I was sent to do an admission in a LTC facility. The patient was having respiratory distress with stridor. HORRIBLE stridor!
Past history included Alzheimer's disease with dementia and Psychosis. The patient was treated twice in the last three months in a hospital for respiratiory failiure. The last discharge was on 4/29 and orders were for palliative care. Primary diagnosis was respiratory failure secondary to Alzheimer's Disease, dementia and pscychosis.
He had been evaluated at that time and deamed by the evaluating nurse that he was NOT hospice appropriate, The patient was on Prednisone in tapering doses. He finished the last dose over the weekend. Yesterday, he started with the resp distress and stridor, unresponsive, no eye opening response, no moaning, he did have a withdrawal response when you attempted to move his arms for a B/P, could not swallow, and had copious amount of secretions coming out of his mouth. I did not hear any rhonchi, although difficult to auscultate due to the stridor, but nevertheless, his lung sounds were what I called diminished but clear. Do to the drooling, I surmised the patient could not swallow or he would have swallowed the secretions. I admitted under general debility based on the rapid decline in condition and level of consciousness. He also had a HX of CAD and HTN. His B/P for me was a systolic below 90 and is diastolic was in the 40's. Heart rate was 100, respirations were 28.
Our clinical manager, who has not been in the field forever I might add, said to put him on inpatient level of care, which I felt he did not qualify, we had him under control before I left, with levisin (which the facility all ready had ordered) and one dose of Roxanol quieted his breathing. He was comfortable.
The medical director, agreed with me when I told him my findings, that Debility was teh best DX to use.
Now, I am being told he does not qualify for this DX because we do not have a BMI at 22 or below!! I thought that was for failure to thrive?
I understand nutrition is a big part of Debility, but with this rapid decline in LOC and his respiratory distress, wouldn't that be an appropriate DX? ALso, H&P's from the last two hosiptalizations for this visit the MD's all DX with Respiratory Failure.
I also felt that was the appropriate DX for him, Respiratory Failure, based on the DX from the hospital docs and it was on his community referral form. But was told NO, because there is no HISTORY of COPD????
I am not a new hospice nurse, but I am new with this company. Was I taught wrong? All of my "cheat sheets" and criteria information I used does not say a BMI has to be a deciding factor in a debility DX. BUt, nutrition is a factor, this man could no longer swallow! I did put that in my summary note as well. I put all my findings in my summary note to support the DX.
Can you help me out here? It would help me to understand this. I am totally baffled.
Specializes in Hospice and Palliative Care, Family NP.
Do you know which fiscal intermediary you are under? I could help you find the link to the latest guidelines online and then you can print it out and give it to her with the appropriate sections highlited.
It is Palmetto. That would be great! Thank you so much. :)
I tried that and was shot down. As I pointed out on the CRF and the H&P, he was hospitalized twice in two monts for Respiratory Failure. THe documentation clearly supports it. I was told, "there is no history of COPD" I was thinking to myself "WHAT THE????
WHere I worked before we had several Respiratory failure patients and I know one of them was never diagnosed with COPD.
I'm telling ya, I think this place is weird. Not one of these nurses has a year in hospice care yet! (I have four as a hospice case manager, did my community based nursing in hospice care, )The CPM has not been in the field in forever. They do not attend seminars to keep updated on the latest rules and symptom managment options. THey rely entirely on the corporate office to update them. You can't work in a bubble and keep on top of changes.
I take my CHPN in June, after that, I think I am going to look for another agency. This one seems almost comical to me. They make everything so dang hard and it's not.
How stupid! Respiratory failure does not have to be associated with COPD! Oh well, if they'd rather you use the debility unspecified diagnosis, then that is what I would do. We try not to use this diagnosis if we don't have to because it is a flag. Respiratory Failure is not a flag. What does the primary physician want to use as a diagnosis?
Specializes in Hospice and Palliative Care, Family NP.
How stupid! Respiratory failure does not have to be associated with COPD! Oh well, if they'd rather you use the debility unspecified diagnosis, then that is what I would do. We try not to use this diagnosis if we don't have to because it is a flag. Respiratory Failure is not a flag. What does the primary physician want to use as a diagnosis?
The primary doc is also our Medical Director. The doc in the hospital, a pulmonary specialist stated in his H&P, it was resp failure due to upper airway obstruction. They did a bronch and found mucus plugs. NOt sure the cause. His d/c instructions listed respiratory failure as primary DX.
I agree, Resp failure is the appropriate DX based on the presenting problems at the TWO ED visits in two months and the pproblems he was having during admission. My enitre documentation of my assessment was related to his decreased LOC and respiratory distress and stridor.
She has not asked me to sign another summary so, I am assuming it stayed with debility. Whatever! When I pointed out the H&P and hospital summary report, she said there was NO DOCUMENTATION TO SUPPORT RESP FAILURE because there was no history of COPD again. THere were no labs or other DX test to support the findings is what she said. I just kept my mouth shut and walked out of the office.
Specializes in Hospice and Palliative Care, Family NP.
Your medical director sounds like a piece of work! Good luck!
LOL He has only been the Medical Director for this agency since November. Guess who is "training" him of the ways of hospice? The PCM, the one who works in a bubble. She does not stay ahead of what is going on in hospice at all!
Ya know, when you don't get what you want, you gain experience. That is how I have to look at this situation or I would go bonkers. Just pray something else opens up in the area for hospice. Right now, this is all there is. :*(
Debility unspecified.. I am a 5yr vetran of hospice Nursing in Houston Tx all criteria meets dx. (BMI is for Aftt,Dementia,Alz amoung others) standards we use. Resp failure would work but not much to support.
Specializes in Hospice and Palliative Care, Family NP.
Debility unspecified.. I am a 5yr vetran of hospice Nursing in Houston Tx all criteria meets dx. (BMI is for Aftt,Dementia,Alz amoung others) standards we use. Resp failure would work but not much to support.
I agree BMI below 22 for Failure to Thrive, documentation of weight loss of 10% or more in a short period of time (6 months) for the others but BMI is not a necessary criteria.
Investigating the admission summary and criteria, this company added BMI to the other DX. I checked all my sources and went to CMS site, it does not have BMI for the others, just FTT
Specializes in Hospice and Palliative Care, Family NP.
I searched the CMS website for links to Palmetto's LCD's but I couldn't find one for debility there.
Thank you Aimee. I also searched and did not find one specific for debility. I am thinking that it would fall under a "general" diagnosis criteria but not sure.
Thank you Aimee. I also searched and did not find one specific for debility. I am thinking that it would fall under a "general" diagnosis criteria but not sure.
I appreciate your help though! Thank you!
We use debility unspecified interchangeably with general decline
CANRN, MSN, RN
238 Posts
It is Palmetto. That would be great! Thank you so much. :)