Problem with an admit and Survey

[LegginMF]

Facility is LTC

Resident to sent out to E.R. Flu going through the facility like wildfire. Resident readmitted with Dx of dehydration.

D.O.N is insinuating that admitting Dx of dehydration should NOT have been in the admit paper work. I did not do admit....but... was there the following day and seen order for STRICT I&O's. I spoke with D.O.N and told her to the best of my knowledge that since resident was incontinent and wore a brief that we needed a scale to do strict I&O's. Am I correct in thinking we need to weigh the brief to calculate output? Was told by D.O.N to change order to just monitor how many times we had a wet brief per shift. State is coming back to further review this case. Was nurse wrong to put Dx of dehydration on paper work? It's clearly written on the hospital paper work. If she didn't put it would it be considered hiding info or falsification? Also at that time the Administrator had staff pull ALL of the bedside water pitchers from the rooms. Operating on the assumption that because we have a lot of ambulatory (and very confused) residents this would prevent the spread of the flu even further. Any feedback would be appreciated. Thanks.

[Batman25]

The state is coming to further review and she wants staff to alter and change documents and orders?! DON'T DO IT. Falsifying docs is illegal and a good way to lose your license. You can't just leave out a Dx of hydration because you don't like it. She seems worried blame wll be assigned to your facility. You are to follow the orders as written. She could set you both up and deny it all.

I would think taking water away could lead to more cases of dehydration. I don't think this was a wise move either. i don't think state will either. Make sure the patients are staying hydrated.

[gentlegiver, ASN, LPN, RN]

My experience in LTC tells me that if the DX is written in the hospital discharge paperwork then it goes into the re-admitting paperwork. I'm not sure if not entering the DX would be considered hiding or falcifying, but it's not like the faculity purposefully caused the DX so why the fuss?? Strict I&O's on a resident requires weighing the brief before & after use. And if flu is rampant, the last thing I want to do is remove water from them, the risk of dehydration is to high. Better to have house keeping washing floors, rails, and anything else they touch more often.

[Doc Lori, R.N.]

From my LTC experience, a couple of thing could have happened:

1: Your marketing/adm person reviewd the pt's hospital chart, and one of pt's admitting dx's to the hospital could have been dehydration

2: The admitting MD for your facility deemed it as such, therefore that's what it is!

Good luck :)

Oh.what does your MDS person think? And why is it such a problem as per your DON? Sounds like something you may have been tagged for in a previous survey and the DON doesn't want any red flags. Bottom line, it is what it is. I wouldn't change a dang thing !

[mamamerlee, LPN]

I am confused. The dx to the hospital was dehydration due to flu, but the readmitting dx would be resolved dehydration. And yes, you need to somehow keep track of I&O.

Does the doc know that the client wears diapers? Ask the doc if the order can read to track the # of wet diapers.

Do not ever falsify records. It will come back to bite you.

[nyteshade, BSN]

Facility is LTC

Resident to sent out to E.R. Flu going through the facility like wildfire. Resident readmitted with Dx of dehydration.

D.O.N is insinuating that admitting Dx of dehydration should NOT have been in the admit paper work. I did not do admit....but... was there the following day and seen order for STRICT I&O's. I spoke with D.O.N and told her to the best of my knowledge that since resident was incontinent and wore a brief that we needed a scale to do strict I&O's. Am I correct in thinking we need to weigh the brief to calculate output? Was told by D.O.N to change order to just monitor how many times we had a wet brief per shift. State is coming back to further review this case. Was nurse wrong to put Dx of dehydration on paper work? It's clearly written on the hospital paper work. If she didn't put it would it be considered hiding info or falsification? Also at that time the Administrator had staff pull ALL of the bedside water pitchers from the rooms. Operating on the assumption that because we have a lot of ambulatory (and very confused) residents this would prevent the spread of the flu even further. Any feedback would be appreciated. Thanks.

As a former MDS nurse, let me see if I can shed some light on this. What your DON probably meant was residents generally should not be readmitted with a dx of dehydration, it should be S/P dehydration (on your facilily paper work, not the hospitals), reason being is that the hospital should have resolved that prior to sending them back to your facility. It may look as though you are accepting a resident that was not "ready yet" (for lack of a better term). She does not want an active dx of dehydration, because it will trigger in the MDS.

I'd hate to be the MDS nurse handling that case! Dehydration is a sentinel event to CMS, and the MDS nurse reviewing that chart probably wants to cry right about now. When they schedule the MDS assessment, they will have to look back 7 days for clinical s/s of dehydration in the medical record (the hospital counts). If that is captured in the 7 days, it will trigger to the inspectors, and they will look for patterns in your facility.

I hate to be blunt, but I gotta say it: your administrator sounds like an idiot. Taking water pitchers away at such a critical time??? From what I gather from the situation the dehydration was preventable, and that's a big problem esp. if the inspectors pick up on the patterns. It will appear to be a massive failure among the nursing staff such as poor handling of the flu outbreak (removing pitchers). Hydration will become a huge issue. Nurses will probably have to prove how they indeed provided hydration, if and when they noted any s/s of dehydration, if a MD was notified at first sign, labs ordered prior, etc. And sadly your admin. probably will throw all the nurses under the bus, and never admit they had the bright idea to remove pitchers.

[southernbeegirl, BSN, RN]

Our DON had all the water pitchers removed from patient rooms a few years ago. Her thinking was that we couldn't get tagged by the state for not passing ice if they weren't in the rooms. According to her, patients get more than enough fluids daily from their meals, med passes and snacks. She said that if the patients wanted something to drink between those, then we could just get them a cup of water.

Although we are LTC, we are mostly short stay rehab. Can you imagine telling people that were there for therapy after a TKR "we don't have ice pitchers, sorry".

thankfully, that didn't last long at all.

about the strict I&O...the only way to truly do that is to put a foley in or, as you said, weigh the brief. Being that LTC is not acute care, the thinking is that if a patient truly needs strict I&O then they should be in acute care settings. Once they are readmitted to the LTC, normal I&O should suffice. The less you give CMS something to look for mistakes on...the better.

LTC can be frustrating because of all the CMS regulations we have to follow. They are completely different than joint commission. So sometimes in LTC we do things that leave a new nurse or an acute care nurse saying "wtheck??". It's frustrating to us too.