Patients who stick around after discharge/legal risks

[JKL33]

Hi, everyone...I've really enjoyed lurking here, now have a question I'm hoping someone can help with.

Anyone willing to comment on the risk-management/legalities of allowing patients to loiter in the waiting room for hours and hours after being discharged from ER? Our community hospital is having an issue with this and I'm concerned that it is a legal risk. For example, a patient who is VERY well-known to our department, comes by EMS and never has a way home - has abused every option available and burned most all bridges, so it is by sheer luck that he EVER gets a ride home. This patient always presents with the same potentially-serious complaint which (thus far) has never panned out to be anything. After being adequately evaluated and eventually d/c'd from ER, he ends up out in the waiting room and is more than happy to sleep there all night. Occasionally bothers other patients/visitors and staff by pandhandling for money or food or rides.

I think it is unwise legally to allow loitering on our premises - seems like a nightmare waiting to happen if the patient has some sort of 'event' while spending hours on OUR cameras just mere feet from our department (i.e. stops breathing while sleeping in one of our chairs and no one notices it -on camera- immediately). Most recently I have been told by management that I could make notes in the chart (post-discharge) with regard to the patient's activities ("sleeping", "reading magazine", etc.) which I think is even MORE dangerous for me to accept that level of responsibility. If I'm going to do that, I might as well keep the pt on tele until a ride can be found.

I think mgmt is leery of taking a 'hard stance' with anyone given that we are a community hospital, lest we appear un-compassionate. Also, there is a fear that if we call the cops, for example, the pt will just make the same original complaint again and end up needing to be re-seen in the ER even sooner than he otherwise would!

Thoughts? Especially comments related to the nurse's responsibility to discharged patients who don't leave the premises....and feel free to let me know if I'm blowing the issue out of proportion.

Thanks in advance.....:)

JKL

[Dolce, RN]

That is a tough situation. I hope others with ER experience will post so we can hear what others are doing. I think it is completely inappropriate to chart on the patient after discharge. He is no longer your patient and you shouldn't be charting on him.

It sounds like he needs some serious limit setting. For instance, he needs to be out of the waiting room in a certain amount of time or you will call the police. It is loitering. Panhandling in the ER waiting room is not acceptable.

Can your hospital give him cab vouchers to get him where he needs to go? I know he is already abusing the situation but it might help.

Wish I had a real answer for this problem. Sounds like a situation for the risk management/legal department. You guys need to have a policy in place for how you deal with this type of situation. I can just imagine how the news would portray it if he coded in your ER after discharge. "Man Dies in ER Waiting Room." Top story on CNN for sure.

[ecat81]

This recently happened to one of our patients on a night I was in charge. Except the patient was intoxicated when brought in and was about an hour away from his home. We exhausted every relative and friend he was willing to give numbers for. We do have cab vouchers but have stopped using them because of abuse. The patient was told to find a ride by using the phone in the lobby and didnt get home for about 14 hours. He was fed and given a blanket. I hope someone can give a good answer to your question. I was approached by someone as to why I let him sit in the lobby and I gave my explanation of abuse of EMS-vouchers. If he was able to come with friends an hour away to go drinking then he had money and friends to take him back. Not being uncompassionate but not allowing patients to take advantage of the hospital. Also I believe an employee going home in the direction he lived carried him home. To me this is a huge liablity also for the hospital. What if they got in a wreck and the patient dies?

Thanks

[HR_LPN]

I work in an OB dept in a community hospital. Occasionally we get pts that come in from EMS that have no way home once ready for d/c; and they are usually a little loopy after their Nubain/Phenergan cocktail. We usually call the Police dept and tell them that we have a patient being d/c with no way home; usually they are pretty willing to give them a ride. That is not always the case, but most of the time it is. Just my . Hope this helps! Have a great day!

[aknurs]

When I worked in the ER, we had a policy."No Ride, No Shot". It worked pretty good, but we had the few who would, lie & tell us their ride was either coming, getting the tire fixed, or whatever excuse..They were still told ,sorry we have to know for a fact , that your ride is ready, to take you home after your 20 min. shot time was up.(Anyone who received an injection, had a mandatory 20 min. wait, before they could be D/C..(the hospital was afraid of the liability issues that could arise, if the pt. was discharged & got involved in an accident, because of a narcotic inj.)..The only exception I made to that rule ,was one time, when I placed a phone call for a patient, to their friend, & got a verbal confirmation, that they would come & pick up the friend(pt.).They were true to their word, & took the pt. home.

[Straydandelion]

Possibly writing up a risk management report on these types of patients would let a lawyer look at them and encourage the facility to develop a policy to help?

[traumaRUs, MSN, APRN]

I live in the midwest in a medium-sized city. Worked in the inner city level one ER for 10 years and once people were discharged, they had to leave, no ifs, ands or buts. Security would stay on them until they left. Our waiting room was small and there was no place to lay down, no coffee, no snacks, nothing. If we had the ETOH'er who was generally sobered up, we would still escort them to the curb.

In the winter, it was a different story. I was a case manager for 2 years and had a very large storage bin of coats, socks and basic toiletries which I would provide for those that were walking to the mission or to crisis shelter.

I totally agree that this is not ideal. However, I think it is only going to get worse with the economy tanking.

[gonzo1, ASN, RN]

This happens in our ER alot. The pt just sits until their ride comes or the buses start running.

Do not chart on this pt and their activities after they are discharged. After discharge they are members of the community and responsible for their own welfare.

This always bothers me a lot, but it is the way it is.

I would keep half of one eye on them and if I noticed something wrong I would alert security or the charge nurse. At which time if something was wrong they would be tr-triaged and admitted for yet another ER visit.

It is a great idea to say no ride, no shot. The person taking you home has to be in the room when I give you the shot.

Had someone the other night who said they had a ride but really didn't.

[whoofers]

Once you discharge the patient they are no longer an emergency room patient. If you were to chart on them, it could be taken that you have accepted them as a patient again and are responsible for them. Don't chart on them after they formally leave the ER.

If they decide to stay and loiter in the waiting room or hospital, they become a security issue & it is security's responsibility to handle it, not the ER's staff. Ask your charge nurse to talk to security about this and let security make a policy for it since those that loiter are no longer patients there.

[Roy Fokker, BSN, RN]

Discharged means just that - discharged.

Sometimes folks end up waiting in the waiting room because we are a small town and have no taxi service after 1-2 am in the night.

Some of our chronic homeless population end up waiting in the waiting room till the morning. They may get blankets and a meal but they are not "charted" on.

Nobody post discharge should be "charted on". It's a huge liability issue!

cheers,

[BrnEyedGirl, BSN, MSN, RN, APRN]

I'm kind of surprised we haven't gotten any of the "you cruel, uncompassionate ER nurse!" posts here.

This is a huge issue in our ER as well. We often get the frequent flyer who would rather come to ER than go to jail. We have many pt's who are weekly visitors via EMS c/o chest pain, stroke like sx or the infamous "some dude" beat me up while I was walking down the street (at 3am) minding my own business. These pt's get the full MI/CVA/trauma work up,.we never find anything other than ETOH and non prescribed drugs on board. Some of these people show up twice in one shift! We used to give out cab vouchers, one month we had close to $10,000 from our ER budget going to cab vouchers! No more cab vouchers, which is sad for those who really need it.

During night shift security allows discharged pt's to sleep in the waiting room as long as they aren't bothering the other pt's. I'm waiting for the day someone dies in the waiting room,.camera's going and we as nurses are held responsible. Not sure what the answer is, other than personal responsibility, which we obviously can't teach at discharge. Many times these pt's are found in the parking lot drinking from a bottle only moments after discharge. We can't take the bottle. We can tell them to stop drinking or at least drink inside somewhere safe,.but what else can we do?

During a meeting to discuss this very issue, someone brought up the theory that if these people have the money to buy cigarettes and booze then they can scrape together cab fare. Our social worker reminded us that cigarettes and booze can be stolen, it's kinda hard to steal a cab ride. Ok,...but as an RN in an ER how is that my responsibility?

[iluvivt, BSN, RN]

We have a contract with Yellow cab and give them a taxi voucher, If a pt is causing problems after discharge security should be notified and they should be asked to leave and escorted off the property. If they refuse to leave law enforcement can be called. I would try everything else first since I am certain that would be a low priority for the police. I would never chart on pts chart post discharge about his or her activities in the waiting area or lobby....I think that advice is scary.