I work in an ED in the Hampton Roads, VA area, and I see it all the time. There are good SNF's and bad ones. Every time I get a patient from certain SNFs, I know I can expect a "hot mess", not just the chief complaint. I hate seeing these poor people like this. I try to take extra time with them and be kind even if they are not so pleasant sometimes. I will feed them and make sure they are comfortable. Lots of times, they don't even have a family member with them in the ER, so I will try to sit for a little while with them if I have time. The other problem with the SNF's is that the nurses there are overloaded, and they do not have the freedom that we ED nurses do to use their critical thinking (i.e. a SOB asthma patient comes in, I can start stacked nebs without an MD order since we have protocols in place) so the policy at the SNF is to transport for anything abnormal rather than try to treat there because an MD has to see the patient before any new treatments. It sucks all the way around. I have an advance directive already to NEVER put me in a nursing home.