Pt. nonresponsive on transfer to SNF

[southernbeegirl, BSN, RN]

I work in a rehab/LTC facility. I just have to tell yall about a patient I received last friday. I'm still in shock about it.

We were expecting this patient for strengthening and gait training.He is able to shower himself, dress himself but his dementia is progressing fast. He and his wife had made the decision to move him to an ALF and she was going to move in with him after selling their home, etc.

4 days after admit to the ALF, he and his wife both caught a horrid virus. He ended up in the hospital from the dehydration.

He has been monitored by a geriatric behaviour program for his dementia. has been stable on seroquel 25mg tid.

While in the hospital with the vomiting, diarrhea, and dehydration his confusion got real bad. they transferred him down to the geriatric psych unit. the ALF had sent him to this hospital due to closeness to their facility but his doctors are at another facility so these people knew nothing about him.

Due to the dehydration, etc. his confusion got worse, he became combative at times and agitated. While on the behavioral unit they increased his seroquel to 50mg tid and 100mg qHS. they didnt gradually increase it either...just did it.

when he couldnt/wouldnt take the seroquel they gave him IM Haldol and also had him on IV benadryl. they also had him restrained.

so his dehydration, etc had resolved, the diarrhea stopped so the hosp. told them they needed a SNF to get him stronger and back to his prior level of functioning before he could return to the ALF.

so on the day of transfer, I got no report from the hospital, and he just sorta showed up (happens all the time doesnt it?). Before the EMT's would transfer him from their stretcher they came to me and asked that i see him before they did. (im the suprvisor).

What I found was a completely nonresponsive male. not even responsive to a very hard sternal rub or other painful stimuli. I looke at the EMT's like "wth???". they took me out in the hall and told me that when they picked him up at the hospital they were shocked when they saw him. here they were supposed to be transferring him to a SNF for therapy and this man was totally nonresponsive. they told me that in front of the wife and daughter they asked the nurse to reassess him and told her they were not comfortable transferring him out of the hospital. the nurse refused to reassess him, told them he was "just sleeping due to the seroquel" and he was fine.

i went straight to the phone and called the nurse that had him and asked her for a report. she tells me that he is "just sedated" and if we were smart we'd keep him that way. she said he was very combative, "especially when you change his brief". I questionedher over and over on his condition and the fact that he was nonresponsive. Eventually I ended up talking to the charge nurse because the floor nurse got angry at me when i told her i couldsnt believe they had transferred him in this condition and that i was probably sending him right back via the ER.

so the charge gets on the phone and she tells me he's just sedated as well. she tells me "if you dont believe me, get your CNA to go in there and change his brief...that'll perk him up!". I'm like "omg, are you serious? this man is COMPLETELY nonresponsive!". she then says "well he was sleeping so we held his 2pm seroquel". geez. so i asked her exactly what meds he had had that day so that when i sent him to the ER i could relay that to them. she faxed me his mars for that day. he also takes dilantin for seizures.

i ended up talking to the nurse, the charge and the CNA that had him. seperately, they all told me the same story. "up until 2 days ago he was severly combative and had to be restrained". um...ok, what happened 2 days ago that made him change? "the seroquel kicked in" (i swear to all that's holy the charge nurse really said that)

i grab the administrator and go back to the room to talk to the wife and daughter. needless to say the wife was very aprehensive about sending him back to the hospital. she kept telling me "i told them 2 days ago something was wrong with him but the ywouldnt listen and just kept giving him drugs".

his VS were decent. i put o2 on him. his wife really didnt want to transfer him so i told her that we would CLOSELY monitor him until morning. at that time, i would draw a bunch of labwork and we could go from there. that way if it WAS the seroquel, he should be more alert. i also put all of his psych meds on hold. not that it really mattered becuase this man was out of it.

early the next morning i drew his labs and sent them to the hospital. the results? dilantin toxicity(45) and hypernatremia (165), BUN ~98.

i sent him straight to the hospital but not the one he came from.

he ended up in ICU as you can imagine. i spoke at length with the doc when he got there and he told me that he didnt think he would make it.

the whole thing has made me very angry. if I had transferred him to the ER like that, the hospital would have called CMS on us in a second!

they all said he'd had a change 2 days ago. his granddaughte is a neurologist at Emory and she questioned the doc at the hospital over the huge increase in seroquel but they kept telling her how combative he was and he "needed it". his wife said she hadnt left his side for 2 days and he kept getting worse and worse. their daughter told me that they had questioned the nurses and doctors for 2 days asking them what was wrong with him and they kept telling them it was the seroquel. they would shake him awake and pour the meds, mixed in liquid, in his mouth.

i told the charge nurse that the EMTs had asked the nurse to re-eval him prior to transfer and she refused saying "there aint nothing wrong with him, get him out of here". she said that in front of both EMTs, the wife and the daughter. when i told the charge that, she asked the nurse while i was on the phone. the nurse adamantly denied the conversation took place. i told the charge i wasnt going to call anyone a liar but that i had 4 people telling me the same exact story.

Can yall believe this? Can you believe that he was sent to a rehab facility in this condition? I am by no means perfect. I've missed things too. But, IMO, this was just a case of gross neglect. this is also the first time in my whole nursing career that i have ever said that about another facility. i'm still in shock over it.

His wife called me the next morning thanking me over and over for taking care of him. i spoke with the doc when he called to ask me some questions and he told me "you saved that man's life, i hope you know that".

What are your thoughts? Have yall ever had a patient transferred to you like this? What do you think about it?

[Little Panda RN, ASN, RN]

"WOW" thankgoodness you took the time to make sure this man was taken care of. I have heard similar stories before of this type of thing happening. All I can say is the good Lord was watching out for this gentlemen by sending him to your facility. I am sure the family is deeply grateful. You sound like an awesome nurse!!!! You should be very proud, you saved a life not just any life but the life of a fellow human being!

[WildcatFanRN, BSN, RN]

OMG!!! I have worked in SNF and I have never witnessed anything like that, though I worked night shift. Believe me if something like that had happened, the whole facility would have heard about it at some point. The hospitals I've worked at would have given the man a CT scan to check such a drastic behavioral change. Especially, if the family kept asking what was wrong. Seroquel zonks you, but it does wear off.

Document everything because I smell a lawsuit coming. Why is it that dementia patients are automatically restrained and sedated without checking for another reason for the change. Granted, I have been hit, scratched, and spit at by dementia patients in the hospital but sheesh....listen to the people who know him for goodness sake.

[southernbeegirl, BSN, RN]

OMG!!! I have worked in SNF and I have never witnessed anything like that, though I worked night shift. Believe me if something like that had happened, the whole facility would have heard about it at some point. The hospitals I've worked at would have given the man a CT scan to check such a drastic behavioral change. Especially, if the family kept asking what was wrong. Seroquel zonks you, but it does wear off.

Document everything because I smell a lawsuit coming. Why is it that dementia patients are automatically restrained and sedated without checking for another reason for the change. Granted, I have been hit, scratched, and spit at by dementia patients in the hospital but sheesh....listen to the people who know him for goodness sake.

this was a first for me too!

I'm like you, I just couldnt believe that they hadnt even done any lab work on him at the very least. that would have took what? 2 minutes?

the part i didnt get was the family saying over and over something was wrong with him and they sorta blew them off saying it was the seroquel. but in a way, i could see it happening. he was probably very very confused from the virus to begin with and got combative with them so they probably did wanna zonk him out. we've all been there. say he finally quiets down on one shift so in report you are saying "thanki you God!", am i right or am i right, lol. and if you get a nurse the next day that hasnt had him before, she might not realize somethings going on. but when the family is upset and telling you somethings wrong, why not check it out. ESPECIALLY when you know he has a granddaughter that's a neurologist! not only that but his wife and daughter are wonderful! sweet as all get out.

all it took me was talking to them for about 10 minutes before i could tell he'd had a significant change in the past two days.

granted though, i had the benefit of being able to put all the pieces of the puzzle together. and God knows i dont want to see ANY nurse get sued! but you best believe i read my charting in his chart over a bazillion times to make sure i covered all MY bases. thats why i got the administrator involved at our facility too.

i dont like how people are so easy to sue these days. but this was one case that, silently in my head, i thought "now here's a legit lawsuit".

i tried to be careful not to criticize the nurses at the hospital though. i hate it when people do that. i wasnt there so i dont know what happend. i just had the benefit of hindsight. and Lord knows i've had patients i wished i could sedate that way, lol.

thought, it makes me mad sometimes with how people says that it is the nursing homes that give poor care. how many of us have received pts from a hospital with a big ole whoppin decub when in report we are told skin intact?

that was one reason i kept in contact with his nurse at the hospital i transferred him too and talked to his doc a few times. i wanted to make sure they all knew he was transferred to ME that way and that we didn't do that to him.

[southernbeegirl, BSN, RN]

"WOW" thankgoodness you took the time to make sure this man was taken care of. I have heard similar stories before of this type of thing happening. All I can say is the good Lord was watching out for this gentlemen by sending him to your facility. I am sure the family is deeply grateful. You sound like an awesome nurse!!!! You should be very proud, you saved a life not just any life but the life of a fellow human being!

thanks a lot for your kind words.

but i'm just a nurse, same as all of us. and like i said, i had the benefit of hind sight so it was easy for me to put the pieces together.

i see you are about to graduate, huh? well good luck to you and welcome to the family!!!!!!!!

just remember, listen to your gut...your inner voice...your intuition. sometimes you just KNOW somthings wrong but you cant put your finger on it just yet. and always listen to the families. they know the pt better than we do.

but all of us have had days where we wish the pt would go to sleep or the family would just be quiet. at the hospital, they probably felt that way and didnt realize something wasnt right with him.

but i still cant believe they sent him to me that way.

[Jailhouse nurse]

awesome example of excellent nursing practice.

thank you.

[LeesaRN]

WOW, I'm sorry for you situation with that patient, but hey you saved his life. That is awesome, as a NS soon to be R.N. I hope to some day be the kind of R.N. you are. :redbeathe Leesa

[WildcatFanRN, BSN, RN]

this was a first for me too!

I'm like you, I just couldnt believe that they hadnt even done any lab work on him at the very least. that would have took what? 2 minutes?

the part i didnt get was the family saying over and over something was wrong with him and they sorta blew them off saying it was the seroquel. but in a way, i could see it happening. he was probably very very confused from the virus to begin with and got combative with them so they probably did wanna zonk him out. we've all been there. say he finally quiets down on one shift so in report you are saying "thanki you God!", am i right or am i right, lol. and if you get a nurse the next day that hasnt had him before, she might not realize somethings going on. but when the family is upset and telling you somethings wrong, why not check it out. ESPECIALLY when you know he has a granddaughter that's a neurologist! not only that but his wife and daughter are wonderful! sweet as all get out.

all it took me was talking to them for about 10 minutes before i could tell he'd had a significant change in the past two days.

granted though, i had the benefit of being able to put all the pieces of the puzzle together. and God knows i dont want to see ANY nurse get sued! but you best believe i read my charting in his chart over a bazillion times to make sure i covered all MY bases. thats why i got the administrator involved at our facility too.

i dont like how people are so easy to sue these days. but this was one case that, silently in my head, i thought "now here's a legit lawsuit".

i tried to be careful not to criticize the nurses at the hospital though. i hate it when people do that. i wasnt there so i dont know what happend. i just had the benefit of hindsight. and Lord knows i've had patients i wished i could sedate that way, lol.

thought, it makes me mad sometimes with how people says that it is the nursing homes that give poor care. how many of us have received pts from a hospital with a big ole whoppin decub when in report we are told skin intact?

that was one reason i kept in contact with his nurse at the hospital i transferred him too and talked to his doc a few times. i wanted to make sure they all knew he was transferred to ME that way and that we didn't do that to him.

And I hate to say, I've seen combative dementia patients zonked just to make life easier for staff. Of course I've also been the admitting nurse doing the med reconcillitation and the Dr d/c-ing most of the psych meds because the patient is on two or three of the exact same drug...but thats a whole 'nother kettle of fish.

But when you have attentive family like it seems he had, there was no excuse for not checking labs at the very least just to CYA. I still can't believe they blew off the daughter who was a neurologist....talk about cajones.

[BelleKat, BSN, RN]

Nurses always,always need to listen to the family(I'm addressing the nurse's behavior who took care of him at the hospital). I hope he makes it but his prognosis is poor and that Hospital should be sued for the neglect and downright abuse they inflicted on that poor man.

[Batman24]

You're an excellent nurse. The family must be so grateful he ended up in your care. I can totally understand why they didn't want him going back to the hospital. I'm glad you have all your ducks in a row because I do think the family will sue the hospital. It's so important to listen when family says something isn't right. Their answer unfortunately was to drug him to the high heavens. Really sad to read.

[isis07734]

Good job!

[Spritenurse1210, BSN, RN]

We has a patient like that sent to my facility 6 months ago. He ended up coding 4 hours after transfer and was doa when transfered back to the same hospital.