"Don't Send Anyone Out!"

CHATSDALE · Aug 18, 2006

gomer gomer nurse, and i use the term loosely, who use this term are lazy and have no compassion

Daytonite, BSN, RN · Aug 19, 2006

I'm a newer LVN and employed as a weekend-double shift nurse at an upscale nursing home. My weekend RN supervisor has a happy-go-lucky, coolly unconcerned personality. He unrelentlessly picks on some nurses but tends to leave me alone.
He has made it crystal clear that we are to refrain from sending any resident to the hospital unless they are extremely ill. His reasoning is monetary: if a resident spends one week in the hospital being evaluated and treated, then the nursing home will lose one week's worth of money from that resident. Private-room residents pay $6,900 monthly and semi-private residents pay $4,600 monthly. This seems fishy and unethical to me. I usually will send a sick resident out because I want no person to die or worsen under my care. Any thoughts or comments on this issue?

Yes, something you many have not considered. Since you have private patients, the family has to pay for the ambulance services every time the patient is sent out. They are expensive and I am sure that if the visit to the ER turns out to be minor and the patient gets sent back, the administrator hears about it from the family.

Otherwise, I wouldn't have any problem calling the doctor, notifying the doctor of the patient's change in condition. (Most states have rules the nursing homes must follow about acting on a change in a patient's condition.) If the doc says, "get him/her to the hospital", it's off my back. The person the administrator should be blaming is the doctor, not the nurses. You have to consider your license and the patient's welfare first. The administrator isn't going to stand up to the board of nursing for you if something goes very wrong because you followed his silly rule instead of good nursing practice.

Daytonite, BSN, RN · Aug 19, 2006

Update: over the weekend I sent one of my elderly patients out to the hospital. He had prostate surgery three days earlier and had returned to our facility with mental status changes, low blood pressure readings, and grossly bloody urine. As time passed, this continent resident could no longer urinate. I sent him to the hospital without consulting my weekend supervisor. Once my weekend supervisor found out about this resident being sent out, he stated, "Couldn't you have catheterized the guy?" I told my supervisor that the resident is extremely confused with low blood pressure and tachycardia, and that his urine is bloody. The supervisor stated, "Well, the paramedics want to file a complaint against you for being mean."

I just read this post. I'm sorry, but there are some things that you left out. Did you call the surgeon? Did you call any doctor? What did they suggest you do? Supposing this gentleman was already in the hospital, then what would you have done as his nurse? Calling an ambulance wouldn't have been an option for you? I think you need to review post-op male urological surgery textbooks because you could have done better here beside just assessing the patient and turfing him off (sending him out). If this kind of thing is what the administrator is upset about, I can see why. The facility expects it's charge nurses to act like charge nurses and solve problems, not shove them out the door. I think you failed to provide better nursing care as a professional nurse for this patient.

catlady, BSN, RN · Aug 19, 2006

Yes, something you many have not considered. Since you have private patients, the family has to pay for the ambulance services every time the patient is sent out. They are expensive and I am sure that if the visit to the ER turns out to be minor and the patient gets sent back, the administrator hears about it from the family.

Most private pay residents still have Medicare, and Medicare will pay for emergency ambulance transportation when certified as medically necessary.

ktwlpn, LPN · Aug 19, 2006

I just read this post. I'm sorry, but there are some things that you left out. Did you call the surgeon? Did you call any doctor? What did they suggest you do? Supposing this gentleman was already in the hospital, then what would you have done as his nurse? Calling an ambulance wouldn't have been an option for you? I think you need to review post-op male urological surgery textbooks because you could have done better here beside just assessing the patient and turfing him off (sending him out). If this kind of thing is what the administrator is upset about, I can see why. The facility expects it's charge nurses to act like charge nurses and solve problems, not shove them out the door. I think you failed to provide better nursing care as a professional nurse for this patient.

You have to remember that the charge nurse may have 20,30 or more other residents to care for and resources can be limited.Labs and X-rays are not on site at my work and take hours to obtain.We don't start lines and give fluids.I would have attempted to cath the guy-if I was not able to easily pass the cath I would not have forced it. I think his condition warranted a faster work-up

banditrn · Aug 19, 2006

Update: over the weekend I sent one of my elderly patients out to the hospital. He had prostate surgery three days earlier and had returned to our facility with mental status changes, low blood pressure readings, and grossly bloody urine. As time passed, this continent resident could no longer urinate. I sent him to the hospital without consulting my weekend supervisor. Once my weekend supervisor found out about this resident being sent out, he stated, "Couldn't you have catheterized the guy?" I told my supervisor that the resident is extremely confused with low blood pressure and tachycardia, and that his urine is bloody. The supervisor stated, "Well, the paramedics want to file a complaint against you for being mean."

So, how were you mean?? :uhoh3:

CapeCodMermaid, RN · Aug 20, 2006

You have to remember that the charge nurse may have 20,30 or more other residents to care for and resources can be limited.Labs and X-rays are not on site at my work and take hours to obtain.We don't start lines and give fluids.I would have attempted to cath the guy-if I was not able to easily pass the cath I would not have forced it. I think his condition warranted a faster work-up

You don't start IV's at your facility?..hard to believe in this day and age. Sometimes we have no choice but to send the resident out...if they are a full code especially. I try to honor the family's wishes. They ask me if I think their family member would be better off at the hospital. If I think the person is getting ready to die, I tell the family I think they'd be better off with us..people who know them and care about them. On the other hand, if they really are sick and are a full code, I wouldn't hesitate to send them...we do lots of things at my facility, but if someone needs a telemetry bed or a ventilator ...out they go.

Daytonite, BSN, RN · Aug 20, 2006

You have to remember that the charge nurse may have 20,30 or more other residents to care for and resources can be limited.Labs and X-rays are not on site at my work and take hours to obtain.We don't start lines and give fluids.I would have attempted to cath the guy-if I was not able to easily pass the cath I would not have forced it. I think his condition warranted a faster work-up

Having 20 or 30 other patients is not an adequate excuse. I doubt that the board of nursing would accept it either. The care of those 20 or 30 patients can be delegated to another nurse. Priority of care is at question then. A LTC facility as part of it's license to operate is supposed to have access to services like lab and IV access. Pharmacy services usually have an IV nurse oncall for placing IVs. Labs services are also supposed to have stat lab service. So, I'm not buying that reasoning. If you don't think your facility has these services, you all need to have a sit down with your leaders and discuss these things. Now, if you can't relieve a distended bladder and pass a catheter, that is a situation that requires action and a transfer out. But, I will still stand by what I said. A licensed RN should exhaust all avenues of care that can be given before turfing the patient off. That is part of the responsibility of being a charge nurse.

ktwlpn, LPN · Aug 21, 2006

Having 20 or 30 other patients is not an adequate excuse. I doubt that the board of nursing would accept it either. The care of those 20 or 30 patients can be delegated to another nurse. Priority of care is at question then. A LTC facility as part of it's license to operate is supposed to have access to services like lab and IV access. Pharmacy services usually have an IV nurse oncall for placing IVs. Labs services are also supposed to have stat lab service. So, I'm not buying that reasoning. If you don't think your facility has these services, you all need to have a sit down with your leaders and discuss these things. Now, if you can't relieve a distended bladder and pass a catheter, that is a situation that requires action and a transfer out. But, I will still stand by what I said. A licensed RN should exhaust all avenues of care that can be given before turfing the patient off. That is part of the responsibility of being a charge nurse.

Not only do we not start lines we are a 'no code' facility.This is made clear at the start of the admissions process..We only accept residents with central or picc lines for long term antibiotics-we don't accept vents either-we do have plenty of catheters.... You can't delegate the care of your 20 to 30 residents to another nurse whom has 20 or 30 residents.I don't know where you are-I'm in Pa....We do have access to labs and x-rays but it takes hours for even a stat order....If I have a resident CTD at 7pm on a Saturday night unless their SO wants them on comfort care then they are going to the ER because I can't do much more.-and neither can the RN....

TheCommuter, BSN, RN · Aug 21, 2006

The facility expects it's charge nurses to act like charge nurses and solve problems, not shove them out the door. I think you failed to provide better nursing care as a professional nurse for this patient.

In my six months of working as a nurse I have only sent four patients out to the hospital, and three of these residents ended up staying in the hospital for extended periods of time. Please remember that I am an LVN who, legally, is supposed to care for stable patients with predictable outcomes. I do not have the time to monitor one unstable patient every 5 to 10 minutes since I have 30 other residents to care for. I work at a nursing home, not a critical care unit. Critical care nurses have the luxury of 2 or 3 patients that they can closely monitor. You can go ahead and call it 'bad nursing care' if you wish.

I don't send residents to the hospital indiscriminately without careful assessment of the resident and situation. Nine times out of ten, the family will want the resident sent to the hospital. In addition, two-thirds of the residents at my workplace have Medicaid as their payors. I have never sent a private-pay resident to the hospital.

TheCommuter, BSN, RN · Aug 21, 2006

The care of those 20 or 30 patients can be delegated to another nurse.

Not realistically. Hell will freeze over before I accept another nurse's 30 patients because my workload will double to 60 patients. Additionally, no other nurse is going to accept my 30 patients.

ktwlpn, LPN · Aug 21, 2006

In my six months of working as a nurse I have only sent four patients out to the hospital, and three of these residents ended up staying in the hospital for extended periods of time. Please remember that I am an LVN who, legally, is supposed to care for stable patients with predictable outcomes. I do not have the time to monitor one unstable patient every 5 to 10 minutes since I have 30 other residents to care for. I work at a nursing home, not a critical care unit. Critical care nurses have the luxury of 2 or 3 patients that they can closely monitor. You can go ahead and call it 'bad nursing care' if you wish.
I don't send residents to the hospital indiscriminately without careful assessment of the resident and situation. Nine times out of ten, the family will want the resident sent to the hospital. In addition, two-thirds of the residents at my workplace have Medicaid as their payors. I have never sent a private-pay resident to the hospital.

Good post- I would not call it "bad nursing" It is just the nature of LTC.And these residents deserve the same level of care as anyone else.This thread is proof that the older you are the less value society places upon you.Many of our residents are considered an "inconvenience" in the ER and on the acute care floors.Remember-someone loves them......