Background: I work in a skilled rehab nursing facility. I have been a nurse for 9 months. This is my first and only job as an RN. Most shifts I am the only RN on the floor, responsible for close to 100 pts. My day supervisor is an LPN. She leaves by 5pm then its me for the entire building caring for my own 25 pts plus overseeing 3 LPNs and the other 75 pts in the building until 11pm. I am not a supervisor.
I had a pt today that has a hx of ALC, going AMA, and head trauma. She is a very acute pt with a PICC, 2 jp drains and psych issues to boot. Today she had an episode where she was sitting in her chair talking with her family and all of a sudden her eyes rolled back, and slowly fell to to floor from her chair. When I found her she was on the floor unresponsive, limp, pupils not reacting but alive. VS were normal. Gave her some o2 and stayed with her until medics arrived. Sent her to the ER for eval and tx.
Meanwhile I am the only RN on the floor. My "supervisor" is an LPN and was not in the building. She called me from her home and told me that our DON told her to tell me that if ER does not admit her, that we ARE NOT TO TAKE HER BACK TO OUR FACILITY due to her acuity and hx. So I get report from the ER nurse who says that everything came back negative and they are ready to send her back to us.
Problem: She was never officially taken from our care. She was sent to ER for eval and tx only. I felt if I had followed the instructions of the DON (via telephone from an LPN) that that would be pt neglect and did not want to be responsible for turning away a pt that I had already accepted care for. So I went against orders from my DON and accepted her back into our facility.
So my questions are: Did I do the right thing? Could I have been charged with pt neglect had I not taken her back? Isn't it out of scope of practice to for an RN to take orders from an LPN? Can I get fired for not listening to my DON?
I never actually spoke with my DON and I never heard the words from her mouth. She called the supervisor who is an LPN to tell me "don't take her back." I called my DON several times for a clarification and left several messages but no return call. I felt I made the best decision at the time. I am worried about ramifications next week from DON for not following her orders. but I NEVER HEARD FROM HER DIRECTLY AND SHE WAS UNAVAILABLE!! I know our facility can get into trouble for not have a supervisor in the building.
I am worried about getting fired. My thought at the time was "I would rather be fired than to loose my license." I feel like my DON should have been the one to call the ER and tell them we were not taking the pt back and it was not my place to do that. I feel its was unfair for her to put me in that position. I am sick to my stomach over this. Please any honest advise would be appreciated thank you.
Dumping is something that happens everywhere, not just LTC/SNF. The reality is that a lot of the patients in LTC/SNF facilities are there because the hospital dumped them. It happens a lot with patients who are elderly, DNRs, on Medicare, and with a poor prognosis.
Hospitals don't want to keep them in a bed that they can use for someone else who is going to bring them more money.
So there can be a lot of complex issues that arise, especially when a patient is booted out of the hospital, who is far too acute for a lower level of care. And your patient was most definitely too acute.
I have worked with patients in SNF that were dumped directly out of the ICU, and believe me, we try to find any reason possible to send them back to be re-admitted to the hospital.
It takes a lot to motivate an SNF to release a patient back into the hospital, especially if those are Medicare patients, because those are the ones that bring in the big bucks to the facility-- a direct contrast to the patients that are desirable for a hospital.
What happens often is that a SNF will send a patient out to the ER, the ER tries to bounce them back and then you've got a war going on beause the facility cannot and does not have the resources to provide a level of care necessary for such an acute patient.
And I have seen some cases where the administrator of a SNF will go all out to make sure that patient is admitted into the hospital where they belong, rather than accept them back into a situation where they cannot get the level of care that they need.
So there is a lot more going on than just one facility not wanting to take care of a patient.
As far as the other concern about who is communicating what, I think that you were right in feeling that you needed to communicate directly with the DON. I don't think it really had anything to do with LPN/RN giving the order -- LPNs function at a much higher scope in LTC/SNF and can most certainly take orders where I live.
The bottome line is that the DON or facility administrator needed to make this call and needed to communicate that directly with you, and should have also probably taken on the hospital her/himself.
It takes a lot to motivate an SNF to release a patient back into the hospital, especially if those are Medicare patients, because those are the ones that bring in the big bucks to the facility-- a direct contrast to the patients that are desirable for a hospital.
Very common misconception but
Medicare reimbursement for SNF patients is pathetic, especially with PT/OT/ST; the facility loses money, but to keep their Medicare/Medicaid "standing" in good order, they have to take them. I used to do the MDSs for PPS reimbursement, and PT alone would eat up the daily payment. It's a flat rate to include EVERYTHING the patient needs- not charging for what they actually get, so SNFs want Medicare patients to keep their Medicare rating. But they often lose their shirts. When PPS first was introduced, entire companies went bankrupt, or merged. Many just faded away.
Medicare reimbursement for SNF patients is pathetic, especially with PT/OT/ST; the facility loses money, but to keep their Medicare/Medicaid "standing" in good order, they have to take them. I used to do the MDSs for PPS reimbursement, and PT alone would eat up the daily payment. It's a flat rate to include EVERYTHING the patient needs- not charging for what they actually get, so SNFs want Medicare patients to keep their Medicare rating. But they often lose their shirts. When PPS first was introduced, entire companies went bankrupt, or merged. Many just faded away.
But still can't dump :) To OR from the hospital
OK, OK, I agree, I'll restate that. Most patients in SNFs/LTCs are on Medicare, as opposed to those who are on private pay or other insurance like BC/BS, who are going to have a lot more resources to either stay put in the hospital or go on to home health. Or be a collosal PITA to administration because they have money/resources/familly, etc. to be demanding quality care.
And the sad truth is that a lot of the Medicare patients who end up in SNFs do not have that and so are not able to advocate as well for themselves, and so are highly desirable for a facility, especially if it is one that doesn't give a crap.
So, I'll say, Medicare patients bring in the bucks -- whether big or small. And I do agree that the Medicare ratings will make or break a facility so they do want those patients. And as a result, they do want, at some level, to be able to provide good care (to keep those ratings) or rather, and what is more likely, to be able to at least maintain the illusion that they are providing good care.
Which is often the heartbreakingly frustrating situations SNF nurses find themselves dealing with. Because those of us who are working with such patients have to struggle with the knowledge that we really cannot provide the level of care they need given the patient load and lack of resources.
We see them go down the tubes because of that, and we have to fight with administration for every little thing to make sure that the patient doesn't come to harm in the facility, which they very often do.
However, there is a point where even administration knows that the patient is too acute, and then they have to weigh the pros/cons of keeping a patient who will probably tank in the facility and bring down such a conflagration of legal/liability issues that it is really not in their best interests to hold on to that patient.
At which point they will send them out and try to make sure that they don't come back, at least right away. But again, this is not the kind of decision that should fall on the nurse that is running the floor. It should be the DON who handles something like that.
It seems to be although the hospital did not find a room for her overnight, they still had assumed patient care. And as long as you didn't pick her up from the ER after the visit it would not be your fault. That sort of thing is too acute for a rehab hospital.
As for an RN taking orders from a LVN/LPN. It doesn't matter, you can still take orders from a LVN/LPN. It's not even a scope of practice issue. If you had a supervisor or a manager that was not an RN and they told you to jump. How high would you jump?
Medicare only covers the rehab/SNF aspects of reimbursement. If they don't show progress, they have to be discharged from Medicare,and either go private pay, LTC insurance, or Medicaid. Medicare pays 100% of days 1-15; all days after that the patient is charged roughly 100bucks/day OUT OF POCKET unless they have supplemental insurance, which has different levels of coverage, and different amounts they pay towards that 100bucks. Medicare is no where near comprehensive. There is no dental coverage unless on an advantage plan (which Obama-care is eliminating).
Example of Medicare reimbursement....a CVA patient comes in and needs PT/OT/ST...that gets the highest reimbursement- a rehab category. Medicare (in their infinite wisdom) says that the facility gets 350.00/day (depends on rural/urban). PT/OT/ST each see the patient for 2 "units" twice a day- so 12 "units" (usually 15 minutes, or a total of 3 hours/day). Each unit costs 75 bucks. That's 900 dollars/day in COSTs for that patient...the facility doesn't get 550 dollars (and if they have contracted therapy services, they lose that). That doesn't do anything to cover room, board, nursing, medications, CNAs, keeping the lights on, etc.
Medicare patients are a LOSS for the facility in terms of reimbursement. They are needed though, to keep their standing with CMS (Centers for Medicare/Medicaid Services).
A LTC resident who is long term, and not on therapy is not covered by Medicare (some of their supplies may be- tube feeding, diabetic supplies, walker, etc). But Medicare does not pay for custodial/ADL care. Medicaid residents give up their retirement/pension checks to the facility, minus a small monthly stipend for their own use; the state pays the rest. Private insurances have to be specific for room and board; they generally don't include meds or MD visits.
There are a lot of misconceptions about Medicare and Medicaid- and it doesn't help that they change things every year (mostly minor things, but the PPS system that came about in the late 90s was a disaster- I can understand the reasons- people were abusing it- ordering equipment patients didn't really need, etc). :)
After working in admissions, doing MDSs for PPS/Medicare, and just working several years in LTC- primarily administrative/supervisory I'm amazed any of the LTCs can stay open.
Good job, it is always easier to defend yourself when you put the patient's welfare first. I think you also showed good practice by trying to contact your DON for confirmation and clarification. Her acuity sounds actually no different than it was previously. I think you did the right thing.
First of all i nmy opinion an LPN should NEVER be supervising an RN or functioning in a supervisory role. And I have NOTHING against LPN's (I was one for 4 years). LPN's can NOT take a verbal order. I think you did EXACTLY the right thing!
Believe it or not it depends on where you are practicing.
I agree that you did the right thing. The DON should have taken the responsibility for refusing the patient if that is what she wanted, and she should have taken responsibility for talking to you. If you lose your job over this, then somewhere down the line you were probably going to lose it anyway.
Thank you so much for posting this. There is a lot to be learned from this (at least for me). I agree with nurse 2033 and I certainly agree with your disapproval of being put in this situation in the first place. This is stuff they don't teach in school.
And I do agree that the Medicare ratings will make or break a facility so they do want those patients. And as a result, they do want, at some level, to be able to provide good care (to keep those ratings) or rather, and what is more likely, to be able to at least maintain the illusion that they are providing good care. 
leslie :-D
11,191 Posts
lpns can supervise rns, administratively (is that a word?), but cannot supervise them, clinically.
either way, don't ever accept an order that isn't directly from the horse's mouth.
op, you made an astute decision.
but i also want to add, that even if i had received the order directly from the DON, i still couldn't accept it.
believe me when i tell you that DONs/ADONs will often delegate orders that they wouldn't dare do themselves.
if anyone ever challenged the order, the DON would deny ever giving this order, almost always.
great job, op.:balloons:
leslie