In and Out Privileges

[LibraNurse27, BSN, RN]

Hi all,

Just wondering what the policy is at other facilities about admitted patients leaving the hospital and coming back in. Because I work at a county hospital, in addition to our acute patients we also house about 40 long-term stay patients who we are unable to place in nursing homes, group homes, and shelters because of their behavioral issues. Some of these patients have dementia with severe behavior disturbances and others are alert and oriented but are homeless and either ineligible for shelters due to behaviors. These patients have caused our hospital many issues, including acute patients spending multiple nights in the ER hallways and acute patients being disturbed and even in some instances attacked by long-term patients. Staff are often attacked as well.

It is difficult to contain people in a hospital room long-term and some of the patients stay for months or even years (record so far is 3 years, 7 months for extremely violent TBI patient). Sometimes staff take confused patients out for fresh air or at least walk around the unit with them to prevent agitation. Alert patients are allowed to leave the unit unsupervised as long as they sign out and return within 30 minutes (although this is often not enforced). When they leave they often use drugs, sell drugs, drink, go to Wendy's while NPO with an NG tube... so many other examples. We have had patients fall and also get their belongings stolen or get beat up in a drug deal. Then we become liable for the injuries sustained because they were still "under our care". Does this exist anywhere else and does anyone have any suggestions? We are trying to enforce the policy that patients who don't return within 30 mins or who commit extreme violence against staff (nurse got STABBED by a placement patient last week and he is still living in our hospital). Thanks and sorry for long post!

[Davey Do]

Wow. Just: Wow, LibraNurse. Your case is above and beyond anything with which I have dealt.

The only thing that I can come up with is to objectively document, attempt to follow the chain of command within the facility, and when that's exhausted, inform benefiting and surveying entities of the situations.

Contacting law enforcement professionals might help.

I don't hold much stock in outside agencies having been burned by them before, but perhaps you will have better results.

I look forward to reading what others have to say.

Good luck and the very best to you, LibraNurse!

[CX_EDRN]

Wow. I can't believe your facility puts up with that stuff but I also can't believe you have that many long-term patients! We usually have a handful but that's about it. No one is allowed to leave the units, once you're admitted you're here to stay. No leaving the floor, especially with IVs, etc. Our long termers get to walk (with staff) if they're reasonably behaved and not a true fall risk.

As far as the nurse who got stabbed? Why was that patient not arrested?! That's insane! I'm sorry you have to deal with all that. Ugh.

[CX_EDRN]

And if we find out that they've snuck out, they're considered leaving AMA.

[LibraNurse27, BSN, RN]

Thanks for the replies! I will definitely document when patients do things that go against medical advice... for example shooting meth into a picc line! I will document that I educated them and they chose not to follow advice, etc. I had not thought about contacting law enforcement or regulating agencies but I think that will be the next step if things don’t improve.

[JKL33]

Under what admission status are these people being housed, out of curiosity? I don't understand. Does this facility have some beds that are designated as something other than acute care beds?

Anyway, this sounds like a complete disaster.

[LibraNurse27, BSN, RN]

Sometimes they are admitted for actual medical diagnoses and then when those have been treated they become a placement issue if they came from the streets or if their families say they are no longer able to care for them, they are deemed gravely disabled, etc. Some are brought in by police after calls from neighbors. The diagnosis is usually dementia with behavior disturbance, grave disability or sometimes it literally just says “discharge planning issues”. I really feel for these people who have nothing and no one, it’s very sad. But housing them in an acute hospital is not safe. We don’t have subacute or long term beds, supposed to be acute care facility ?

[Emergent, RN]

Wow! This sounds extreme! What an out of control situation! I've never heard of such a thing! Wow!

[LibraNurse27, BSN, RN]

Oh gosh I didn’t realize that these things are not happening frequently at other hospitals... maybe time to look for a new job, haha. Well many of our upper admin have never worked as floor nurses so maybe they don’t know what is acceptable and what is not... I’m really not sure what’s going on!

[Sour Lemon]

I worked on a unit somewhat like yours, although yours sounds especially awful. We had several long-term, hard to place patients- most of them drug addicts, and a few who'd actually been there for years.
It was an easy unit to work on, at first. Patients were rarely in their rooms, and when they were present, they usually refused everything except for their Q3 hour dilaudid. When someone didn't show up for their dilaudid at the exact available time, that's when we'd worry and go find them slumped over in the parking lot (hopefully).
We had patients smoking pot in their rooms regularly, patients calling saying they were stranded at various places and needed to be picked up, patients inviting other people to "live" with them in their hospital rooms ....like the patient would be out and the "visitor" was in the room sleeping. Oh lawd!
The unit was opened specifically for "problem" patients and patients that had placement issues. We also had normal med/surg tele patients mixed in on occasion, as they preferred to keep our small unit full. Eventually a new unit manager stepped in and made a BUNCH of new rules. The job got a lot harder with actual patients around. ?

[JKL33]

12 hours ago, LibraNurse27 said:

The diagnosis is usually dementia with behavior disturbance, grave disability or sometimes it literally just says “discharge planning issues”.

Yeah, "discharge planning issues," I would say so!

Wow.

Sometimes ridiculous situations like this are purposely overlooked knowing that there is no good answer and there are really no advocates for these patients who are going to make a stink over the way their care is delivered.

Regardless, this is a disaster. I've worked in an acute care situation where a few certain patients came and went according to their pain medication schedule. I wouldn't do it again today and I certainly wouldn't stay where violence is tolerated.

Not to mention the issue of drug abuse/ODs being at the forefront. I don't think this is going to end with staff unscathed (even if they don't get stabbed!)....

[LibraNurse27, BSN, RN]

We have had a patient overdose by injecting heroin into her PICC. Her consequence was removal of the picc (because it also got infected) but our consequence was a CLABSI counted against our unit and having to try to get peripheral IVs on her. We are not empowered to set limits with our patients due to fear of poor satisfaction scores. Thank you all very much for your input I really appreciate it!