Unsafe discharges

SummerGarden, BSN, MSN, RN · Mar 13, 2015

According to the Commission for Case Management Certification, it is one of the responsibilities of a nurse case manager to provide resources and arrange for a safe discharge from the acute care setting. However, understand that caregivers, as well as patients, are very much responsible for his/her own actions and learning. There is only so much a RN or any professional can do to assist with preventing poor health outcomes and so a patient's learning or lack thereof is not the sole responsibility of a nurse case manager!

In addition, patients are not to remain in the hospital setting forever just because the patient or the caregiver does not know something or is not comfortable with a discharge because hospitals are not hotels. Other resources are available outside of the hospital setting to include caregivers (both family/friends and private duty/paid), home health, community courses, and primary medical providers to assist with supporting the patient's learning and positive outcomes in the home setting.

Further, I do not know on what planet a RN Case Manager that is not caring for a patient medically and directly in the home setting would be responsible for the patient getting a UTI at home. We (hospital case managers) are not omnipotent, although we are magicalâ€¦ Fairy wings, wands, and all!

Can a RN case manager lose her license if you discharge someone and something happens when they get home? Can't do blood sugar, has UTI diagnosed very soon being home,

By the way, OP are you asking because someone wants to blame you? Or do you want to blame someone else for the above? Either way, we are not lawyers or representatives of the BON and we do not give legal advice on this forum, so check with the BON of that state to answer this question. The BON of the state that gave the license to the nurse case manager is the organization that can discipline it's licensed nurses. Good luck!

nurseprnRN, BSN, RN · Mar 13, 2015

While I agree with MBARNBSN on most of what she says, every RN, case managers included, has responsibility for patient safety well-documented in both the NPA and the ANA Scope and Standards of Practice.

If you feel that a patient is not safe to go home, or the discharge plan is not safe, you have the obligation to pursue a safe one, and you cannot delegate that away to social work or the like. Yes, if you have documentation that a demented elder who is unsteady on her feet is going home to an empty apartment in a 2nd-floor walk up with no one to shop or cook for her and no idea how to take her meds, you would be liable for just putting her in that cab and saying, "Good luck dear!"

SummerGarden, BSN, MSN, RN · Mar 14, 2015

While I agree with MBARNBSN on most of what she says, every RN, case managers included, has responsibility for patient safety well-documented in both the NPA and the ANA Scope and Standards of Practice.

Yes absolutely, this is true!!! However, I was actually not trying to imply that we are not responsible and that a nurse can be negligent in discharging a patient to the home setting without consequences... On the other hand, based upon my experience I was pointing out that we are not solely responsible for every single outcome good or bad that happens to a patient especially when we have made appropriate arrangements to include patient teaching (some patients are taught and it is documented, but they still make poor choices which is not the fault of the nurses).

In fact, I was supporting the Case Manager in question (if this is a real scenario) because I suspect the Case Manager in question discharged the patient appropriately, documented patient teaching and interventions, but the patient still returned to the hospital setting shortly afterward. And so, the patient and/or family may want to blame someone rather than taking personal responsibility for their lack of understanding because they did not get clarification during the original admission, their lack of participation in the original discharge plan, their lack of providing appropriate care and supports to this patient once the patient got home, and/or their lack of following up with appropriate services outpatient with the patient.

KelRN215, BSN, RN · Mar 15, 2015

Things happen at home all the time. It doesn't necessarily mean the discharge was unsafe or shouldn't have happened. People get UTIs all the time. The chance of someone developing a UTI is not a reason to keep them in the hospital, not by any stretch of the imagination. If the patient is unable to grasp teaching on something like checking blood sugars, a family member or other caregiver needs to step up to the plate to help. If no such person is available, the patient will need services at home or possibly placement in a subacute facility but I hardly think any hospital would keep such a patient indefinitely. If a patient is able to demonstrate the skills in the hospital and verbalizes her understanding of the teaching but then just decides not to check her sugars at home or to check but not treat, that's on her.

On the other hand, if a discharge plan is obviously unsafe, it behooves the Case Manager and the nurse who would be discharging the patient, to advocate for a safe plan. I'm on the other side- in home health- and there have been times when I've had to refuse a discharge from my end because it's obvious that it's not safe but the inpatient team is trying to push the patient out the door because of a bed crunch.

For example, recently I had a referral for a patient s/p stem cell transplant who was to be discharged with NG feeds, IV antibiotics, IV fluids and a whole slew of critical meds (cyclosporine, prednisone taper, morphine/ativan tapers). Parents were illiterate. They wanted to send the child home with once/day SN visits. This was obviously not a safe plan so I advocated for A) a referral to Medicaid's Case Management program which evaluates patients for private duty nursing hours and B) for the patient to remain hospitalized until she was weaned off morphine and ativan. Errors made with these medications because of the parents' inability to read had the potential to be fatal. The child ended up being discharged with BID PDN shifts instead of daily SN visits, which was much more appropriate for her situation.

Emilysmom11 · Mar 15, 2015

What is Medicaid case management program? Is It also available to the elderly who have no family or money?

KelRN215, BSN, RN · Mar 15, 2015

What is Medicaid case management program? Is It also available to the elderly who have no family or money?

In my state it's the program that evaluates patients for private duty nursing hours. An elderly person who simply has no family or money likely wouldn't qualify for private duty nursing- there needs to be a continuous skilled nursing need for that.

SummerGarden, BSN, MSN, RN · Mar 15, 2015

What is Medicaid case management program? Is It also available to the elderly who have no family or money?

What KelRN215 said is correct. Also, in my state, if a person needs too many hours (the state determines number of hours based upon level of functioning and medical needs an eligible candidate/patient gets), he/she likely does not need to be in the home setting any longer. In which case, a social worker should be involved to place the patient permanently in a SNF (most care) or Board and Care (just below SNF) or Assisted Living (more independence than the other two, but more care than the home setting).

KelRN215, BSN, RN · Mar 16, 2015

What KelRN215 said is correct. Also, in my state, if a person needs too many hours (the state determines number of hours based upon level of functioning and medical needs an eligible candidate/patient gets), he/she likely does not need to be in the home setting any longer. In which case, a social worker should be involved to place the patient permanently in a SNF (most care) or Board and Care (just below SNF) or Assisted Living (more independence than the other two, but more care than the home setting).

In my state, 112 hrs/week is the max number of PDN hours that Medicaid will give. 16 hrs/day. And that's reserved for the most complex of the complex patients- usually a continuously vented patient. If someone needs 24 hr care/if the family isn't capable of caring for them without a nurse, placement in a long term care facility is needed.

d'cm · Mar 17, 2015

I hate that phrase "unsafe discharge". Define unsafe. My experience is that it can mean whatever part or extent of their ass the user of the phrase feels needs covering. That's not to say there is no such thing. An unsafe discharge is one where the patient is lacking essential information, material or resources to survive or escape harm. I have seen two cases in my career where those essential items were lacking. I was sent by my employer to see a woman for reasons totally unrelated to her hospitalization who had recently been discharged home. She had a PICC line, open wound, uncontrolled diabetes and no physician. Her discharge instruction, signed by a case manager stated that her pcp had legally discharged her from his practice due to her non compliance. She had no idea what to do or where to turn. She died the next week. The other woman was a diabetic who kept having hypoglycemic episodes in the hospital. Upon discharge the patient nor her family were told to stop her diabetic meds. She suffered a prolonged event with subsequent severe brain damage. I doubt anyone was found culpable in either case.

i think it is important to keep in mind that discharge plans, like any other plans sometimes fail. There is nothing wrong with that as long as that possibility is understood and agreeable to the patient and its part of the plan that the patient knows what to do when things go wrong.