Why do people don't like it when we send resident out?

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I've been working on a long term care facility for a month now, on the 3rd shift. Recently, a diabetic resident had a rapid decline in condition. Moments earlier, I happened to pass by her room when she was about to go to the bathroom, had a small talk and assisted her. About 10 minutes after, when I was about to give her meds, CNA rushed to the station and reported her vital signs (BP 200/140, Temp 103, Pulse 90, RR 22) and that the resident looked like she was in distress. So I went to her room, did a quick assessment and she told me he felt cold. I checked his blood sugar, it was 300+. I called two of her doctors but did not get a call back, one went straight to voicemail and one had to be paged. After 5 minutes, I called again and still got no call back. All the while, my resident's vitals just kept getting worse, she was dazed and started vomiting small amount of blood. One of the old nurse told me to wait for the doctor and keep her here but my gut told me otherwise and call 911, and so I did. I was worried she might go into a CVA. So she was sent out, I informed the family and finally got a call back from the MD like 45 minutes after. I called the hospital and asked what admitting diagnosis was and was told it's fever but they're still evaluating her. When the day nurse knew about this, she was like "you called 911 for fever?" and got a "pfft" face. ***** What am I supposed to do? Wait for an eternity for a doctor's order? They also always check if someone was sent out first thing in the morning. What I don't get is why ltc people seem to not like it when a resident is sent out? and when am I supposed to call 911 without doctor's order? I used to love coming to work but now that I get to see how politics, bureaucracy and "business" plays out, I can't wait to pack up and leave.

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Specializes in LTC,Hospice/palliative care,acute care.

Couldn't you freaking scream!!! Every doc I work with would have sent her out via 911 as soon as the heard the words " bloody vomit" and probably would not have stayed on the phone long enough to hear the whole set of vitals .......

That's the thing in LTC, someone is always looking over your shoulder, second guessing you. Practice saying "Yes, I understand what you are saying but you were not here so I made this decision based on MY assessment at the time" and walk away. I work with some really territorial nurses, they seem to believe no other staff members can have a valid opinion or are competent enough to care for their residents when they are off. Last I heard we were a team....You really need to be confident in your skills and strong willed to get along and you need to be able to shrug off those comments.It is not easy,I feel your pain.

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You did the right thing for the patient by calling 911 to get her to the ER. Don't worry about what other nurses say. If you didn't call 911 the same people probably would've said " well you should have called 911!" Sometimes you are darned if you do and darned if you don't.

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Specializes in Geriatrics, Transplant, Education.

Don't sweat it, you definitely did the right thing!!

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Specializes in NICU, PICU, Transport, L&D, Hospice.

ask that this be a topic of discussion at the next staff meeting.

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Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.

Sometimes, in our field I think we have to make the choice between taking an action that our bosses/coworkers don't like or taking an action that protects our license. It sounds like you used your nursing judgement in a manner that protected both you and your resident. I think you did the right thing. ((Hugs to you)))) during this turn of events.

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Specializes in retired LTC.

And did you ever notice how hung up admin gets about the hospital's 'time of admit'??? It all has to do with who will get paid for day of admission and day of discharge. And the diagnosis? I'm surprised they didn't add UTI with the fever dx! Your pt did have other significant S&S.

Sounds like you tried to do everything right. It's just that the NH doesn't get paid for empty beds and with mandated bed holds, there is significant loss of income when expenses still continue. It's a disservice to NHs that the real diagnoses (why we send them out) aren't correctly reflected in the data. Makes us look stupid (hence the comment from the day nurse). Oh, and esp with the attitude of the ambulance/EMT squad to boot!

Just know also that there is some program that reviews and evaluates hospitals on their admissions & discharges, esp for the 'frequent flyers'. Again money is in the picture as the monitoring considers if the hospital discharged a pt too early AEB the pt returning to the hosp too soon with same problems. It affects the hosp's review and can *po* the hosp big time! And if they get *po'd* enough, they can start diverting their discharges (our admissions) to other facilities. That is SERIOUS big stuff!!

NHs are becoming more high-skilled techy and there are diagnoses that should be able to be managed within the NH. For example, fever with UTI should be able to be managed at the NH - like why can't we manage fever/UTI?!? Our reputation is on the line and it becomes a marketing issue.

In all my experience in LTC, I really don't regret or question any of my decisions to send someone out. But I was fortunate that my decisions were appropriate. I did have to discuss many of my transfers-out in the morning many times with admin.

It's just the nature of LTC today that staff are on the front-firing line. Just no pleasing everyone. It is so frustrating even for those of us antique-ones who know the system; I really feel for you newbies who are just getting your feet wet! Just stay with it. Other posters are saying the same thing. It is NOT just your facility - so the problem will be out there no matter where you go.

Good luck and hugs.

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The bp with temp would have me concerned..possibly trying to get the fever down might have reduced the BP so Might have tried that first. I missed the part of vomiting blood. I would have sent out too

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Specializes in Case Management, LTC,Rehab.

I second what Amolucia said...I work in admissions and its all about the money at the end of the day. You did the right choice. Don't second guess yourself and always be sure and confident about your decisions.

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Specializes in retired LTC.

My motto for my practicing has always been 'when in doubt, err on the safe side'. OP practiced being safe for the pt.

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Specializes in Gerontology, Med surg, Home Health.

You might not like how business works but we all work in a business. True,ours is the business of taking care of people, but it's a business nonetheless. How do you think your salary is paid? Do you realize that Medicaid does NOT pay the cost of a resident? In Massachusetts, we lose $38 dollars for every Medicaid patient every day. I have 112 Medicaid residents...multiply that by 365 days a year...it's hundreds of thousands of dollars.

If you can treat residents in house, your facility will get "good" admissions. Facilities that can't manage complex residents won't survive.

Given what was said in the original post. I wouldn't necessarily have sent the person out. Fevers can be managed. A blood sugar of 300 isn't that alarming. If I couldn't reach her doctor I would have called the medical director for orders. A little blood in vomit might look bad, but it doesn't always spell doom.

We weren't there so our assessments are only guess work. We spend a lot of time figuring out how to take care of our residents. Of course there are times we have to send someone out but it's usually after we've tried everything possible.

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yes, the big thing here is the amount of blood....could have been oral irritation, even nasal....treat the other things and monitor....

You might not like how business works but we all work in a business. True,ours is the business of taking care of people, but it's a business nonetheless. How do you think your salary is paid? Do you realize that Medicaid does NOT pay the cost of a resident? In Massachusetts, we lose $38 dollars for every Medicaid patient every day. I have 112 Medicaid residents...multiply that by 365 days a year...it's hundreds of thousands of dollars.

If you can treat residents in house, your facility will get "good" admissions. Facilities that can't manage complex residents won't survive.

Given what was said in the original post. I wouldn't necessarily have sent the person out. Fevers can be managed. A blood sugar of 300 isn't that alarming. If I couldn't reach her doctor I would have called the medical director for orders. A little blood in vomit might look bad, but it doesn't always spell doom.

We weren't there so our assessments are only guess work. We spend a lot of time figuring out how to take care of our residents. Of course there are times we have to send someone out but it's usually after we've tried everything possible.

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