily or family gets him out it is considered AMA (against medical advice) and medicare or insurance will cover nothing! Must watch for that big time! AMA is serious, especially with medicare/medicaid.

Just a reminder there....

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Specializes in Med-Surg, , Home health, Education.

In order to be considered "incompetent" a form must be signed by 2 physician's stating the reason he is unable to make medical decisions. Often, this form would then make the person who is the HCPOA activated. Sometimes if there isn't a HCPOA drafted- a person is assigned guardianship- but usually it is a family member. I agree it sounds like the resident, family, MD and social workers- as well as the rehab services need to have a family meeting to see what's best for the resident.

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Specializes in Med/Surg, Ortho.

I was under the impression that legally, in most states anyway the legal next of kin would be the oldest living child as viewed by the court unless that person isnt willing, then it would fall in succession until such time no family would be willing to act. Was family notified of a court date, because in most cases the court appoints a POA who is assigned legal guardianship if there is no family willing to take responsibility.

Were the family concerned that they would be held responsible for medical bills or something? It just doesnt sound right to me that they just arbitrarily sent this case to the court and did this without speaking to someone in the family or whomever he had listed as an emergency contact when he was admitted. If they did, they totally violated his right of informed consent and probly family rights also.

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That sounds like the kind of horror story I've dreaded for myself since I started working in LTC.

If he's competent I don't see how he can be forced into a nursing home, and falling certainly doesn't qualify him as incompetent, if fact, blacking out and falling don't either -- I do that a lot when I get tired and no one has locked me up.

At the place I worked we had people (both competent and incompetent) walk out all the time. The facility policy was that if they elope they are not allowed back. The only "disciplinary" action they took was to not give the resident his remaining medication so the resident had to go back to the Dr. and get his own perscription.

I think it's really important for your family to get involved in this. It sounds like you are going to have to do a lot of screaming and yelling with the powers that be. It also sounds like your father-in-law is very independent and is having difficulty dealing with the fact that against his will he has been put in the position of turning to his children for help. I don't blame him at all! What a nightmare.

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Specializes in Gerontology, Med surg, Home Health.

Zowie...as far as I know, CT scans can NOT determine if someone is competent or incompetent....only an MD can and in this state it only takes one MD to invoke a Health Care Proxy. If there is no proxy and the family can't or won't step up, then a court appointed guardian can take over. BUT...it has to go to court and isn't done very often.

If this poor gentleman isn't getting rehab or toileted or whatever, call the ombudsman first, the state DPH second, and find an attorney who deals with elder law. He can call a taxi and get his own ride home and no one could stop him. IF they are that worried about him, then they shouldn't send him home against medical advice so they could at least set up after care services for him when he gets home.

Is he in the facility under his Medicare A benefit? Does he have part B??

Please keep us posted on him.

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Good heavens, what state was this? He or his family have the say, not social services or the doctor. The term is incapable in florida, not incompetent. The family of this man needs to meet with the administrator, social services and the director of nurses immediately, then they need to find another facility, and move him out. Then call the state, the ombudsman, and write a letter to the home office of the facility. The treatment of this man is intolerable!!!!

The ombudsman is not the "state" that caused this mess, but they may be able to help get him taken care of. Most likely the hospital social worker called in the depatment of children and families, elder care section, and they made the decisions.

I have been doing geriatrics, in LTC for 35 years, and have worked hard to change from chairs tied to the wall, activities consisting of a birthday party once a month and incompetent staff. This cases sounds like a "throwback to those days. Sorry, this realy upset me!

Marie

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If he goes out voluntarily or family gets him out it is considered AMA (against medical advice) and medicare or insurance will cover nothing! Must watch for that big time! AMA is serious, especially with medicare/medicaid.

Just a reminder there....

I agree AMA might be a terrible move for this resident financially. The scenanrio does not sound right to me. How did he do on his mini-mental exam? If he is Medicare A they can skill him for nursing care for 5-14 days. I have seen this done to help the overly exhausted or still medically unstable resident adjust before the different therapies step in to work with him. Facilities want the famlies involved. Might there be more to the family dynamics? I don't know a facility that would risk a complaint to Public Health or a call to an attorney. The family needs to join together and have a care plan conference with the facility ASAP. I wish them luck.

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Thanks for the replies! I'll print them out for my friend and her family. Maybe I'll print a few extras for anyone who dares sugggest that LTC nursing is any less of a specialty- there's obviously a lot of caring and knowledge here! Honestly, after all this I was beginning to wonder myself. It's an embarrassment to the nursing profession when I think of how many nurses in the hospital and the home have worked with him on the past week and is anyone advocating for him? Do any of you an empty bed in your facilities?

I was a CNA for a few years full time staff, then home care and agency staffing. My first position was on a unit mixed with alzheimers and true psych; I remember the transitions from poseys to pull tab alarms and bed sensors and I haven't done that in years. This just made me wonder what decade this facility is in!!

I was really worried that the family really did lose legal rights as well as he, himself. Sounds like there's just a lot of over-stepping going on! Really, if the county agencies are bored, I'd be happy to provide them with a list of elderly people I've seen over the years, scrimping and trying to get their resources to meet! This guy had it under control, thank-you. I hate to think this way but could it be because they heard he owns a farm? We all know that medicare will only pay 30 days and after that his assests become liable and at this rate he rally won't be OK in 30 days. I don't even want to imagine anyone is thinking that way...but... :uhoh21:

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