Question for RN's reagrding CHF in LTC

[begalli]

I have a question for RN's in LTC regarding CHF in LTC facilities.

What would you do with this patient:

Female, late 80's, DNR (a very clear advance directive and POAHC follows her everywhere)

Previously independent living alone with daily checks and help from family and friends

Her husband of nearly 70 years just passed away beginning of December

Longstanding hx of afib

Coumadin until recently (see hospitalization below)

ACE inhibitor

Lasix

Inhalers

Vitamins

Synthroid

(I'm sure there are more meds, I just can't think of them right now)

Week long end of December hospitalization for GI bleed (scoped and cauterized gastric bleed) - coumadin d/c'd, UTI developed, altered mental status

Discharged to a "rehab" facility

One month now at LTC rehab facility

Two weeks into stay: dependent edema, requires 02, frequently SOB, very depressed, still somewhat altered mental status with periods of clarity

One month into stay: Severe weeping edema at both lower extremities below the knees; periphery cool to touch; knees mottled, syncope, requires 02 24hrs, SOB, still confused at times, but better, very depressed, no appetite

I'm not completely clear on meds except that lasix was started last week (finally!).

I'm just wondering at what point would a person such as this be sent to the hospital for treatment. Before her hospitalization in December, her CHF was under control with occasional exacerbations that were usually picked-up on and treated right away, succesfully. They did do a ultrasound to check for clots - negative (thank goodness!), but especially with her a-fib, I'm afraid they are letting this go too long. I'm not sure of her renal staus or if she's actually diuresing from anywhere other than her lower legs, and I don't know if they've even checked her blood or have done a chest xray. I'm afraid she'll end up either with pneumonia or pulmonary edema and rotting lower legs and feet.

This is my grandmother. My family, especially my mom, has been through the ringer in the last several months with first my dad dying in October after a year filled with surgeries, illness, and a 4 month hospitalization, then my grandfather (my mom's dad) died in December, and now she's dealing with her mother in this condition. My mom has been the primary family caregiver for both her parents and my dad's mom who's also in LTC.

I'm trying to get information from my mom so I can help her help her mom. Unfortunately, I live 2000 miles away and my mom's burning out BIG TIME. It would be her's and my dad's 49th wedding anniversay on Tuesday. I feel so sad for her, she just really doesn't need anymore stuff like this.

So what do you think? Does this sound like a patient who needs to get more agressive care for the CHF probably in the hospital? My mom told me that when she visited on Sunday, she changed my grandmother's socks 3 times in 3 hours because they were soaked. She ended up taking paper towels from the bathroom and wrapping them around grandma's legs. :stone

She's brought this up with the Nurse more than once, actually each time she visits (3-4x/wk), but doesn't feel she's getting anywhere and fears for her mother's well-being. DNR doesn't mean ignore things that can be treated.

What can/should we do or what are some thoughts? What would you normally see in a case such as this?

I have absolutely NO experience in LTC. I'm an ICU nurse who's very uncomfortable with the way this is being handled.

[medsurgnurse, RN]

I hope your grandmother gets well.

[snowfreeze, BSN, RN]

If this was my patient she surely would have had quicker treatment. If she has poor renal function then dobutamine IV 3 or 4 times a week does help. Good renal function, lasix or bumex. The legs need to be kept elevated when possible and wrapped with stretch bandages, we have healed stasis ulcers many times this way. Accurate Intake and output each shift will help to see if you need to limit fluid intake. Does the POA truly understand the treatments and consequences? The nurse caring for this patient should try to educate the family and especially the POA on what is happening. How involved is the doctor, many facilities have more than one doctor available, ask staff for names of other doctors that can be used and interview them if possible.

And I am sorry that you are having such trouble with LTC, I work in that type of facility now and am appalled at what goes on in other facilities.

Always call your social worker at the facility if things are becoming a problem. They are your advocate and liason to all other departments.

[snowfreeze, BSN, RN]

As far as what the patient wants and family wants, where I work I just send the patient to the hospital according to what their POLST says when their medical condition becomes something beyond what I can treat effectively where they are. If they desire hospitalization and will accept treatments for problems then they go, I page the doc and send em. Most of our docs call before the ambulance arrives but sometimes they don't. I write it as a verbal order from the doc anyhow as the POLST is my standing order for what the patient desires and it is signed by the doc. I also document my findings and what I am doing, this shows me being a patient advocate.

[fuerza757]

This is an outrage......

Until your Mom is able to add you to the list....your grandma can designate you as the family advocate....I would call that charge nurse every hour on the hour until I am satisfied...that this is done.

If I where you I would call the Facilities Administrator and the Medical Director of the facility....ASAP regardless if they won't release any information is not the case you are partially aware of your grandmother's condition and you as a concerned family member you have the right to voice your concerns. We never turned away concerns of family members period, POA or not this is your Grandmother. The Administrator must hear you...You are advocating for your elderly grandmother on your family's behalf, as concerned family representative. Tell them either they talk to you or you will ask the state to intervene, if need be tell them the next call they recieve will be from your Grandmother's attorney. It is abvious that she needs medical attention that the LTC is unable to provide. Make sure your use lots of words like Family advocate, Resident rights. Your Grandma is not able to speak for herself and pass this info to your Mom She should go straight to Facilities administrator. Do what ever you have to, to get your grandma to the hospital. Alot of time this about $, if they are not treating as they should and she sent to the hospital w/ the same dx the LTC will be made to pay that hosp bill. All the nurse has to do is call the MD on call stating that the family (your Mom) is here and demanding her mother be seen in the ER with those s/s they have to be able to get the order....Best of luck.... sorry if I got carried away...

As far as what the patient wants and family wants, where I work I just send the patient to the hospital according to what their POLST says when their medical condition becomes something beyond what I can treat effectively where they are. If they desire hospitalization and will accept treatments for problems then they go, I page the doc and send em. Most of our docs call before the ambulance arrives but sometimes they don't. I write it as a verbal order from the doc anyhow as the POLST is my standing order for what the patient desires and it is signed by the doc. I also document my findings and what I am doing, this shows me being a patient advocate.

[begalli]

Grandma got to the ED within an hour after my mom demanded she be evaluated and the hospital is keeping her. CXR showed "severe left lung fluid" - my mom's words. EMT's and RN's were shocked at the degree of edema that was present and without palpable pulses! She got a hit of IV lasix and already put out almost a liter in urine since arriving to the ED a few hours ago.

:angryfire You better believe that this facility is going to hear from me, fuerza757. There is some culture of fear going on there wherein the direct care RN was AFRAID to advocate for her patient - "don't tell my nursing supervisor" - but KNEW very well that something was VERY wrong.

My mother was told by the nursing supervisor that the CXR done this am was completely clear and that there was no chf and that no hospital would take her if they sent her out?!?!?!??!?!

Okay. I spoke with both mom and grandma just a few minutes ago. Still in the ED but will be admitted within the next couple of hours. Grandma's got her cardiologist there and from what it sounds like, a really great nurse. I feel that things are safe at this point. Grandma sounded in good spirits (she's such a tiny sweet little old lady!) I told mom to go home and now I can take a deep breath too.

You know, maybe tonite was the night that with a little exertion, grandma would have had a flash pulmonary edema (and then what? she's a dni/dnr), maybe she would have hit her leg on the side of the bed and tore 4 inches of skin off or maybe her heart would have given out because of working so hard for so long in chronic afib no less! Maybe that won't happen now and there's absolutely NO excuse that this place didn't try to prevent this ealier!

[begalli]

OH! I almost forgot...the posters here at Allnurses are the BEST! Thank you so much for your thoughts and support through this rocky day!

:flowersfo

p.s. Mom and I already talked briefly about this...grandma's NOT going back to that facility.

[UM Review RN, ASN, RN]

Is there some loss a LTC place takes when a patient goes out to the hospital?

Yeah, it costs money to send a resident out to the ER, but my understanding was it only costs money if the resident is sent back without being admitted. I could be wrong, it's been a long time since I did LTC.

I'm surprised and puzzled that her doc didn't get involved sooner. The facility can't override his order to send her out to the ER, after all. I'd definitely get the doc on the phone and discuss this. And a telephone conference sounds like a great idea. You should be involved in that, begalli. It's not like you're just an interested bystander here after all.

Might be a good idea to get a copy of her chart before she leaves the facility.

[TracyB,RN, RN]

Ditto to getting a copy of her chart. There was a definite lack of BASIC nursing care for your Gram, LTC or not.... & a nurse, afraid to send a pt out? Sorry, no peripheral pulses, severe weeping edema? HEELLLLLLLLOOOOOO!?!?!?!? Anyone with a license working here? Doesn't sound like it. I am wondering, though, about the CXR.. was it portable, where the company brought it to the facility... Sometimes, I think some of those clowns, that I have experienced while working LTC didn't even really DO an xray. I would follow them, watch them position my resident, & step out, when they were ready for the picture... No wonder I always got "talked to" about OT. Sorry, part of my job, & 8 hrs IS NOT enough to adequately assess, chart, medicate, provide dressing changes, assist my CNA's with boosts, passing trays, etc, etc, etc... So, when you will hire another competent nurse to split these 40 medicare patients that are ALL in desperate need, with families present, asking ??'s, etc, don't complain about the OT, b/c you know I am doing my job 200%. End of story.

Sorry, got a little off topic.... what i am trying to say, any nurse should have known better, to get the appropriate medical eval for your Gram.

Good luck to you. Prayers for Gram & your mom, especially, to get some rest......

[UM Review RN, ASN, RN]

Sometimes, I think some of those clowns, that I have experienced while working LTC didn't even really DO an xray. I would follow them, watch them position my resident, & step out, when they were ready for the picture

Just wanted to mention that during an education course I took, our Head Radiologist gave a very interesting talk about portable chest x-rays. He said that most of our CXRs won't be diagnostic for CHF because the patient is in bed, because the machine used for portables has less distinct contrast, and because the distance is a tad further away. So really, he concluded, the picture is a bit fuzzier and it really appears like all of them have CHF.

So I understood that to be a basic difference in the quality of the portable chest x-ray versus the kind where you can stand up and be right in front of the machine in the X-Ray Department and not necessarily a failing of the reading doc or the techs themselves to get the picture properly.

If an X-ray was ordered but wasn't done although it appeared that it was done, of course, that's fraud and needs to be reported to the proper authorities.

[CoffeeRTC, BSN, RN]

I'm soo angry I needed to respond.. So many questions. If this was my resident, she would have been out to the hospital last week. Yep you need a docs order, however. If family and pt request an eval at the hosp...they got it. Send first, deal with the BS later. Heck, I don't ask my doc...I send them out. Yep we can do a lot in LTC these days..xray, IV meds etc, but after a certain point....they are going out. For the common everyday staff nurse, we don't give a crap about payment issues reguarding sending to the hospital.

Seems like the staff knew about her worsening condition? There was a whole process that was missed here. What about daily shift report..2 or three nurses took care of her every day. What about care planning and MDS...what were they doing for her? How about the therapist....our PT/OT/SP would be pestering us for some type of treatment. Heck...don't they discuss their residents. As far as HIPAA...if a family wants me to talk to or explain issues with another person I will. Makes things easier. As far as the doc..if I didn't feel like they were doing enough, I would bring it up with the DON. We have a medical director who would step in on these situations.

Remember tho...the docs rarely see pts. Most of our docs come in once a week or every 2 weeks. They are only required to see skilled pts every 30 days then I think its q 60 or 90. The nurses were assessing her....or were they.

Definatly have your mom and/ or you bring this up with the DON. By regualtions (state and fed) family and resident should be made aware off all changes in status..that would include a room change, change in meds, diet,condition. If possible start looking for another place now...have mom visit if she can.

Hope Gram gets better soon.

[CoffeeRTC, BSN, RN]

Just wanted to add....I just got told that I send to many people to the hospital. It seems that every weekend I work....someone is going bad.

Well...when you actually lay a hand on a pt, look at them and listen to them...gee maybe you will notice something????

Ohh...if you are getting a chart copy..don't expect great assessments in the nursing notes...I never find any when I'm looking!

[begalli]

Great, interesting thoughts and critiques on this!

I'm in complete agreement and VERY appalled at the course of my granny's treatment. I can't imagine what would have happened if I didn't know what I know. It makes me obviously wonder and worry about the safety of other patient's at this place.

My mom DID notice some of the signs of heart failure in grandma. She did bring it up to the nurses more than once and over a period of a couple of weeks. Mom's seen chf in her mom before, NEVER to this extent, but this time she was in such complete denial as far as the inaction of the medical team there. When I spoke to the RN yesterday she said that on 1/22 LLE infiltrates were noted in the chart and that an ultrasound was done to rule out clots. Then she told me that on 2/3 lasix, 20mg/day was started. And then finally yesterday a cxr was done. Look at all of the time elapsed between the first signs and any kind of treatment at all! Incredible.

My grandma's regular docs weren't the ones following her? It was some other doc affiliated with the facility. THAT, I don't get? When a person checks into LTC, do they relinquish their own docs for the docs who are used by the facility? Granny was in the "Medicare section" of this facility. Is it up to my mom to get in touch with my grandmother's docs and take her to appointments? My granny has been seeing the same GP and cardiologist for years. I know it's been only a month, but granny's regular docs knew about the GI bleed hospitalization and I would think that their office would have wondered where granny has been or how she has been doing over the past month? Embarrassingly, I really don't know how LTC works when it comes to stuff like this, but I'm bound and determined to learn NOW.

A note about the "Medicare section" of this LTC place. The plan was to keep grandma there under medicare for the 90 days. Granny's not rich but my mom is in the process now of "spending down" my grandmother's savings so that she becomes eligible for medicaid once medicare runs out. She's doing things such as paying for granny's funeral. There's no doubt that she'll be private pay for a little while once medicare runs out. It was my mom's understanding that medicare will not pay for granny's room at the LTC place while she's in the hospital, but will pay for the ambulance rides to and from and the hospital care itself (as told by someone at the hospital). She was told by the nursing supervisor at the LTC that medicare will not pay for anything, not the ambulance, not the ER visit, the docs fees, anything, if grandma was sent out to the hospital because, in her opinion, this was not an emergency and there's no way the hospital would keep her! My mom told her to send her anyway! I will pay out of pocket for this! - you go mom!

Mom and I talked about everything this morning. I don't blame my mom for one iota of what's happened, but I really wish my mom would have brought up these symptoms to me sooner, and now she knows. Her focus, like I mentioned much earlier in this thread, was grandma's emotional and cognitive deterioration. My mom is a woman who has been under an almost inhuman amount of stress over the last year, and especially the last 6 months. Both my mom and my grandma just lost their husbands of decades! It was a blessing that my (stroked a thousand times) grandfather passed, but a whole different story with my dad who was a relatively young active man.

Yesterday, I was dealing with all of this coming off a night shift and with no sleep all day until about 8 o'clock last night. I have not yet contacted the LTC place as I'm on my way to work again tonite, but will first thing in the am. I was so angry yesterday that it's a good thing I didn't call them. :stone

You know, I'm so confused. This facility is the same facility that my other grandmother (dad's mom) resides. She's in a different section (private pay) of the place but we have never had any problems whatsoever with anything there. Regular care plan meetings take place monthly. My mom is also the POA for her. The reason she's there is because she's oooooold (93), but is still pretty well cognitively intact and gets around well in her wheel chair and is very active and quite the socialite in activities and is a happy and funny old lady. She's also a dni/dnr but has been sent to the hospital over the 3 years for pneumonia, GI problems and one fall that she had.

I can see where my mom may have put her complete trust in this place. My mom is very familiar with them and them with her. I wonder what happened?? And now what do we do? *sigh* Is this going to affect my other grandmother's care? Do we pull her out to? This would be devastating to my mom and my other grandmother.

Today would be my mom and dad's 49th wedding anniversay. Mom's doing pretty good in spite of everything.

Anyway, I hope I get called off tonite (a good possibility). I'm exhausted.