When should nursing homes be allowed to evict residents?

AdamantiteEnigma · Feb 28, 2016

The article is indeed interesting. I'll definitely side though with the folks who are stating there must be more to the story. Currently, I'm working in a rehab center which also houses a small amount of long term care residents (5% of the total beds in the building). I took this job to have something low key and consistent while pursuing the next rung in the ladder. This employer pays well, but the administrative end is absolutely and undeniably money hungry. Anyone who's worked rehab knows you shouldn't see these types of patients being admitted under normal circumstances:

1. Active chest tube with full orders, including wall suction (which doesn't exist in the building).

2. Resident with Scabies (active/diagnosed/but no TX).

3. 670 lb patient without DME. Who is also well over the weight limit of 350 per P&P.

4. Male and Female patients sharing adjoining bathrooms.

5. Ventricular Dementia patient with masturbation/inappropriate touching/aggressive behaviors.

***side note*** Number 5 on the list was put in a room with an adjoining bathroom with a Female resident who was Non English Speaking. Any guesses on what was discovered when the screaming started?***

6. Resident with TPN, when there is not RN coverage in house on NOCS.

7. Neutropenic resident actively receiving chemotherapy being placed in a semi private room with a roomate that is on contact precautions for having E-coli.

8. Double amputee with combative behaviors, elopement behaviors, and a chemical dependency issue.

9. Patient who was a MVA. Who, as it turns out, had not only an epic opiate addiction problem, but also epic behaviors when denied being able to receive Valium/Morphine SL/Percodan/Dilaudid every three hours.

10. Patient who screams all hours of the day save three, removes their dressings to dig in their wounds/dc's any and all lines and tubes at least 12 times a day.

Those were the top ten over the last 30 days.

This facility uses their marketing personnel as admissions representatives. And they only answer to corporate. Nursing is voiceless in these decisions. Then, when the patients have been accepted and are in house - they balk at nursing stating that we cannot manage these patients in this setting with current equipment/staffing/resources available. They do not send them back to the three hospitals of origin they have agreements with. Instead, they insist when we have to send someone out that we send them to a 'list' of hospitals. It turns out that this 'list' details hospitals that have refused to enter into an arrangement with their marketing er... I mean admissions(?) people.

So, in short, our otherwise lovely rehab center accepts anything and everything. And promptly dumps them back into the hospital system when things become unmanageable. But hey, I guess it's allright... we were paid for 2-4 days.

Scary stuff really.

The man in the article reminds me of some of these patients. It's all good, at least, until the camel's back breaks and things become unmanageable. Then it's dump and refuse to accept back time...

Hoosier_RN, MSN · Feb 28, 2016

The article is indeed interesting. I'll definitely side though with the folks who are stating there must be more to the story. Currently, I'm working in a rehab center which also houses a small amount of long term care residents (5% of the total beds in the building). I took this job to have something low key and consistent while pursuing the next rung in the ladder. This employer pays well, but the administrative end is absolutely and undeniably money hungry. Anyone who's worked rehab knows you shouldn't see these types of patients being admitted under normal circumstances:
1. Active chest tube with full orders, including wall suction (which doesn't exist in the building).
2. Resident with Scabies (active/diagnosed/but no TX).
3. 670 lb patient without DME. Who is also well over the weight limit of 350 per P&P.
4. Male and Female patients sharing adjoining bathrooms.
5. Ventricular Dementia patient with masturbation/inappropriate touching/aggressive behaviors.
***side note*** Number 5 on the list was put in a room with an adjoining bathroom with a Female resident who was Non English Speaking. Any guesses on what was discovered when the screaming started?***
6. Resident with TPN, when there is not RN coverage in house on NOCS.
7. Neutropenic resident actively receiving chemotherapy being placed in a semi private room with a roomate that is on contact precautions for having E-coli.
8. Double amputee with combative behaviors, elopement behaviors, and a chemical dependency issue.
9. Patient who was a MVA. Who, as it turns out, had not only an epic opiate addiction problem, but also epic behaviors when denied being able to receive Valium/Morphine SL/Percodan/Dilaudid every three hours.
10. Patient who screams all hours of the day save three, removes their dressings to dig in their wounds/dc's any and all lines and tubes at least 12 times a day.
Those were the top ten over the last 30 days.
This facility uses their marketing personnel as admissions representatives. And they only answer to corporate. Nursing is voiceless in these decisions. Then, when the patients have been accepted and are in house - they balk at nursing stating that we cannot manage these patients in this setting with current equipment/staffing/resources available. They do not send them back to the three hospitals of origin they have agreements with. Instead, they insist when we have to send someone out that we send them to a 'list' of hospitals. It turns out that this 'list' details hospitals that have refused to enter into an arrangement with their marketing er... I mean admissions(?) people.
So, in short, our otherwise lovely rehab center accepts anything and everything. And promptly dumps them back into the hospital system when things become unmanageable. But hey, I guess it's allright... we were paid for 2-4 days.
Scary stuff really.
The man in the article reminds me of some of these patients. It's all good, at least, until the camel's back breaks and things become unmanageable. Then it's dump and refuse to accept back time...

Sounds like a facility in my area. It's a nationwide group, so its possible. I think state hospitals should come back and be better managed as a PP stated. That's where the behaviors need to be. And LTACH for the others.

My current employer recently took on a case that was way beyond its scope because they thought 'we have RNinIN, and she's worked ICU'. Really, they told me that. I told them, #1-not appropriate equipped for care, #2-I'm not there 24/7, #3-while I could train coworkers for some situations, not every little thing could be anticipated, and I was not going to be tied to my phone 24/7 at their beck and call, #4-what if I had emergency, had to be off long term or decided to quit. They never considered those things. It was a bad outcome, but luckily so far no legal issues. But for our person who accepts admissions, I hope it was a lesson learned. I hope...

CryssyD · Feb 28, 2016

There is a long-term geriatric psychiatric facility not too far from where I live. It is state-run, no doubt at great expense and surely it runs perpetually in the red. My family, who have lived here for decades, tell me the state has been trying to close it for 20 years. Trouble is, there is nowhere else for these people to go. No other LTC facilities want them; sometimes they just don't want to provide the expensive, time-consuming care, sometimes they really aren't able to provide the care and supervision the residents need. So the state keeps the place going, because it has to.

Sadly, I wish every state had several of these places--homes of last resort for the poor old folks that no one else wants.

Just had an interesting idea, though. When our long-term pediatric sub-acute unit finally closed (since it was distinctly unprofitable), several of the kids went to approved homes for foster care; one couple had actually adopted six or seven trach and vent-dependent kids. They got donations of clothes and toys from the community, the nearest pediatrician came to the house on a regular basis, and the kids were cared for by an RT and several nurses 24/7. Admittedly, it's much, much easier to place cute, barely-mobile children than it would be to place very sick, dual-diagnosis adults. Most states provide a stipend to families who take in foster children--no doubt it's cheaper and (usually) healthier than keeping them in institutions; maybe states could try to start similar programs for hard-to-place adults, with appropriate nursing care and supervision. I'm sure it would be expensive, but I can't even begin to calculate whether keeping people in hospital beds for months would be better or worse--I don't have the background in healthcare finances to know how to work those numbers.

I know it's hard enough to place troubled kids, let alone adults. But it's the only option I can think of other than a state-run institution, like that one near me. No matter how badly they want to close it, they just can't do it. Nor should they.

Nurse Leigh · Feb 28, 2016

Something that has been mentioned here and in another thread have me curious about registered sex offenders.

How are they placed if the facilities are too close to schools or if there are minors as residents (are there ltachs that take only peds cases?) What about children who come to visit their loved ones and there is a convicted child predator down the hall?

Sounds like a cluster all around.

CryssyD · Feb 28, 2016

Also near where I live: a residential facility for civilly-committed convicted sex offenders who have served their criminal sentences.

It's a real problem that sex offenders have such a hard time finding places to live, let alone places to work so they can support themselves. I haven't worked there, but I know a couple people who have, and they say the place is a horror show. A big problem is that, no matter how badly the residents are acting out, they can neither be kicked out (nowhere for them to go) nor really punished or sanctioned in any meaningful way. Their possessions and rights cannot be taken away, and they can't be locked up. In the event of an assault, all the staff can do is call the cops--they are afraid to even restrain them, lest they be accused of abuse. So I have heard stories (and they're only anecdotes--I can't vouch for their veracity) of regular masturbation and other inappropriate sexual behaviors, groping, rape of other residents and of staff, and assaults.

I work in a prison, and, although I have limited sympathy for sex offenders, the fact of the matter is that once they've served their time they don't deserve to be thrown out into the street to live like animals. So we need places like the one in my area. It's just such a logistical nightmare, since they are sometimes very dangerous people but they have to be treated with kid gloves because they still have all their rights, are lawyered up after all their time in prison, and know how to take advantage of the system. It's a mess.

I have no idea how they manage stuff like visitation. The institution itself is in a rural area, and it's right next to a prison. The residents are confined to a fenced enclosure, as they are technically committed so their freedom to leave is restricted. However, within the facility itself it sounds like no one is terribly safe.

TriciaJ, RN · Feb 28, 2016

The article is indeed interesting. I'll definitely side though with the folks who are stating there must be more to the story. Currently, I'm working in a rehab center which also houses a small amount of long term care residents (5% of the total beds in the building). I took this job to have something low key and consistent while pursuing the next rung in the ladder. This employer pays well, but the administrative end is absolutely and undeniably money hungry. Anyone who's worked rehab knows you shouldn't see these types of patients being admitted under normal circumstances:
1. Active chest tube with full orders, including wall suction (which doesn't exist in the building).
2. Resident with Scabies (active/diagnosed/but no TX).
3. 670 lb patient without DME. Who is also well over the weight limit of 350 per P&P.
4. Male and Female patients sharing adjoining bathrooms.
5. Ventricular Dementia patient with masturbation/inappropriate touching/aggressive behaviors.
***side note*** Number 5 on the list was put in a room with an adjoining bathroom with a Female resident who was Non English Speaking. Any guesses on what was discovered when the screaming started?***
6. Resident with TPN, when there is not RN coverage in house on NOCS.
7. Neutropenic resident actively receiving chemotherapy being placed in a semi private room with a roomate that is on contact precautions for having E-coli.
8. Double amputee with combative behaviors, elopement behaviors, and a chemical dependency issue.
9. Patient who was a MVA. Who, as it turns out, had not only an epic opiate addiction problem, but also epic behaviors when denied being able to receive Valium/Morphine SL/Percodan/Dilaudid every three hours.
10. Patient who screams all hours of the day save three, removes their dressings to dig in their wounds/dc's any and all lines and tubes at least 12 times a day.
Those were the top ten over the last 30 days.
This facility uses their marketing personnel as admissions representatives. And they only answer to corporate. Nursing is voiceless in these decisions. Then, when the patients have been accepted and are in house - they balk at nursing stating that we cannot manage these patients in this setting with current equipment/staffing/resources available. They do not send them back to the three hospitals of origin they have agreements with. Instead, they insist when we have to send someone out that we send them to a 'list' of hospitals. It turns out that this 'list' details hospitals that have refused to enter into an arrangement with their marketing er... I mean admissions(?) people.
So, in short, our otherwise lovely rehab center accepts anything and everything. And promptly dumps them back into the hospital system when things become unmanageable. But hey, I guess it's allright... we were paid for 2-4 days.
Scary stuff really.
The man in the article reminds me of some of these patients. It's all good, at least, until the camel's back breaks and things become unmanageable. Then it's dump and refuse to accept back time...

Holy crap, Batman! I would have run away screaming at about #7 from the W.T.F. Rehab Center. You are a better nurse than I.

allnurses Guide · Feb 29, 2016

When I worked the floor it was not at all uncommon to get patients that nursing homes would refuse to accept back. There were some who we had to start searching in different counties for care, as they had earned themselves quite a reputation in the immediate area, either due to demanding family wanting unreasonable accommodation (ie super expensive specialty beds, certain types of linen, diets, schedules, etc), family circumventing medical orders (such as bringing in excessive amounts of off plan food to diabetics with ESRD and CHF) and the like. It was sometimes due to abusiveness on the part of the resident toward staff, verbal or physical. And sometimes it was simply due to a level of care that was so over the top that the facility would have had to hire extra staff just to care for this one individual. Usually it was a combination of all of the above to varying degrees.

We had one poor soul who weighed in the 800 lb range, bilateral BKA, ESRD, bed bound, incontinent, chronic diarrhea, young, anxious, abusive to staff, mother full of guilt and also abusive to staff. This patient refused care and would strike out physically at any who attempted to care for her. She would come back to us at the hospital every week to week and a half from wherever we managed to get her placed. It took eight people to turn her safely, which we never had and I imagine the nursing homes had even fewer. She would refuse use of a lift, which also never worked well because she was constantly soiled. Of course, she rapidly developed unstageable wounds, which required wound care several times daily, which she also wanted to refuse and would hit, scratch, bite, scream, cry. The smell from her was amazing. She passed away eventually from sepsis, but was in a never ending game of hot potato because nobody wanted her, including, of course, her own family. They were happy to bring her forbidden food items and go to battle for her against the staff wherever she was but not to participate in her care. She had C.Diff, MRSA, VRE, you name it. Her care was intensive, laborious, malodorous, painful from being physically abused during it, emotionally distressing from ethical conundrums in every direction. The floors took turns hosting her to give staff a break. She eventually passed away from massive sepsis. Horrible, horrible situation and not as uncommon as one would think. In the end, she had to be sent OUT OF STATE to find a place willing to take her!

Families don't plan for what to do with their elderly and/or sick. That is the bottom line. These are conversations as a country we just pretend we don't need to have and then pass the buck on blame.

lepanto · May 16, 2016

The families that scream the loudest about their relative being evicted are the ones that refused to allow that relative to be appropriately medicated for their behavior issues.

TheCommuter, BSN, RN · May 16, 2016

Moved to the LTC forum.

NutmeggeRN, BSN · May 20, 2016

There is ALWAYS more to the story as we all know.

One issue I see is admitting a patient you are not staffed to care for ( $$$ ). But the family said they need just a little more help than can provide at home. Yup, sure... They are incontinent of everything, combative, cannot walk without assistance, cannot do anything in the way of personal care. But ayyup, sure we can take them into Assisted Living. "Oh, you want private duty?, WE can do that!) until there are call outs, vacations etc. Then who ever is left standing on the floor is to care for the regular list of residents and babysit poppa as well. Why? Because adm could only see the higher daily rate going to an outside agency and THAT is certainly unacceptable!

Sort of off topic I know, but it all plays into the issue.