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Discussion

What would you think?

I recently moved from a vent unit to an assisted living. I work on a floor where the people are very fragile, the doctor is in at least twice a week and the nurse practitioner is in on the other days. These people are skilled care at ALF costs.

One of my patients has an order for an H&H monthly and procrit if the HCT is below 30. His HCt on 9/15 was 28.7 and I gave him the procrit. Over the last couple of weeks he has had increasing fatigue, shortness of breath with exertion, and his color has become extremely pale. I called his son in law, who is also his doctor, and asked if we could do another CBC. He agreed, and it came back with an H&H of 7.4 and 22. I spoke with the daughter, who works with her husband. She said she would bring the procrit in after 5 30 pm. She asked me to let the 3 - 11 nurse know. I gave all this information to the oncoming nurse and asked her to be sure the procrit was given. Saturday I came to work and the nurse giving report told me the procrit wasn't given. She didn't know why, and there was no documentation.

The doctor called me a short time later to be sure the medication had been given, he told me the procrit they had was expired and we were supposed to order the med from our pharmacy. The patient is 87, a DNR and didn't want to go to the hospital unless there was no other action to take. I told the doctor I would track the med, make sure it was given, and let him know when it was done. The medication was not ordered so I ordered it. Meanwhile, the 3 - 11 nurse left me a message saying she didn't know why I was confused, the daughter didn't bring the med so it wasn't given. She hadn't done any follow through because it wasn't necessary.

i had trouble getting pharmacy to STAT the med to me but I finally got it at 2 pm and gave it. The doctor called me back right after I gave it because he didn't want to wait any longer for the med. I let him know it was given, and he then ordered niferex for the patient.

My problem with this whole situation is that where I come from those labs and the petient's presentation were significant and required action. I gave the info to the 3 - 11 nurse and she did nothing, she didn't even document. If I hadn't heard from the doctor/family by 9 pm or so I would have called to find out what was going on. The doctor told me they were in and spoke with the 3 - 11 nurse so she knew what was going on. I feel like she neglected to provide appropriate care for our patient. Am I wrong?

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    It's an Assisted Living....not a subacute floor or a SNF. Unless it was a true emergency, it seemed things went as well as they could. I'd be more worried about that gentleman being able to live on his own without 24 hour care. With an H+H that low, he could easily get dizzy and fall.

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    I don't see how you could be wrong if you informed the 3-11 nurse about the order and the expected time of arrival. Sounds like she dropped the ball on that one!

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    You are completely right! Your post identifes a MAJOR problem in LTC care today: ALFs are not regulated and no one is watching them. Admission and discharge criteria are flexible and seldom defined. The ALF industry will be nailed with a few lawsuits and then they will have the regulations that SNFS have and we have ruined a good thing. The majority of ALFs are simply private pay nursing homes disguised as a lower level of care, who get to avoid OBRA and state regulations and "cherry pick" the better residents!

    I am speaking not as Nurse, but as I LNHA who competes with assisted livings for good residents.

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    "Good residents"?? Can you define your term?

    Assisted Livings Facilities are NOT SNFs and at least in this state, they are regulated, although nowhere nearly as much as we are in LTC.

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    I agree. You did the best you could and acted very prudently and professionally. And I also agree that there are ALF's out there that take anyone regardless of whether or not they can care for them...now not all do this...but some. The ALF's are not regulated in my state except by DSS and how often do they go there? Who knows. When I worked in LTC there would be folk that their families discharged to ALF because it was "much less expensive" and I did not know how in the world their family member would survive without 24 hour care as in the LTC...sad.

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