Question for RN's reagrding CHF in LTC

Specialties Geriatric

Published

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.

:confused:

Specializes in Utilization Management.

I hope you're able to get some rest. Your mom & G'mom too. You've all been through quite a lot.

***Hugs to you all ****

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Specializes in Critical Care/ICU.

YAY!!! Got called off!! YAY!!

Thanks Angie, I will sleep like a kitten tonite!

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Specializes in Gerontology, Med surg, Home Health.

OKAY---my 2 cents worth. First...I hope you and your family are better.

Secondly, from what you write, this lady would have been sent to the ER long before this if she were in my facility. If she is MED A at the LTC, then they would be losing money if they sent her to the hospital....we would still send her and hope she would want to return to us after the acute phase was over.

And...many might disagree, at this stage in your grandmother's life, I wouldn't suggest a fluid restriction....monitor sure, but to restrict someone's intake ... seems cruel and really not clinically warranted in an elder.

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Specializes in Critical Care/ICU.

I would like to understand more about the facility losing money. I plan to bring this up directly to the nursing sup tomorrow when I speak with her. I plan to ask her to explain it to me, but I need some background on it myself first. Nothing like trying to have an intelligent exchange with someone and not having some knowledge about the topic to begin with! I do think I know hoards more today than I did yesterday though.

I don't want to end up being a pita, but I do expect some answers and I feel that my family has the right to answers to our questions ethically, morally, and under the law.

I really feel that this nursing supervisor's practice, in this case, was unethical to say the least. And I would like to add that the direct care RN's being put into a position where they feel they might get fired (this is what the RN taking care of my granny yesterday told my mom!), is wrong, of course it is! I really don't want this coming down to blaming the bedside RN for everything, but with the way nursing is no matter where, it seems that 9 out of 10 times according to posts all over this message board, management ALWAYS seems to do this.

So now what do I do about that when speaking with the supervisor? Do I mention that the RN said not to tell anyone that it was also her opinion that my grandmother be sent out - weeks ago? What a damn catch 22. I don't want to minimize the direct care RN's fear, but I feel that she should have been MUCH more proactive. Will she be fired that I mention that her concerns were probably brushed under a rug by her supervisor?!?! It's obvious that this RN had communicated to the doc and the supervisor her concerns, but why didn't she also tell her concerns to my mom?

Boy, they have no idea, but they have messed with the wrong granny! There is absolutely NO intention of reporting them or anything like that, but something needs to change at that place. We'll see. I'm sure I'm about to step into something, just not quite sure what yet. Maybe there is an anonymous way of reporting if I don't get some satisfaction out of this?

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I wouldn't even bother speaking with that nursing supervisor. Talk directly with the DON.

It sounds to me as if that nursing supervisor thinks SHE knows what is best for the patients and doesnt care what the floor nurses think, despite the fact that they take direct care of her.

I would talk to the DON about the things she told your mom, that she never should have. She should have never brought it on herself to tell your mom that your granny shouldnt go to the hospital over money because SHE said she wouldnt be admitted. That isnt her call to make! I would also tell the DON how the RN was a patient advocate but afraid to do so except secretly. She needs to know what is going on on her floors and how that supervisor is doing the other nurses.

Speak to the DON first, bring her up to speed and then let her call the other nurse in.

I would actually have both the administrator AND the DON in the meeting.

about the docs....

when a patient is admitted to LTC, they are then cared for by the docs that have privaleges (god I cant spell) there. It isnt that they are released from their regular doc, but we have docs in our LTC that just do the facility. Kinda like in the hospitals. We do encourage our patients to keep their follow up appts with their regular docs. Transportation is arranged using an ambulance or van if the patient cant be transported by the family. Usually the family does end up having to pay that cost for transport. some patients will get a contract with a local ambulance service and have an agreed upon rate up front for all non emergent transfers (esp for dialysis patients).

When a patient is skilled (SNF...skilled level of care) which means that medicare is paying for that 120 days, then no, their bed can't be held while they are in the hospital if they get sent out. If they are out past midnight, they are considered discharged because medicare wont cover that cost. Sometimes a family will pay the room rate just to keep the bed while the pt is in the hospital if they think no beds will be avail when they get out. When her medicaid takes over, her bed will be held for 14 days if she is in the hospital.

hope that helps some and I hope your granny is feeling better!

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If you want, you can also report the facility to the State and they will investigate your grandmother's case and decide if they believe the facility dropped the ball, they will be given deficiencies and fines.

If your meeting with them is not satisfactory to you, I hate to say this since I work in LTC but in your case it sounds like you may need to, then report them.

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Specializes in Critical Care/ICU.

srb- I really appreciate your knoweldge and advice! Thank you so much for singling out my sentences that have question marks following them and replying!! This just shows the expertise nurses have in their own field of practice and how little another RN in a different field knows about the others.

I will heed your advice about speaking with the DON. Unfortunately this all has to be done on the phone from ~2000 miles away. This would never have happened if I lived close® to my family. I would have been there to see things develop myself. But I can't change that. I do plan a trip out there in about a month and a half, but for now, I have to help my mom the best I can in the only way I can.

I'm a little nervous about what I'm about to stir up, but this doesn't mean that I don't plan to say exactly what's on my mind and expect answers. My mom knows what I plan to do and I think I will also call and talk to the bedside RN following my contact with the DON just to let her know and to give her a heads up. I think that's fair.

Anyway, thanks to everyone again and wish me luck!

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Specializes in Gerontology, Med surg, Home Health.

***Medicare A is what pays for someone's stay in a long term care facility. The benefit is good for up to 100 days IF the person still has skilled needs. The first 20 days of a stay are paid for 100%. For the next 80 days, if the person stays and still has skills, there is a co-pay. At my facility it works out to $114/day. Medicare will only pay for EITHER the hospital bed OR the LTC bed, but not both at the same time, so if the family wants the bed held they must pay the room rate out of pocket.

***Medicaid patients automatically have their beds held for 10 days in this state. We used to get paid to hold the beds, but now we have to hold them and receive no payment from the state. I live in Massachusetts so I am not familiar with the regs of Medicaid in other states.

I have worked in several long term care facilities..started as a staff nurse and now am Assistant DNS of a large facility. I have also been the Utilization Coordinator, also known as the Medicare Queen. We would NEVER hesitate to send someone to the ER based on financial matters. We have people who are DNR's who want to be sent unless we find them pulseless. We have other people who do not under any circumstance want to go to the hospital for treatment, or as one lady put it..."to die with a bunch of strangers who don't care about me." Still, I always tell the nurses to ask the patient and/or family(if they hold the health care proxy) if they want to go to the ER. And, just as an aside, if I think the person needs to be sent to the hospital, I call rescue first, then call the doc and inform him that rescue is on the way.

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I would speek with the facility first. Call and ask for a conference call with the DON and administrator. Bring up all of your concerns. Why did it take so long for action? Also try to speak with the doctor that took care of her at the LTC facility. Was he truely aware of her condition? What the others said about the docs...Her docs that saw her at home prob don't see pts there, however, she still could see them if she wanted...esp the cardiologist.

Since she was medicare...they would have been having to do MDS asssessments (Its a comprehensive resident assesment) quite frequently on her ( 5, 14, 30, 60 , 90 days) in which the whole team (nurses, therapy, Social service, dieatary,activities) should have been assessing her, reviewing her care and updating her care plan. Wouldn't they have noticed the Wt gain (fluid), SOB, mood changes??? If so what was their plan of action??? What were they skilling her for??? Ask if you or mom could see her care plan. In our state, the doc would have had to actually see her every 30 days.

Gosh...this is tough for you!! Hope your family gets some answers.

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Specializes in Utilization Management.

Someone brought up a good point in an earlier post. I've wanted to send some folks out to the ER, but if they're in their right mind and they refuse...

well, I'd beg 'em....:chuckle

but not all of us feel that's appropriate.

Is it possible that your granny nodded and smiled to your mom and then refused to the staff?

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Specializes in Critical Care/ICU.

Is it possible that your granny nodded and smiled to your mom and then refused to the staff?

This has crossed my mind more than once, but according to my mom they were telling her that they didn't think grandma needed to go. If this was the case, which my mom denies, I think they should have at least encouraged my mom to try and convince my grandma to go. They didn't. Just the opposite was happening...she was being discouraged from seeking further evaluation...and the reasons (no chf, who pays for what, etc.)?! I don't think I would consider that advocating for a patient, who herself, didn't want to go.

I've left a message for the DON this morning. Apparently she's in meeting all day. I have a feeling the time difference between CA and MI is going to cause a bit of phone tag at first.

Ah well, I'll get it done eventaully.

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Specializes in Critical Care/ICU.
***Medicare A is what pays for someone's stay in a long term care facility. The benefit is good for up to 100 days IF the person still has skilled needs. The first 20 days of a stay are paid for 100%. For the next 80 days, if the person stays and still has skills, there is a co-pay. At my facility it works out to $114/day. Medicare will only pay for EITHER the hospital bed OR the LTC bed, but not both at the same time, so if the family wants the bed held they must pay the room rate out of pocket.
Since she was medicare...they would have been having to do MDS asssessments (Its a comprehensive resident assesment) quite frequently on her ( 5, 14, 30, 60 , 90 days) in which the whole team (nurses, therapy, Social service, dieatary,activities) should have been assessing her, reviewing her care and updating her care plan. Wouldn't they have noticed the Wt gain (fluid), SOB, mood changes??? If so what was their plan of action??? What were they skilling her for??? Ask if you or mom could see her care plan. In our state, the doc would have had to actually see her every 30 days.

Thank you. I'll ask about these assessments! I did some reading about Medicare last night. Both of your comments, in MUCH fewers words, confirm what I learned.

***Medicaid patients automatically have their beds held for 10 days in this state.

I found out that in the state of MI, it's 14 days.

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