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.
That's the issue with the dumping laws. The nursing home in this situation would be violating federal law if they didn't take them back because that is their residence at the time- even if temporary...UNLESS they sign out of the LTC (would be against medical advice, and the person would have to be able to act on their own rights and make their own medical decisions) It gets complicated :)
Thanks xtxrn. As always, I learned something from you :)
Specializes in Trauma Surgery, Nursing Management.
lpns can supervise rns, administratively (is that a word?), but cannot supervise them, clinically.
yes! this is true.
either way, don't ever accept an order that isn't directly from the horse's mouth.
i agree with this point as well. i think the op made the best decision in the circumstance described. the don was unavailable and did not return calls.
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.
sad, but true.
great job, op.:balloons:
i second that! very good decision making skills under an extremely stressful period. i hope that the don does not have a beef with you when you return to work. if so, then i would be putting out feelers for another job.
leslie
always the voice of wisdom, my dear les! :heartbeat
Mazy, I believe you're confusing Medicare with Medicaid. All US seniors are eligible for Medicare simply because they've reached age 65. (some younger folks are eligible too, for certain disabling conditions)
The LTC payment prospects for Medicaid patients are indeed more complicated. Because most reimbursement is so poor, most facilities limit the number of beds they make available to Medicaid patients. But Medicare does not provide unlimited long-term payment for LTC either, which comes as a shock to many seniors and their families. When my grandparents were still living, basic Medicare paid only a set per diem rate for a maximum of 100 calendar days of LTC per year. Supplemental insurance, or separate long term care insurance, is a must.
Specializes in Gerontology, Med surg, Home Health.
Where to start? I work in Massachusetts which has some of the strictest regs in long term care. In ,y almost 30 years of working in the business, there have been only a handful of times we have refused to take a resident back. In one case the discharging hospital outright lied to the facility to get the resident admitted. In another, the resident was having a psychotic break and continued to be violent. We usually send these guys to a psych facility which knows we' ll take them back when they're "fixed". We are allowed to not take them back if we can't care for them. The last person we sent out and wouldn't take back was a resident who was excruciating pain and horrible behaviors (psychotic and most likely increased from the amount of pain). While in our care,the daughter refused to allow us to give any anti psychotic OR pain medication. We had no choice but to discharge her.
By the way, I am the DNS ... Either the Administrator or I always make the call to the hospital.
Mazy, I believe you're confusing Medicare with Medicaid. All US seniors are eligible for Medicare simply because they've reached age 65. (some younger folks are eligible too, for certain disabling conditions)
The LTC payment prospects for Medicaid patients are indeed more complicated. Because most reimbursement is so poor, most facilities limit the number of beds they make available to Medicaid patients. But Medicare does not provide unlimited long-term payment for LTC either, which comes as a shock to many seniors and their families. When my grandparents were still living, basic Medicare paid only a set per diem rate for a maximum of 100 calendar days of LTC per year. Supplemental insurance, or separate long term care insurance, is a must.
Altra that is the information we got when we had to send my father to an SNF for rehap following his massive stroke. He has only been there for 30 days, still going through rehab..
Where to start? I work in Massachusetts which has some of the strictest regs in long term care. In ,y almost 30 years of working in the business, there have been only a handful of times we have refused to take a resident back. In one case the discharging hospital outright lied to the facility to get the resident admitted. In another, the resident was having a psychotic break and continued to be violent. We usually send these guys to a psych facility which knows we' ll take them back when they're "fixed". We are allowed to not take them back if we can't care for them. The last person we sent out and wouldn't take back was a resident who was excruciating pain and horrible behaviors (psychotic and most likely increased from the amount of pain). While in our care,the daughter refused to allow us to give any anti psychotic OR pain medication. We had no choice but to discharge her.
By the way, I am the DNS ... Either the Administrator or I always make the call to the hospital.
Question, regarding the part in bold. When my father was admitted the SNF would not even consider admitting him until they had received his charts from the hospital. Is this the norm, just wondering if the charts were sent how the hospital could lie to get the patient admitted?? I am just wondering, not disputing the point. Thanks for any enlightenment provided.
Specializes in Gerontology, Med surg, Home Health.
Many hospitals these days do NOT allow screeners in to see the resident. They put what informational they want us to have in an e-discharge report. Basically we see only what they want. This is why it's so crucial for the screeners and hospital to be on good terms and for the hospitals to understand what kind of people we can take care of and even more importantly the kind of people we are unable to care for.
Mazy, I believe you're confusing Medicare with Medicaid. All US seniors are eligible for Medicare simply because they've reached age 65. (some younger folks are eligible too, for certain disabling conditions)
The LTC payment prospects for Medicaid patients are indeed more complicated. Because most reimbursement is so poor, most facilities limit the number of beds they make available to Medicaid patients. But Medicare does not provide unlimited long-term payment for LTC either, which comes as a shock to many seniors and their families. When my grandparents were still living, basic Medicare paid only a set per diem rate for a maximum of 100 calendar days of LTC per year. Supplemental insurance, or separate long term care insurance, is a must.
No, I understand the difference -- but thanks, also, to both you and xtxrn for doing your best to clarify the muddle of info. I wish I had known more about the system before going into healthcare. The more I learn, the more terrified I become about my future.
I worked for a corporation that got hit with multiple lawsuits for Medicare fraud and that was my education on the subject. I guess there's no better way of learning what is supposed to be happening in terms of reimbursements than by seeing all the ways in which a facility is trying to scam the system, and the ways in which the patients suffer because of it.
That facility was going after poor patients with no advocates, that no other facilities would accept, and billing Medicare for services that they weren't giving. Not to mention all sorts of other atrocities that were going on. Medicare pulled their patients several times, the place almost tanked, but then they would make their corrections, get recertified and start the whole thing all over again.
I'm still very bitter about it and I guess I tend to think all facilities operate the same way, even though the place I work now is very rigorous about doing things right.
In retrospect and in following this thread I am realizing that I sent a ton of patients out to the ER at that earlier job, because the level of care was so awful we were practically killing them, and I really hoped they didn't come back.
There were a couple of times the ER did want to bounce them back but there were a few of us nurses who were able to make a good case to those docs for why they shouldn't.
I didn't care at the time if what we were doing was considered dumping or not, the patients were genuinely acutely ill, they needed to go out, and they needed to stay gone.
Thankfully, we do a pretty decent job where I am now, and I no longer go into work worrying about how I'm going to protect my patients from my facility. But I'm still bitter and a bit PTSD-y and somewhat irrational on the subject.
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.
Thank you for your post. I work in LTC . I would like to work doing MDSs for PPS/Medicare someday.
Trust me, that was purposeful. She was keeing her hands clean. Had you not accepted pt back and the facility caught he// , you can be sure that you would have been the first one under the bus.
Good job and excellent judgement on your part. I know it wasn't easy with all the push back from senior staff.
thank you Old.Timer! I totally agree with you and that may be why she dd not return my calls. She did not want to do it herself and thought she could get me to do her dirty work. I doubt she thought there was a chance I would take the pt back.
I love LTC centers "dumping" patients on my ER and refusing to take them back. I clear my patient load and start the phone calls...
I take great pleasure in contacting the state offices for medicaid/medicare to investigate you and shut off your funding. On the weekends I have a state ombudsman to intervene and advocate for residents "not able to return" and have gone as far as to remove/deny CMS funding for the facility as well.
I have been responsible for multiple fines levied on nursing homes and have completely shut down 2 centers for stupid decisions, poor care and neglect. (Soon to have a 3rd attempting pending appeal from another jugement by US Department of Health & Human Services)
There better be a significant change in level of service that exceeds your centers ability to care for patients or you're looking to be out of business soon. Dumping is horrible for the patients and families that entrust their entire care to you and your staff. Be careful about deciding who you deny returning to your facility.
LPN, RN, DON??? I don't care where the order comes from. I don't play that game...
Thank you EmergencyNrse. I had heard of the term "dumping" before but never really knew what it meant. Now I have learned first hand. I agree with you that pts and their families trust us to provide the best care possible for the patient. I can lay my head down tonight knowing I did not turn my back on my pt or her family :redbeathe
SeeTheMoon
250 Posts
Thanks xtxrn. As always, I learned something from you :)