Inevitable Resignation

[pharmanurse11]

In my previous employment, I worked for a company that owned and operated skilled nursing facilities throughout the western states. My position was at a newly acquired 64-bed facility in an area that was extremely aesthetically pleasing. In spite of the fact that the Executive Director lacked experience, he was given the opportunity because his brother held the same position at another facility. His father worked as an Executive Director before branching out on his own. At all costs, management positions are kept within the organization.

We use Whatsapp to communicate and someone asked if we had an EKG machine. Immediately the Executive Director replied, it's hanging on the wall outside of my office. Maybe I am being too critical, but I would think most would know the difference between an EKG machine & an AED.

May 2023 marked the beginning of my disenchantment.

One of our patients was referred with a diagnosis of GLF at admission. The patient had been receiving physical and occupational therapy for a week. To my surprise, he was evaluated by hospice and admitted with a dx of neoplasm of the liver. It is my opinion that he would eventually be an appropriate candidate for hospice care, but not at that time. He was prescribed MS Concentrate 20mg/mL, which was ordered to be given 0.25mL/6hrs scheduled and 0.25mL/2hrs PRN. In addition, he was also prescribed Ativan 2 mg/mL, which was ordered to be given 0.25mL/6hrs scheduled and 0.25mL/2hrs PRN.

Only one nurse administered the morphine and Ativan, and she was not even assigned to him. I for one did not based on my assessment. Despite never being assigned this patient, my colleague contacted the hospice provider to inform them that some nurses were not following orders.

Since the DON was on vacation, the ADON informed us that she had received a complaint from the hospice nurse. We were instructed to follow orders. MS Concentrate & Ativan dosage was also increased to 0.5mL/6 hours. This was then changed the next day to every 4 hours scheduled & 2 hours PRN. These changes were made without Hospice stepping foot in the facility to reevaluate the patient's needs.

It was just two weeks ago that this feisty patient was able to perform all of the activities of daily living without assistance, had a good appetite, and was participating in therapy, and now he barely gets out of bed and barely speaks. I was medicating as per the orders at this point.

After the DON returned, I sent her an email outlining my concerns and my opinion that he was not an appropriate candidate. In her reply, she agreed that he was not an appropriate candidate for hospice. His physician had called her to inform her that he had spoken to his wife and recommended that he be placed in hospice care.

At the time of his death, I was on duty, and his wife was by his side. When I contacted the hospice nurse, she informed me that she was not coming to the facility. However, she would call the mortuary to pick up the remains. It was shortly after midnight, and as I walked his widow to her car, she shared memories of the life they shared. Asked about his cancer, she replied that he had a golf-sized tumor on his liver about six years ago. It was removed, and he underwent treatment, and was cancer-free. I was confused at this point.

In the words of the widow, the resident was experiencing frequent falls, and his doctor informed her that it could be no other explanation than the return of cancer. Although there was no official diagnosis, she trusted what his physician said, since what else could it be?

The facility was acquired in October 2022. Various acute care hospitals refer patients to us, but most of them come from one hospital in particular. Considering we are strictly a skilled nursing facility, with no long-term care, hospice involvement is quite rare. By May 2023, we had two patients in hospice, and by June 2023, we had three more, making a total of five patients in hospice. I noticed that the same hospice provider was being used. During my time at other facilities, there have been as many as three different hospice providers.

I asked my colleague why we continue to use this hospice provider even though we know they provide substandard care.

What I was about to hear shocked me.

The hospice's founder and president is the father of our executive director.

During my fact-checking, I also discovered that the administrator of the hospital we received our referral from was a co-founder of the hospice. I met with the DON who informed me that it was the family's decision to choose this hospice provider as if these families were hospice connoisseurs. My position was clear that continuing to use this hospice provider was neither appropriate nor ethical.

I was having difficulty adjusting to the passing of my patient, which was made worse by the fact that he was referred by the hospital whose administrator co-founded the hospice. Whenever I was at work, I found excuses not to go in, and I felt ill every time I did. There was no doubt in my mind that it was time for me to resign.

[Emergent, RN]

WOW! After you resign,  the next step should be to report all this to the appropriate regulatory body. This is totally appalling.

[0.9%NormalSarah, BSN, RN]

Oh dear this is all very terrible! I second Emergent's suggestion to take this to a regulatory body. I have a friend that worked in hospice for a long time and she told me they have to be super careful about referrals and how it looks, I'm surprised they have been getting away with this. Also that poor woman, her husband quite possibly had a different reason for the falls. 

[toomuchbaloney]

Make your case to CMS. 

[chare]

In my lay opinion, there is clearly a conflict of interest here.

toomuchbaloney said:

Make your case to CMS. 

That's one option.  The state attorney general's office would likely be just as interested and much easier to access.  Either way, you should be able to make an anonymous report.

[pharmanurse11]

I have filed a report with our compliance department and the hospital's compliance department. The fact that I did not receive any correspondence from our compliance department was a surprise to me. After being charged with Medicare fraud years ago and paying over $40,000,000 in fines, I would have thought that something like this would never occur.

The correspondence below is from the hospital.

7/13/2023 6:43 AM
The Integrity and Compliance Office has received your concern and will engage the appropriate staff to conduct a review. You may be contacted through the hotline follow-up process and asked for additional information or clarification. Thank you for bringing this concern to our attention.

27/2023 6:11 AM
Thanks for submitting your report. The Conflict of Interests Office has reviewed your concerns. Per ##### conflict of interest policy, #### is following the bi-directional recusal conflict of interest management plan as it relates to #####. If you have additional evidence of further concerns, you can submit it to the hotline and we will review any further details.

[brandy1017, ASN, RN]

pharmanurse11 said:

I have filed a report with our compliance department and the hospital's compliance department. The fact that I did not receive any correspondence from our compliance department was a surprise to me. After being charged with Medicare fraud years ago and paying over $40,000,000 in fines, I would have thought that something like this would never occur.

The correspondence below is from the hospital.

7/13/2023 6:43 AM
The Integrity and Compliance Office has received your concern and will engage the appropriate staff to conduct a review. You may be contacted through the hotline follow-up process and asked for additional information or clarification. Thank you for bringing this concern to our attention.

27/2023 6:11 AM
Thanks for submitting your report. The Conflict of Interests Office has reviewed your concerns. Per ##### conflict of interest policy, #### is following the bi-directional recusal conflict of interest management plan as it relates to #####. If you have additional evidence of further concerns, you can submit it to the hotline and we will review any further details.

You can file a whistleblower complaint to CMS medicare if there was no proof this patient had cancer.  If you were his nurse you saw his medical records.  If they investigate and find wrongdoing you could actually get a financial reward a percentage of what CMS fines them I believe.  I would look further into this for his sake and others out there.  It sounds more like euthanasia for the sake of profit!

[Been there,done that, ASN, RN]

Conflict of interest of course. Greed of course.  You made a mistake reporting it internally.  I hope you have another job lined up.

[pharmanurse11]

Been there,done that said:

Conflict of interest of course. Greed of course.  You made a mistake reporting it internally.  I hope you have another job lined up.

In the week leading up to my resignation, I contacted compliance without anonymity. There are employers who are counting on their employees' fear of reprisal to discourage them from reporting a problem. I have never and will never remain silent. There is a great deal of vulnerability among patients, especially the elderly, and their fear is real. The majority of us will experience being a patient at least once over the course of our lives, and I am confident that most of us will want a nurse who will speak up for us when the time comes.

[pharmanurse11]

brandy1017 said:

You can file a whistleblower complaint to CMS medicare if there was no proof this patient had cancer.  If you were his nurse you saw his medical records.  If they investigate and find wrongdoing you could actually get a financial reward a percentage of what CMS fines them I believe.  I would look further into this for his sake and others out there.  It sounds more like euthanasia for the sake of profit!

When a patient is admitted to a SNF, the hospital sends a D/C summary, H&P and medication list. In addition, we are not provided with the entire medical history of the patient. The hospital is not expected to have a comprehensive or entire life's medical history of the patient. It will be his primary care physician who will have all of that information. A nurse who uses a patient's EMR for the purpose of discrediting a finding is in violation of HIPAA. 

Not looking for any financial reward.  Contacting the OIG is one of the first things I did. 

 

[klone, MSN, RN]

Sounds like a blatant Stark Law violation

[Been there,done that, ASN, RN]

pharmanurse11 said:

In the week leading up to my resignation, I contacted compliance without anonymity. There are employers who are counting on their employees' fear of reprisal to discourage them from reporting a problem. I have never and will never remain silent. There is a great deal of vulnerability among patients, especially the elderly, and their fear is real. The majority of us will experience being a patient at least once over the course of our lives, and I am confident that most of us will want a nurse who will speak up for us when the time comes.

Yeah.. but speak silently and move on.