Resident's family wanted to discharge AMA at 10:00 PM Sunday night!

[smartypants22, LVN]

Let me give you some background on this situation: I have been working at my LTC for about 5 months now, doing only weekend double shifts 6AM-10PM. The 10-6 nurse doesn't come on time because she has another job and I have had to wait for her to come. Also recently we got a new DON and she's been making some changes, mainly wanting my unit to become a medicare unit, having residents come in and out.

Now this past weekend, a new resident came in during the week, being transferred from a hospital during the week. He was a bilateral below knee amputee, but he planned on being at the LTC short term and going home when his therapy was finished. Sunday night, I finished my shift and was doing some computer charting while waiting for my relief to come. I thought something was fishy when this particular resident had his daughters come to visit him at 10:00. They rang the call light to his room, so I went to see what was going on. That's when they told me that they wanted him out of there. Apparently during the week, he had not been visited by his doctor even though the doctor was supposed to remove the dressing from his hip surgery, and he also had not had therapy. The daughters were not happy with his care. I didn't know what to do and luckily my weekend supervisor was still there so I went to her office and she got the necessary paperwork. The daughters said the hospital had transferred him to the nursing home without her permission, though the reason was because the doctor he had at the hospital practices at the nursing home. There was no talking them out of it so they signed the paper work, they also wanted me to remove his catheter, so I did that as well. To top it all off, since he didn't have a wheelchair, they wanted to get a wheelchair to take him out. There were no available wheelchairs at that time! All the wheelchairs belong to a resident, so they had to borrow a wheelchair. They finally got him out at 11:30PM.

What frustrates me about all this is that they chose to come so late at night on a weekend. I mean, who does that when they had all day to do this?

[sideshowstarlet, BSN, RN]

Wow. If they're going to pick up their father that late, they could have at least come prepared. How were they expecting their father to move around a few days after being in the hospital for an amputation without a wheelchair? I wonder if there will be a part 2 to this where the daughters discover that the car/house is not wheelchair accessible? And in my thus far limited experience, when it is a dressing that is meant to remain in place after surgery, the nurses are responsible for scheduling a follow up appointment with the doctor and arranging transport to the office. What did the resident have to say? Is he able to speak for himself?

[smartypants22, LVN]

He wanted to leave too, he wasn't happy with his care and being left in bed all day since he didn't have a wheelchair. Rehab therapy is supposed to provide the wheelchair, but I don't know what happened during the week. The doctor that was responsible for him comes to the facility since he's actually the medical director, I think he comes at least once a week, but the resident had missed him since he was admitted Wednesday.

[smartypants22, LVN]

Another thing I want to add is this particular resident was placed on contact isolation for having infected wounds.

[amoLucia]

Sounds like the dtrs may have been hoping the late hour would provide the least amount of interference in getting their Dad out of there. On the other hand, Dad may have 'guilty'ed ' them so badly that they just acquiesced and came in to do the deed.

However, it does sound like Dad has quite a deal to manage with all his illness issues. Not handling the grief & grieving process too well. Denial & anger phases anyone? I will give it to him that he does have it very rough right now.

Like you mentioned, I'd like to know where Therapy was for week??? Usually they're the first ones chomping at the bit and falling all over new Rehab pts. (Sometimes, we barely get them off the stretcher & into bed before someone from therapy is checking in.) Also newly adm pts are supposed to be seen within a brief window after admission. I hope the onus of that issue is on the MD. Likewise I hope the place has all its ducks in order because there may be a part 2 coming.

I do agree that they will all prob be in for a real eye-opener when they get home as PP commented. My guess is that they'll be back in the ER within 24 - 48 hours. That'll be another whole other issue.

Glad & fortunate that your supervisor was there to help out. His case sounds like it might have been doomed to fail even before it started. This kind of thing does occur infreq, altho often enough that I've seen it plenty. Life altering health issues, NH stigma, sudden unprepared hospital discharge. And probably insurance/health care benefits coverage lack of understanding/knowledge all played a part in this admission/discharge.

Sadly, the money in NH care is tied to 'skilled' Medicare level pts. If your facility is just wading into that pool then you'll be on a learning curve with potential for screw-ups. And your DON is learning too.

Sounds like you did all you could under the circumstances. Isn't it a bummer when you (and ME at times) get stuck with all the mess of others. Of all the issues at the time of the AMA disch, the one that concerns me most is the foley cath removal. I hope he pees in a timely fashion on his own. Ouch!

[Hoosier_RN, MSN]

Most persons are admitted with PT/OT orders, so that seems like a failure. And did they think you should just give them a w/c? Those jokers aren't cheap. More things I noticed. Some hospital/MD, some facility fault, and probably some family/resident. Wow, he's been off to a rough start if everything outside of the discharge realm is true 😩

[sideshowstarlet, BSN, RN]

Ooh... catheter removal without bladder training. I missed that the first time. And therapy should definitely have been there a lot sooner. Therapy evaluates our residents within 24 hours. They work Saturdays, so the longest they would have to go without a therapy eval would be if they were admitted Sunday. It's these little things we take for granted until they don't get done. Unfortunately, there was little/nothing you could do during your shift to help with these issues. I mean, I suppose if he had an armchair in his room, he could sit in that for a while instead of lying in bed. He still wouldn't really be able to leave the room due to his isolation precautions. But even then, without a therapy eval or the md looking at his surgical wound, his main reason for being in your facility was not being addressed during his stay. So the family would have still been upset about that. Sorry you had to deal with this, OP.

[mtjoanna]

Just to play a little bit of devil's advocate, perhaps the daughters (not knowing them or the situation) also work irregular hours and 10pm on a weekend is a normal time for them to be up and about? The facility that I recently left had a few rehab residents leaving AMA recently because of promises made that our facility could not provide. Two residents in one week (one rehab, the other hospice) were told that they'd receive 1:1 CNA care, that there were always 2 nurses on and that the doctors were the best. Recently, we've been running 3 CNAs during the day (one on the locked SCU, the other 2 caring for the other 41 residents, several of whom are actually 2-3 assist even with a lift), and 2 at noc--one on the SCU, and one to the rest of the 41-not exactly 1:1 care for anyone. One nurse at noc, never 2. Sounds like you are also dealing with a number of unfulfillable promises made by someone else. It's not fun bearing the brunt of broken promises!

[kbrn2002, ADN, RN]

Sadly there will probably be a readmit in his near future, though very probably not to your facility. Unless the family and the payer source are really on the ball about setting up some home health to deal with the wound care, infection, therapy and needed equipment he will have a hard time functioning at home. It also sounds like your facility seriously dropped the ball on this one. I am surprised therapy wasn't all over a new admit. I am also surprised that the dressing removal and follow up MD visit wasn't taken care of right away.

Obviously none of this was your doing since you only work weekends, so it really is too bad you got the fallout from this.

[CapeCodMermaid, RN]

OK...it's 2016-people don't get shipped off to a nursing home or rehab without someone's permission. Can the man speak for himself? If so, the daughters didn't need to give their permission.

Rehab hadn't come in to assess him?? Even in the worst places I've worked, rehab is always in the next day even if the original admit was on a weekend. I don't blame the guy for being tweaked because he was left in bed.

If your facility is going to take short term residents it better come up with a plan for taking care of them properly. I can see the Massachusetts DPH citing at least 3 things in this story.

Maybe as someone said the daughters work all week and this was the only time they were available.

Lucky your supervisor was there.

I'd suggest a meeting with the administrator, the DON, and the director of rehab to make sure the next patient receives the care they need. You shouldn't be taking patients (and let's face it, short term people are patients, not residents) you can't care for.

[lifelearningrn, BSN, RN]

If he left AMA, did you have orders to remove the cath? :/

[CoffeeRTC, BSN, RN]

Yikes! This is a messed up situation. No therapy for days? Not OOB? (what about using a lift?)

I've seen some crazy dc AMAs in my day. Some I kinda agreed with the family. I wouldn't have removed the foley unless the MD ordered it. As for a wheelchair?? They cost hundreds of dollars, so I wouldn't have let them borrow it unless I knew I was getting it back within the hour.

AMA dc= no meds and insurance won't be paying for the stay. I'd make sure the family know about that too.