Need Help FAST Please. RE: Inappropriate discharge

[Monica RN,BSN]

Hello friends

I need some serious help here....

I have a serius and ethic delemia to figure out fast.

I have an ethical delemia and need some good advice. In my 120 bed LTC facility (I am a DON) I was MANDATED and instructed by my corporate office that I MUST discharge a lady to the hospital tody...because she owes 56, 000to the facility. Ok.. I ordered stat labs, to include a CBC, BMP, UA, dig level and an EKG.. (in hopes to find a reason to send her out.. tests were uneventful.. EKG Sinus brady with S-T elevations and HR 57, labs good except for low dig level at 0.53 (has no meds for a week, pharmacy cut off her orders because she owes them 10,000, the CBC - RBC is a little low at 3.56 (I asked if the doc could admit for anemia)

Long story short: MD ran a bunch of tests probably did a 10,000 work up. and NO DICE>. She has nothing that warrents a hospital stay.

Primary MD was willing to do a direct admit as long if something justified could be found.. well, 7 hours later she is ready to come back:

I have a direct order from corporate that she is NOT to return back under no circumstances. but there is no case for an admit. In fact she is alert and keeps telling the ER that "I have nothing wrong with me" I asked if she could stay because of the finacial debt, they said it is not their problem (understandable) Now if I bring her back, I, the DON and the administrator get fired..:angryfire

I have to go with my gut feelings on this and do what is ethically correct, I do not want to be facing the board of nursing for failure to take her back from an unneccessary ER send out.

Choices:

1) do not take her back per corporate mandate and face AHCA tomorrow with a possible big fine and a big tag, and possibly have personal charges brought against me by the board of nursing

2) accept her, and face getting fired tomorrow for allowing her to return to the faciltiy.

I want to call the hospital and have her sent back because it is the ethical and legal thing to do, regardless if I get canned tomorrow..

What are your thoughts on this. We are under Florida laws.

Thanks in advance to anyone who can offer help.

[judy ann]

I recently completed a course for ombudsman. I remember that this was covered under the heading of Resident Rights. The FEDERAL law states that, in order to remove a resident in a LTC facility, the resident and the resident's family/POA must receive written notice 30 days in advance of the required date to leave the facility. Furthermore, the facility MUST assist the resident/family/POA to find an appropriate home for this person. To fail to do this can earn you a prison sentence and a heavy fine. This is administered under the Older American's Act, and can be reached by your state health department.

When I say that "you" would have to shoulder the responsibility for this crime (yes, it is a crime) I speak only of the facility, not the DON.

Hope this helps.

[pepperann35]

I recently completed a course for ombudsman. I remember that this was covered under the heading of Resident Rights. The FEDERAL law states that, in order to remove a resident in a LTC facility, the resident and the resident's family/POA must receive written notice 30 days in advance of the required date to leave the facility. Furthermore, the facility MUST assist the resident/family/POA to find an appropriate home for this person. To fail to do this can earn you a prison sentence and a heavy fine. This is administered under the Older American's Act, and can be reached by your state health department.

When I say that "you" would have to shoulder the responsibility for this crime (yes, it is a crime) I speak only of the facility, not the DON.

Hope this helps.

The patient can also be removed if the patient goes to the hosp. for a legitimate reason, is admitted and the family cannot afford a "bed hold" Then the facility has the choice to accept the patient back or not when he/she is ready for discharge.

[southern_rn_brat]

I hope you come back and let us know what happened. I really commend you on being honest here.

It's a tough situation. Even though it isn't nursing's fault that the patient has racked up the bill, it's nursing's job to take care of it. typical corporate crap:uhoh3:

you know what they are wanting you to do is wrong though. stand up for yourself and your patient. your license is not worth losing for the company.

We had a patient that nobody wanted. it took us MONTHS to find a place to send her. It's frustrating when you have a patient eating into your budget that way but they still have to be cared for.

I think the facility should have to pay for the patient's meds if she cant. As long as she is there she has to be cared for. Does the doc know she hasnt had her meds? If you dont have orders to d/c all her meds then you better get her some meds pronto.

Where is social services and administration in all this?

I love what the poster said about getting it in writing. That still won't save you from the BON though.

wow what a situation. so sorry for you!

[kmoonshine, RN]

The patient can also be removed if the patient goes to the hosp. for a legitimate reason, is admitted and the family cannot afford a "bed hold" Then the facility has the choice to accept the patient back or not when he/she is ready for discharge.

What you have posted is true, but only for facilities that do not receive government reimbursement. If the facility accepts Medicare and other assistance, they cannot transfer/discharge a patient solely based on nonpayment without giving 30+ days notice. The following is right from Florida's law on LTC resident rights:

• The right to be transferred or discharged only for medical reasons or for the welfare of other residents, and the right to be given reasonable advance notice of no less than 30 days of any involuntary transfer or discharge, except in the case of an emergency as determined by a licensed professional on the staff of the nursing home, or in the case of conflicting rules and regulations which govern Title XVIII or Title XIX of the Social Security Act. For nonpayment of a bill for care received, the resident shall be given 30 days' advance notice. A licensee certified to provide services under Title XIX of the Social Security Act may not transfer or discharge a resident solely because the source of payment for care changes. Admission to a nursing home facility operated by a licensee certified to provide services under Title XIX of the Social Security Act may not be conditioned upon a waiver of such right, and any document or provision in a document which purports to waive or preclude such right is void and unenforceable. Any licensee certified to provide services under Title XIX of the Social Security Act that obtains or attempts to obtain such a waiver from a resident or potential resident shall be construed to have violated the resident's rights as established herein and is subject to disciplinary action. The resident and the family or representative of the resident shall be consulted in choosing another facility.

My point is this: any LTC facility accepting medicare/government payments must abide to the above law. It is applied to all residents of the facility; patients recieving government assistance and self-pay patients.

[annmariern]

Agree with all who acknowledged your honesty. Obviously, they are acting unethically and apparently illegally. How can they fire you for obeying the regs? I would call the ombudsman, keep records and get as much as I could in writing before acting on it. They know their wrong. I would also consider consulting a lawyer. This is a malignancy in the entire health care system. I see it, with shoving out pts from the hospital to a SNF, with no insurance. No labs for a week, etc (because god forbid there abnormal and the doc will have to intervene). Hospitals dump all the time. Do0 what your gut is telling you, protect your license and your pt.

[pepperann35]

What you have posted is true, but only for facilities that do not receive government reimbursement. If the facility accepts Medicare and other assistance, they cannot transfer/discharge a patient solely based on nonpayment without giving 30+ days notice. The following is right from Florida's law on LTC resident rights:

• The right to be transferred or discharged only for medical reasons or for the welfare of other residents, and the right to be given reasonable advance notice of no less than 30 days of any involuntary transfer or discharge, except in the case of an emergency as determined by a licensed professional on the staff of the nursing home, or in the case of conflicting rules and regulations which govern Title XVIII or Title XIX of the Social Security Act. For nonpayment of a bill for care received, the resident shall be given 30 days' advance notice. A licensee certified to provide services under Title XIX of the Social Security Act may not transfer or discharge a resident solely because the source of payment for care changes. Admission to a nursing home facility operated by a licensee certified to provide services under Title XIX of the Social Security Act may not be conditioned upon a waiver of such right, and any document or provision in a document which purports to waive or preclude such right is void and unenforceable. Any licensee certified to provide services under Title XIX of the Social Security Act that obtains or attempts to obtain such a waiver from a resident or potential resident shall be construed to have violated the resident's rights as established herein and is subject to disciplinary action. The resident and the family or representative of the resident shall be consulted in choosing another facility.

My point is this: any LTC facility accepting medicare/government payments must abide to the above law. It is applied to all residents of the facility; patients recieving government assistance and self-pay patients.

If the patient is sent to and admitted to the hospital for a real emergency and the family does not want to pay to have the bed held, the LTC facility does not have to accept patient back. I work in LTC in Florida in a non-profit facility that accepts all forms of payment.

[pepperann35]

If the patient is sent to and admitted to the hospital for a real emergency and the family does not want to pay to have the bed held, the LTC facility does not have to accept patient back. I work in LTC in Florida in a non-profit facility that accepts all forms of payment.

However, if the patient is sent out for non-legit complaints, then they will most likely not be admitted and therefore must return to the LTC facility they came from unless the patient themself does not want to return.

[horrorxgirl]

That is scary! I would definitely choose to get fired over losing my license. And if they fired me for it, you can bet they would be getting reported. I would also document everything you are being told to do. Keep us updated.

[chasingmydream]

what is the health community coming down to.

money plays such an important role and its not fair.

these darn insurance companies etc...its ridiculous.

this woman may not have family and cant be left alone 24/7. if she doesnt have money, and no insurance..the state should step in.

id say no meds...wow neglect bigtime.

this is a big shame

that lady , poor thing, no one wants her, no place to go, no home, and she spent her life probably working , paying taxes, taking care of others and when she is in need, she is hung out to dry.

i hate the system

and this is in the good ole usa no less.

[teeituptom, BSN, RN]

As a long long time ER nurse. This happens all the time.

ER gets dumped on the LTC with these kind of problem pts

They tell us the pt has no money. Or the pt is unhappy and wants to leave the LTC, or the pt is to much work for the LTC. Or the pt is combative. Yes they sent a 97 yo lady to us one night as she was too combative and they wouldnt take her back ever. Ive seen it all and heard it all from LTCs

Which is why Im the King of turning LTC's into adult protective services, the health department, and anyone else I can get involved. Im sorry this happens to the elderly. Particularly life long American Elderly who have helped this country all of their lives. Now it our turn to help them.

[crissrn27, RN]

As a long long time ER nurse. This happens all the time.

ER gets dumped on the LTC with these kind of problem pts

They tell us the pt has no money. Or the pt is unhappy and wants to leave the LTC, or the pt is to much work for the LTC. Or the pt is combative. Yes they sent a 97 yo lady to us one night as she was too combative and they wouldnt take her back ever. Ive seen it all and heard it all from LTCs

Which is why Im the King of turning LTC's into adult protective services, the health department, and anyone else I can get involved. Im sorry this happens to the elderly. Particularly life long American Elderly who have helped this country all of their lives. Now it our turn to help them.

Not saying it is right to dump LTC pts on the ER, but I once sent a 70y/o schizophrenic lady to the ER b/c she was going into others rooms and abusing them. Of course it was weekend nights, and doc didn't want to "deal with it". He gave me a ativan 2mg order (IM), and when that didn't work he said send to ER. This was back when the absolutely no restraint thing started, so we couldn't do anything. ER called me back, said there is nothing we can do we are sending her back. I stated I would have to speak with my administrator before accepting her back, nurse said pt would be waiting in the ER waiting room when we were ready for her, unsupervised. I thought they would direct admit her to a mental health facility, but I guess not.

BTW, Monica, how did this work out? Do you know yet?

[teeituptom, BSN, RN]

Not saying it is right to dump LTC pts on the ER, but I once sent a 70y/o schizophrenic lady to the ER b/c she was going into others rooms and abusing them. Of course it was weekend nights, and doc didn't want to "deal with it". He gave me a ativan 2mg order (IM), and when that didn't work he said send to ER. This was back when the absolutely no restraint thing started, so we couldn't do anything. ER called me back, said there is nothing we can do we are sending her back. I stated I would have to speak with my administrator before accepting her back, nurse said pt would be waiting in the ER waiting room when we were ready for her, unsupervised. I thought they would direct admit her to a mental health facility, but I guess not.

BTW, Monica, how did this work out? Do you know yet?

She is 70 yo, and she would benefit from a psych facility in which way. She is already in an LTC because she cant take care of herself. So you send her to the ER to dump your problem on us. After only one dose of ativan. What, did you want her committed to psych facility, under an order of protective custody. Where they can adjust her meds which is something that can be done where you are at. So she gets an ambulance bill, an ER bill, An ER doctor bill, An ER psych assessment bill. Transport bill back to her facility. All this rather than adjusting her meds, or having a sitter with her or some other simple form of care?