Signing out AMA

[CapeCodMermaid]

OKAY here's the question....a patient signed out AMA 2 days ago...all well documented that we told her she wasn't ready to go and was at risk....she left anyway. She is now back in the ER wanting to come back. I said NO. I've never worked in a place that took someone back after signing out against medical advice. My administrator wants to take her to make nice with the docs. I am outraged and know I will be over ruled (another story altogether)..what do all y'all think.?

[Noryn]

Since the original poster posted this in the geriatric and ltc forum, I am pretty sure she is talking about a nursing home in which case EMTALA or other hospital regulations do not apply. I have known a few nursing homes to not accept pts back after signing out AMA. It really depends on the facility policy.

It also should depend on the circumstance, the one big question mark I have is also the insurance. I am pretty sure in my state she would have to be authorized again if she was on Medicaid which can take a few days to a week or longer. Was she there for acute rehab or long term placement?

I agree with the other posters that most administrators are just going to want to fill the bed. Why did she sign out AMA? It would have to be horrible to be in a nursing home (or hospital) for Christmas, so I can understand leaving.

[CapeCodMermaid, RN]

1. It's a SNF, not a hospital.

2. She's more than a little nutty and wanted to go back home to her best friend Jim Bean and their pet Wild Turkey.

3. She is Tufts managed care and the case manager said she'd auth. a SNF admission again.

What bothers me the most is the fact that when she got to the ER, her blood alcohol level was over the legal limit. She was only there an hour before my ED said she could come back....we DO NOT do detox. I have very sick patients on my sub acute floor and it is just not right to admit a drunk.

[Noryn]

Yeah I dont think detox is appropriate for a skilled nursing facility. The pt should be monitored for a few days in the hospital and started on Ativan. There is a strong chance the pt could go into DTs and a snf is not the place to provide appropriate treatment.

[gitterbug]

Agree AAW is certainly a great potential here. Why is medical facility not willing to detox for 48 hours? Perhaps mentioning this problem to DON will shed a new light on this problem.

[CapeCodMermaid, RN]

Gitterbug,

I AM the DON. At my facility the ED has the final say on who gets admitted which is totally absurd because she is NOT a nurse.....one of the big reasons I'm looking for a new job outside of LTC.

[Daytonite, BSN, RN]

when we are the employee, we have no say and no authority. if you become an owner of a ltc then you can make the rules and get the final word. that's part of the beauty of owning your own business. the owner also gets to shoulder the failures.

[PANurseRN1]

By ED, do you mean "Executive Director"? I think many of us are confusing that with ED as in "Emergency Department."

[CapeCodMermaid, RN]

Regardless of who owns the business, as the DON it's MY license I have to worry about, not their bottom line. If we admit people we are not capable of caring for, it's on me, not them.

[Daytonite, BSN, RN]

I used to work on an alcohol detox unit. You know, I was thinking that elderly alcohol abuse is not as uncommon as people think. Some alcoholics do make it to old age. Add the neurological damage that goes along with long term alcohol abuse and you've got one rip roaring patient to deal with. One of the things I think you should do is get some education on this subject of alcoholism and the elderly. I think you have a couple of options with this patient. Push for referral of the patient to a healthcare professional who is a specialist in treating alcoholics. Try to get the patient to cooperate with counseling. I know that may not be possible. However, a good counselor or the professional the patient is first referred to can be immensely helpful to you and the staff in learning how to handle the behavior of this patient. In a sense, you and the staff will become the family of an alcoholic. Families of alcoholics need just as much support and guidance as the alcoholic does. With the help of a professional trained in working with alcoholics you may not be able to stop this resident from imbibing, but you can certainly develop strategies to prevent them from getting their hands on the stuff and learning how to deal with the behavior they are going to exhibit. It's important that a very clear plan of care be developed for a patient like this and that it be shared openly with the staff so everyone knows exactly how the patient is to be approached and treated. Consistency in nursing intervention is important. The interventions are going to be more interactive and behavioral rather than physical ones that you are accustomed to performing. However, these are not totally outside the realm of basic nursing care. It might end up being a very challenging learning situation for all and require more focus and attention than many of the other residents will get. But, then again, we treat by what each patient needs. You will feel very proud of any positive work efforts you put into this. I think that a sense of accomplishment is just as important for you to feel as a professional nurse and a leader as it is to keep the patient safe.

The last LTC I worked in took on a patient who had been turned out of a number of other LTCs because he was confused, but very strong, and often hauled off and punched CNAs causing some pretty bad injuries. Physical restraint of his hands was not an option. They assessed his history and observed his behavior thoroughly. They developed a care plan and made sure that every single CNA and charge nurse was aware of how he was to be handled. They had a very clearly written plan of what everyone was to do if this patient became belligerent. He never hit without given some warning first. The care plan stressed this and listed the warning signs to watch for and that you were to back off and attempt to approach him at a later time. Problems always developed when a CNA or a charge nurse didn't follow the plan and specific rules that had been laid down about working with him. This patient remained a resident of that facility for many years and received very good care. There were actually times when he would smile and when that happened all were encouraged to notice and interact with him. There were also times when his dressings didn't get changed for a day because he was in a foul mood. The care, however, was designed to follow his routine of good and bad moods, not the staffs. The various state surveyors were always impressed with his plan of care and how he was attended to. And, that is how good individualized nursing care should be. This is one of the reasons why I love LTC so much--the autonomy we have as nurses to successfully solve problems like this.

[CapeCodMermaid, RN]

Daytonite,

While I appreciate your compassion for elderly alcoholics, and believe me, the area I live in is known for having more than its share of both old people and drunks, it just isn't realistic to expect one nurse to be able to devote that much attention to a drunk (or anyone else) with behavior problems on a short term, sub acute unit. If the drunk goes 'off' and the nurse has to spend all that time with him, what happens to the other 19 patients she is supposed to be caring for? What happens to the man with the brand new knee who needs pain medicine before he goes on the CPM??? What happens to the woman who is s/p CABG who is having chest pains? Sorry, but drunks, drug addicts, and demented people do NOT belong on the same unit as other sick people.

[Daytonite, BSN, RN]

i was taught not to be judgmental and compassionate for all the patients i had to care for not just the drunks or the stroke patients. some will be easy and i wish i had 10 of them at one time. and, then there are those times when i had one patient with a complex disease and multiple problems to match that tried every nursing bone in my body. this, however, is what all my nursing skills prepared me for; not so much the easy cases, but the hard ones. plan and strategize. if a patient codes i drop what i'm doing and attend to that immediate problem. if a patient begins vomiting i prioritize my task and attend to that problem by delegating someone to deal with if i need to. if a patient elopes, ditto.

so, what you're saying is any patient with complex needs, particularly drunks, drug addicts, and patients with dementia are just out of luck in your facility? your area? when it comes to getting good nursing care. hello. . .state board of nursing. . .state department of health. . .medicare. . .i want to make you aware of something going on. . .

[CapeCodMermaid, RN]

PUHLEEEEEEZE- I didn't say they didn't get care...cripes...everyone gets care. BUT when the focus of the facility is on elders who are sick....I'm sure there are places who can and delight in taking care of drunks and drug addicts. The people who came to live at my facility didn't come there to be subjected to the ravings of someone going through the dt's. SNF's are not licensed to do alcohol detox and if we take patients who are withdrawing, we can and most likely will be cited.

You might be able to prioritize but the majority of nurses I've worked with in more than one facility are not able to and someone gets the short end of the stick.