Refused admission

[savoytruffle]

Hi there! I currently work as an executive director/ RN administrator at a dementia care adult home. It's not a skilled facility. We are considered more of an assisted living level. NY state regs are very specific about what kind of person I can retain. I have a resident that is exceeding my level of care and has a PRI that places her at a skilled level. (Not a real high skill level, but just outside my license allows). A SNF accepted her and we discharged her. When she arrived to the SNF she became very agitated and I received a call that they sent her to the ED for evaluation and are now refusing to admit her. After offering a bed and accepting a resident, do they have the right to refuse? I have discharged her! Her meds are gone and her apartment was cleaned out by family this morning. I can't knowingly re-admit a resident that has documentation stating she is outside my scope. Has anyone encountered this before?? It seems very unprofessional to me. Please help!!

[NICUmiiki, DNP, NP]

I guess I thought LTC facilities were required to accept residents back once they were sent out? Especially since they had evaluated her and accepted her into their facility. Why did they send her to the ER? Agitation? Would she not allow the admitting nurse to do an assessment? (I'm guessing that was probably the case), but still, is agitation upon admission that unheard of and troublesome that they wont take the patient back? Is this patient a Geri-psychiatric candidate? I've heard those can be pretty bad places for dementia patients. :/

Our Geri psych is one of the few in the state that will take dementia pts, but they have to have a psych problem on top of the dementia. They won't accept dementia-only pts or they'd turn into a dementia care unit.

[MunoRN, RN]

It's probably for the best that the patient doesn't go back that SNF anyway since they don't seem to have a very good understanding of dementia patients. I'd be amazed if a dementia patient didn't display some agitation when a sudden change in their living environment occurs.

[tyvin, BSN, RN]

I'm not saying you should have kept her, your original post states you sent her to a SNF that had accepted her. In order to do that she had to be skilled for something. What is it that skilled her for the SNF? Had she been hospitalized previously within the last 30 days, is she Medicaid or Medicare?

Was it an illness or injury, did she require PT, OT, etc...

You said she went into a SNF and than you say nursing home. If you applied for her to go into a LTC facility they would have had someone come out to evaluate her. The SNF as well would have had to evaluate her but they usually do that from the hospital. Odds are the SW in the ER would send her to a psych ward as involuntary patient for evaluation and from there she would be put where ever is deemed appropriate.

SNFs are for people being discharged from the hospital (for the most part) after a knee, hip, etc... (basically SNFs are med/surg with extra patients per nurse). There are no floors of dementia patients in SNFs. Unusual to see a dementia patient in SNFs unless they are skilled for wounds, injury, etc... It's their docs that skill them.

It sounds like there was a serious lack of procedural knowledge and communication. Medicaid and Medicare have rules that are specific and can't be bent in most circumstances on both sides. People who deal with Medicaid and Medicare insurance should be familiar with their p/p.

[savoytruffle, BSN, RN]

I was an MDS program leader for many years. NY is a case mix state. The trainers that I took all of my AANAC courses from used SNF to signify the facility as a whole. Not bed designation for Medicare (rehab) vs Medicaid. All the facilities I worked in had dual certified beds. So if I confused the terms others use for this, I apologize. I do know the regs inside out for what qualifies admission. She was going to a long term care floor. She had private pay funds, not Medicaid. The nursing home screened her in person. They had the records available to them, but did not read the chart. We had a PRI assessment from a neutral third party. The chart contained notes and incident reports of her behaviors. I read charts cover to cover when deciding who can live at my facility. I can't believe they didn't do the same, but they are saying they genuinely did not know she had aggressive behavior and resistance to care.

[amoLucia]

Baloney & pooh pooh!!!

Not to you, OP, but to the other facility that accepted her admission. The onus of her suitability for admission was theirs. And I think their admission coordinator may be in for a big headache for doing as lousy-poor screening.

Failure on THEIR part does not an emergency on YOUR part make!!!

(And by the way, some of us also have the tendency to interchangeably combine terms LTC with SNF, NH, rehab, insurance, etc. Esp when we work in facilities that are certified for all its beds. I've been trying to catch myself.)

[savoytruffle, BSN, RN]

Over the weekend the Nursing home still refused to take her. She remains in the hospital while placement is found. I hope she gets settled soon so her family can enjoy Christmas.

[lifelearningrn, BSN, RN]

Thank you for the update. SHAME on the system that doesn't have beds available for these types of patients.

[amoLucia]

I wonder if your State DOH might be interested in the situation??? It does sound like the pt IS theirs. And their refusal to accept her back is inappropriate.

Just hope that YOUR facility was TRULY honest and straight-up re transfer information. You wouldn't want that investigation to come back and bite your facility.

[NurseQT]

We have a saying in the facility I work at "once they walk (or roll) in the door they're ours". Before that, even if we've accepted them as an admission, they aren't technically admitted until they walk through the door.. And believe me, we had one that made it to the front door and we didn't accept her.. She had some crazy acute behaviors and had to be "chaptered". But once they have come through those doors they are our pt and are treated just the same as the pts that have been with us for 10 yrs!

I don't see how this facility can refuse to take her back without following the proper discharge procedures.

[NurseQT]

"I got a call that she saw her name on the outside of the room and got upset. She would not allow the nurses to assess her. She was able to over turn a med cart. She went straight out to the ER to be evaluated for the psych emergency center, but being that she has dementia and not a true psych disorder they would not accept her either."

I am amazed this woman could tip over a med cart!! Those things are heavy and it's no easy feat to tip one!

I feel bad for her though, she must have been so scared!

[savoytruffle, BSN, RN]

She must have been terrified and angry. We have never seen that side of her. Once when she had a UTI and refused to go to the MD we had to call an ambulance and she fought the EMTs. All that info was right in the chart!