Nursing Home MAR’s sent to the ED with all times removed: A new and horrible trend

There is a new, intentional and horrible trend in nursing home transfers to the ED, and it’s not the patients. It’s the records that come with them, or more specifically those that don’t.  Allow me to explain.

The patient is sent with a chief complaint, a lot of weeks-to-month-old labs and a medication list, but all the administration times have been cut off from their typed MAR’s. (MAR stands for Medication Administration Record, and is the only written record of which patient got what medicine, when). Got that? A patient sent from a nursing home comes into the ED with a list of their medications, but the list has the times and dates of administration removed. Intentionally. They come in with little strips of paper with the medication names and doses, but the administration times are on the paper that wasn’t sent. That’s not an accident. Definitely not.

When they’re my patients I now ask for a faxing of the patient’s MAR from the nursing home with the removed information included, because it is, you know, part of the medical record, and may well be useful in the diagnosis and treatment of the patient. A patient often sent in with “AMS” (altered mental status) as the one-line explanation for the transfer, and the patient is on several (usually more than a dozen) medications, at least a third of which could cause an altered mental status. It would, in that case, be nice to know if they got their regular, let alone their PRN (as needed) sedative(s), as well as all their other medications.

The kicker is, since I cannot determine when their medications were administered (because the times were cut off of the copies sent to the ED), a lot of very useful information is now denied to me, the ED physician, and then most likely to the admitting team, since none of us can say who got what medication, and cannot account for their altered mental status. (I’m using AMS as the example here, but there are other complaints that could be medication related).

This intentional removal has happened often enough ( from different nursing homes and at different ED’s) that it’s clearly part of an organized effort on the part of Nursing Homes. I’m at a loss to think of a single innocent reason why this practice would have started. When I’ve called personally to have the information faxed (for patient care, the reason they sent the patient to the ED) the Nursing Home nurses routinely say that “It’s policy”, and then sometimes send the information, and sometimes they don’t.

This is outrageous. A chronically ill patient is sent to a higher level of care for an acute problem, and without a complete information base; but not just that, information crucial to the care of the patient that’s being intentionally withheld.

It is a situation that makes me, frankly, nuts. When did intentionally withholding critical patient care information become acceptable? Seriously, have these people not learned from history? The coverup is always, always worse than the crime, and is looked upon less favorably and punished more severely that any original offense. You could ask Nixon, but he’s dead.

Send me all the info you have, and our patient will live or die based on their problem(s); withhold information I need, and it’s on you, Nursing Home nurses.

(Nursing homes that engage in this awful practice, beware: I now document ‘Patient sent to ED with MAR with times removed’ on my charts, and you’re kidding yourselves if you think this kind of obfuscation will get you out of a medicolegal jam.  Were I a plaintiff’s attorney (and I’m not) I’d be at least somewhat interested in what was withheld, by whom, and why. Still seem like a good practice?).


Comments

  1. rather than send me to a nursing home, shoot me. i’ll pay for the bullet.

  2. TheNewGuy says:

    rather than send me to a nursing home, shoot me. i’ll pay for the bullet.

    Right there next to you… and it’s not just medical people who say that. My mother is an ex-social-worker who has stated up-front that she will never go to a nursing home, whether I have anything to say about it or not, and she owns guns.

    The unspeakable horrors I’ve seen arrive from ECFs are among my most vivid medical memories.

  3. AMEN

    And how about sending their DNR paperwork and advaced directive. That information is helpful too. Yes? And how about NOT sending the patient if they just need a bandaid or some neosporin for an abrasion. There is a lot of 2500$ bandaids being administered if you consider the ER visit and ambulance transport.

  4. Document that the MAR didn’t have the times — and also document that you called and requested it. You don’t want to show that you knew the times were important without also showing that you attempted to get them.

  5. So what do you do if the patient is taking high-dose opioids or an antiarrythmic? You can’t just guess about administering those.

    What does Medicare say about medical records and transfers? Sending a well-documented complaint to their fraud investigators might get results.

  6. Karen Vradelis, RN says:

    Sounding off for Nursing Homes:

    Give the staff a break. Not all nursing homes are hell-holes – and I challenge each and every one of you to spend one day on our halls and not come away with a new appreciation for the resources you have available to you in your hospital and how well we do without. Of course, we get the added benefit of being able to properly get to know our patients and (usually) come to love them like our own families. Maybe even more than our own families.

    Legally speaking – we’ve been advised NOT to send copies of the actual MAR – which contain up to a whole month’s worth of documentation of the medications we dole out day after day after day. Too many Hot Shot ER jockeys with ‘agendas’ against nursing home nurses have tried to use them as ‘proof’ of just how incompetent we are. An entire nursing home MAR is simply not necessary in regards to the emergent condition that we have sent our resident to you to treat. I challenge YOU to be comfortable enough with your skills and competence to send a copy of everything you’ve done for the past month to an unknown medical professional across town. Especially one who’s already hostile to you and your professionism.

    And trust me – we do NOT send our residents to the hospital for band-aids. The cost of the ambulance trip is billed directly to the nursing home (not the resident or their family). Unlike the hospital – our fee scale is NOT limitless and in turn, our income base would quickly become exhausted by trips to the ED for bandaids. (The owner/administrator frequently reminds us that unnecessary expenditures directly affect OUR paycheck). Further – when we send someone out – we have to take the time to put together the paperwork, write up a summary for ungrateful ER personnel about why we’re sending them, and what we’ve tried first. Not to mention dealing with Ass-Hat ambulance personnel who resent ‘wasting’ their valuable time and resources on boring ‘old people who are only going to die anyway’. (We have had 911 refuse to transport simply because some of their personnel were on another call and they didn’t want to tie up their only remaining ambulance on an old person – even a very sick old person. Double that if said old person has a DNR/DNI in place. I personally got chewed out by one particular jerk after doing chest compressions on hopeless ‘Full Code’ (breaking every rib in the poor thing’s body) for the better part of 20 minutes — because we ‘didn’t know how to properly educate residents/families on DNR/DNI.’ I’m sorry, sir, but they were counselled and insisted that they wanted us to try EVERYTHING possible.) and still take care of our other 20 to 25 residents, who all needed something an hour ago… AND their damn families who all want you to treat “Mom” or “Dad” like they are the only person staying there.

    I suspect what you got was a copy of the ‘physician order sheet’ – which is the essentially the “MAR” without the part that has the actual initials of the administrations of the medications. Sometimes we have to improvise when these aren’t available and we make copies of the actual MAR with the signatures blocked out. It’s better than nothing at all (or worse something scribbled by hand in the rush of the moment)

    Someday you can listen to me rant about the ‘Fairy Tales’ (better known as FL-2 – a federal form that’s SUPPOSED TO have a list of the potential dischargee’s diagnoses, medications, and care needs), which hospitals send us when preparing to dump discharge their patients when they need a bed… Or the ‘new admit’ we got from a hospital who was leaking feces from a hernia repair even before he/she reached our doorstep.

    Cripes. Just make a phone call and (politely and respectfully) ask for the information you need.

  7. Methinks she protesteth too much…

    I’m more or less with GD on this one. I seem to be lucky to find any MAR, let alone one that has any dates on it. Yes, I could call for the MAR, I could call for information about why the patient was sent out, ie, what was observed, rather than second or older hand information from EMS — ever played telephone? Same process of misinformation.
    And I suppose maybe the ED could expect for the ECF to call for an appointment to have their patient evaluated, when it’s convenient.

  8. Kudos to Karen Vradelis.

    I think ERs (& physicians outside of long-term care in general) give ECFs a bad rap. It is very difficult to appreciate the often extreme lengths the staff & ECF doctors go in trying to defer a transfer to the hospital. This might even involve IV fluids, IV antibiotics, emergent calls to family to explain futility, etc.
    But in the end, you also don’t want to be sued by someone claiming you did too little too late. I once was threated with a lawsuit on a 95-yr-old man with advanced dementia & prostate cancer, who aspirated & ultimately was sent out to the ER as the family was in total denial about the dementia, & he was full code despite multiple team meetings involving nurses, social workers, medical staff, & even clergy – imagine if i “slow-coded” the guy at the nursing home? i’d be sitting in court now instead of reading this blog.

    Working in a nursing home requires its own set of skills, no more or less valuable than that involving being an ER doc. The population is inherently sick & fragile – compared to my local hospital med-surg floors, my nursing homes floors are actually MORE acute overall.

    I have worked in an ER – gruntdoc, have you worked in a nursing home? If you had, you’d know about the demented screamers, difficult daughters, frequent fallers, and bedsores from prolonged hospitalization that often heal eventually (despite immobile patients). All of these things require hard work & tolerance (not to mention the least appreciated people – the CNAs – make around minimum wage for doing stuff a garbageman wouldn’t touch for any amount of money). All of this is done while families of patients get messages in the hospital (everyone from the idiot psych intern in July to the seasoned ER attending) about what a terrible job we’re doing, we don’t know what we’re doing, your mother’s being neglected, etc. That furthers the family’s misunderstanding that bad outcomes just happen sometimes – it’s not always possible to save a 95-yr-old with a multilobar pneumonia, even WITH hospitalization & intubation & ICU stay & pressors. That leads to lawsuits, which leads to quicker hospitalization on future similar cases, which overloads ECFs & ERs alike, which runs down staff and causes shortcuts like not sending the MAR. get it?

    With the aging of the baby boomers, just imagine how many more “train wrecks” would find their way to the ER without nursing homes.

  9. Karen Vradelis, RN says:

    Let’s blame the EMS attendants… I’ve personally sent all required paperwork with residents (including our standard “this is why we’re sending them to you” form and Day Glow Yellow DNR/DNI form) only to get numerous phone calls up to days later to fax paperwork (again and again) to this person or that person… which I do immediately without (too much) grumbling.

    I think it’s a grand idea to have the nursing home nurse call the ED and give a detailed report – I, like most nursing home nurses I know, know my residents and their medical conditions like better than my own grandparents’… but even if you (or anyone, for that matter) was waiting patiently by the phone for my call while dear little Mr. or Mrs. Jones is en route, I can just imagine the stunned silence on the other end, and I’d bet about 5 cents that the report would get misplaced before the resident was through triage. Hell… I’d love to sit by the phone and wait for you to call me… but alas… sitting around, ‘not working’, is rather frowned upon at my facility, as I’m sure it is in your ED.

    By the way… I worked agency (also at NH’s) for many years before my current permanent job at a lot of Nursing Homes – big/small/private/county-run/big chain/corporation/hell-hole/”Donald Trump” – and ALL of them had policies in place to send copies of medications, DNR/DNI forms, and a brief statement of V/S and last administered meds – particularly narcs/PRNs. It’s practically standard practice. I’m REALLY surprised y’all are receiving ED patients without said information so routinely… One local hospital even has a special form we are to fill out for people we send to them… (our own form is more complete)… your PR/community relations people need to do some work on setting up better communication with your local nursing homes.

  10. I’ve never seen a NH remove med times from a MAR.

    A facility-transfer report and associated paperwork should be as complete as is reasonably possible. I’d be more worried about the legal ramifications of deliberately withholding information from a physician/nurse who is to care for them. Not just forgetting to include a med list, including it and doctoring it with the intent to withhold information that, if known, would likely benefit the patient. That’s a big no-no.

    PS: The crappiest job I ever had was a CNA at a nursing home. Extremely hard work. I got 13 demented, variably immobile elderly people cleaned, dressed, teeth brushed, diapers changed, up to the toilet, and in their wheelchairs (afterwhich it was my responsibility to assemble an a la carte breakfast) in 2 hours then rotated them all through the bathroom again. At least I got medical though. I thought I’d be able to interact on a personal level with elderly people but, no, I mainly just did peri-care.

  11. Working in Nursing Homes is hard. Given. Everyone’s job is hard in some way.

    That in NO WAY excuses intentionally sending incomplete information about a patient you tell me you care so much about but would rather try some ill-considered CYA move. (A move that draws a whole lot more attention to you than sending the information). I shouldn’t have to call to get information I already should have (and have been refused when I call). In fact, it takes more effort to deliberately remove that information than it would to just send it. It’s the patients’ record, not yours.

    Frankly, defending that practice should be embarrassing to you.

  12. The Hospitalists I am working with are starting to get the suspicion that some of the nursing homes are sending us patients who we thought were DNR, but there is no record (they think they’ve been tearing them up) – something about the nursing home not getting paid if they 911 a patient out and they’re a DNR…

    is pretty scary

  13. why is it that when someone makes a general statement about something, in this case a continuing and willfull malpractice by a nursing home in gruntdoc’s area, that someone who clearly does not work at that particular nursing home takes personal offense?

    we have 8 nursing homes in our area. i would never send any of my family members to any one of them. there are two docs who cover about 1000 patients and i can never get them on the phone. i have people come in with open fractures which happened three days prior. i have people with huge decubiti which have never been listed on the nursing home problem list. i code people with DNR orders who, according to the nursing home, are not DNR.

    at least where i live. nursing homes are where tired nurses go to end their careers and where poor souls go to dwindle and die. if you are a nurse who does a great job in a nursing home environment then clearly this post was not directed at you.

  14. I’ve seen things that occur in nursing homes and assisted living centers that make me agree with the above—if I ever have to go to one, I’d rather be shot out back.

    But don’t worry about the patients having narcotics on board. Those are all stolen by staff and the patients never get them anyway. (You think I’m kidding but I’m not.)

  15. A Paramedic who knows says:

    I’m sorry but that RN Karen obviously is protesting too loudly, and then on top of that blaming EMS! I’m sorry but I’m from a large city with over 2 dozen nursing homes and there is only 1 that I would ever even let my worst enemy stay in! The things I have taken out that the “nurse” has no clue of how serious it is, or that it should of been called in at 7am when their sat was 70, not at 10pm when they are now unresponsive and they say it’s just low sat! Oh and knowing your patients?! Yea right, I’m sorry but every time I get a Pt and I need to get a report all I ever hear is “It’s not my patient”, “I just came on”, ” I was on vacation” and no one knows anything! granted I know a lot of nurses do try, but they are greatly understaffed and if you calculate how much time they have to spend handing out meds they see a Pt for an avg. of 8 minutes a shift.

    I myself have had to work several code that should not have been worked because the “nurse” told me that the Pt was a full code, only to have the Pts family yell at me cause he wasn’t and there was no MOLST or DNR form to be found. Just yesterday I almost had to work a code because the “nurse” didn’t give me the proper information on the Pt and had “no clue what his medical history was”. I’m sorry but these places should be more closely regulated and enforced from a set of rule, or better yet, laws.

    *Nurse is in quotations because a lot of these places don’t have an RN but an LPN and even an RN won’t call them a nurse.

  16. The real problem here is simple: Bureaucratic Policy Collision.

    While it’s somewhat fun to watch people cast aspersions on the others in the system, in all seriousness, both Dr. Grunt and Nurse Vradelis have very good points.

    It’s been entertaining to watch the sudden increase in finger-pointing among the online medical community the past few weeks (I first noticed it about 6 months ago with “Dr. Crippen” and the midwife brouhaha.) As entertaining as it is, I’m saddened by what to me is getting to be a sad fact of existance: “Red Tape” is everywhere and the obstinant genuflection to the local rules without regard to how they interact with entities outside the bureacracy are getting progressively worse.

    The more rules and requirements are enacted – in the name and spirit of making things easier and to facilitate cooperation – the more the people they address “work to rule” (or are directed to) and the worse things get.

    And everybody involved will insist that their rules and procedures are obviously right, and the other bureaucracy doesn’t know their ass from a hole in the wall.

    The person in the middle – in this case the patient and their family – is the one who ends up losing, every time.

  17. Having worked as a paramedic in not one, but two large urban areas, Karen Vradelis has a point. Not about blaming “EMS attendants” (which term went out of use a couple decades ago) but that not all nursing homes are bad. I have seen two that are actually adequately staffed with qualified nurses (RNs–Real Nurses) and a supporting team. I have even seen and met a physician rounding at one of those two.

    Of course, those two homes stand out as the exception among the 60+ other warehouses in the same areas. There may be more than those two, but I doubt it. Even the best Homes occasionally need to call EMS for an emergency. We know which these homes are because we don’t get called there for non-emergencies, they don’t smell of old urine, and we see more than one person with “RN” behind their name.

    The lack of information about the patients that A Paramedic Who Knows mentions is rampant in most of the other facilities as is the questionable state of the employees’ medical training. These employees cannot differentiate between emergent, urgent, and routine situations. Granted that emergencies do happen even under skilled care. EMS generally doesn’t have a problem with taking these calls. (The “E” in EMS stands for “Emergency” after all). The ones that get us are the inappropriate use (abuse) of our resources.

    Emergent conditions are those that are likely to result in death or disability if not treated quickly. Certainly a hip fracture may result in death or disability, but if we are not called when the resident fell, but 24-48 hours after the fact (and after a portable X-ray has already been obtained and read) this no longer qualifies as an emergency. This is at best urgent, but more likely routine transfer to the hospital for the patient’s appointment with their orthopedic surgeon. They are already in a care facility where they can be medicated and kept immobile. Calling 911 if the facility’s contracted cabulance is too far away is perfectly appropriate for real emergencies.

    Urgent conditions are those that need medical treatment before the next regular office hours can accommodate them. These are the patients who get fast tracked in the ED. An hour or two wait for the contracted private ambulance is not unreasonable. Taking the local EMS (911) units out of service for these patients is inappropriate and reckless. In most systems, this is the responsibility of the caller/citizen. Once a 911 call is placed, we are obligated to respond. Yes, I know that we need to put out some serious public education as to what requires a call to 911. (No, a sniffle doesn’t).

    Routine conditions should only be going out during office hours anyway and should always use the facility’s contracted cabulance. This one isn’t generally a problem. I can only think of one call that I got for “Mrs. Doe” who needed to go to her dialysis appointment “right away” because the contracted transportation was “really late.” I did eventually get my eyeballs back into my skull.

    These errors can be corrected with an appropriate degree of education, along with the nurse not understanding the difference between 911 and 1-800-MEDI-CAB. The reasons that many of us (including myself) would prefer to be taken out and shot rather then go into a nursing home is the medical incompetence and inattention that pervade these facilities. A couple of examples below:

    We are called for “difficulty breathing.” We arrive 5-8 minutes later (average ALS response around here) and find the patient alone in his room. The patient appears to not be having any difficulty breathing…mostly because he is not breathing at all. He is also room temperature, stiff, and displaying fixed dilated pupils and dependent lividity. We amble over to the nurses’ station to hear the explanation and are told that he has been having trouble breathing “all day” and “a few minutes ago” he said that he couldn’t catch his breath. A few minutes?!? The patient is dead, developing rigor mortis. Umm…yeah. How about calling the funeral home instead? “Oh! He’s a full code!. You have to get in there.” No, Ma’am. He’s very dead. All the way dead. “Celestial Discharge” dead. We only take live and very recently dead people. Have a good day, now. I’d love to see how that got documented on their end. It was quite thorough on mine—including having the police enroute to take a report of a suspicious death.

    And another…
    We are called for the “unresponsive person.” To EMS, unresponsive means what it does in CPR/ACLS/PALS: unconscious/unresponsive even to pain. We find a rather pleasant elderly gentleman sitting in his bed watching TV and ignoring the nursing staff. I wish that we could have. It seems that he is/was somewhat hard of hearing and wears an amplifier and earphones. The amplifier microphone is designed to pick up noises from across the room and filter out noises right next to the box. We conversed with him briefly and he said that he was fine and didn’t want to go anywhere. The “charge nurse” went in to tell him that “the doctor said you have to go.” She picked up the box and yelled directly into the microphone. Amazingly, he found it quite easy to ignore her. She then tried to browbeat us into taking him anyway since she had a “doctor’s order.” We politely explained that unless she has documentation that the patient has a medical PoA or has otherwise been declared incompetent, the state calls transporting him against his will “kidnapping.” Again, have a nice day. I declined to report the attempted conspiracy to commit kidnapping. I figured that it was an honest mistake, and the old guy was quite able to look out for himself.

    And hundreds more examples just like those are why nursing homes have a bad reputation prehospital, let alone in hospital.

  18. I am a lawyer who spends a great deal of time suing nursing homes for the abuse and neglect of their residents. In 20 years of handling these cases I have never seen a nursing home in which I would want any member of my family to live!

  19. I do not work in a nursing home but am a healthcare marketer who entertains in them. Not all facilities are bad. That said, with a WHO of 37th, chronic conditions abounding, fact is we will need these facilities and aging in place will not always be an option. There are many people trying to change the industry. As they do, others of us need to educate the public about aging choices so people do not enter these situations in crisis but with education.

  20. As a nurse who has received these patients from the NH, it takes more time to cut out the medication name and tape it to the blank piece of paper to send than it does to send the MAR.

    Do you tell the doctor what medications you take, how often, and when your last dose was? We are not “miracle workers” and we are not “mind-readers”, we too are healthcare professionals who are asking for information to provide care to the patient you sent to us. Especially the ones that have dementia or unable to speak, without the medication record to try to assess what meds they are on and what medical history they have, you make our job twice as hard.

    Yes, there are abuses of the 911 system, a feeding tube is not an emergency, unresponsive should mean unresponsive and not just an opportunity to get rid of the patient for your shift.

    There is room for improvement on all sides of the equation.

    If your nursing home has to pay for the EMS ride, why do we have to fill out the paperwork for Medicare payment for the patient to go back to the NH?? Guess they only expect a one-way ride.

  21. Hey, at least you guys get info…I can’t count the number of times I’ve been shipped a nursing home resident with “AMS” or “fever” and absolutely NO record with them. I call the nursing home, and inevitably, the answer to my question of “so what’s going on with Mrs. Smith?” is “I’m not sure…when I came on, alls I was told was that the ambulance was on the way to take her to the ER.”

  22. The House Whisperer says:

    HIBGIA: or worse, such as, “I don’t know, the day shift sent her.”

  23. Brolin_1911a1 says:

    Your blog brings memories of my own mother’s treatment before her death.
    When my mother returned to the nursing home from the hospital following a colostomy the nursing home director told my sister that mother had signed a DNR. Sister said no, mother had made a statement that she was “ready to die” but that was in the recovery room while awakening from general anesthesia and that upon regaining consciousness the statement was disowned.
    Mother was given a Duragesic patch. My sister observed that mother was also given her Demerol faithfully every four hours “for pain.” Mom went into arrest two days after returning from the hospital. Was revived. Sis asked for a copy of the drugs mom had been given–the list she got was days old and did not include the Demerol that my sister had personally observed administered. A day or so later, sister was shown a signed DRN. OF course, mom was so drugged she barely recognized my sis and complimented sis on her “pretty plaid skirt” which was actually khaki. State ombudsman’s office said that there was not only nothing they could do since the patient, my mother, “appeared happy” with her treatment and doctor but that further complaints on our part would result in charges against us for interfering. It took three more weeks before she “died of natural causes.”

  24. I am a lawyer in Virginia. My experience as a lawyer convinces me that corporate greed is responsible for low pay and insufficient staff. To improve the conditions in nursing homes, staff shortages (probably due to low pay, especially for nurse’s aids)and other problems, you must complain in writing to the corporate office. They will then fear that someone like me will get their hands on it, and as a result make the changes necessary to help you take care of your patients. If you complain in writing, you will document that you are not the problem and you are taking steps to solve the problem and you will also isolate yourself from guys like me.
    You can’t do more and more with less and less or they will expect you to everything with practically nothing. And, you will be left holding the bag.

  25. doctorlawyer says:

    I am a physician and attorney. I work in a busy ED and I have yet to see this practice, though I’m sorry to say it would not surprise me.

    A couple of quick suggestions to your problem and the subsequent posts:

    1) If a patient is brought to your ED and performing CPR and/or ACLS is clearly futile, YOU DO NOT HAVE TO DO IT!! Yes it is nice to know their “code status” but someone who is in full arrest, who has been “down” for 45 mins and has no vital signs, no spont resp or pulse, boxcar’ed pupils, and is 93 lbs and 93 years old is going to be dead. You do not have to “run a full ACLS code” and exhaust all the meds in your code cart before you can claim you did the right thing.

    2) For you ER docs and EMS folks who run codes on patients who mysteriously later were found to be “DNR’s,” – just tell the family to sue the nursing home. This is battery (doing something to someone who does not want it done) and is legally compensible. You cannot be found liable for acting (resuscitation efforts) in good faith but they have an obligation (legally, morally, and ethically) to make this info (DNR) known. If and when it comes out they did so on purpose, they likely will be subject to additional PUNITIVE DAMAGES for an intentional act.

    3) same goes for any information that appears to be “intentionally” deleted or changed in a chart. This is dangerous and stupid, on everyones part. Never change or destroy a medical record. It is far too easy now to demonstrate a change, and most info in medical records is not “original” with only one possible copy. You can lose your license, your job, and your lawsuit when it comes out that you changed a medical record.

    4) let the lawyers for the nursing home know what is going on. They will get in touch with the Nsg Home administration really quickly, I promise.

    good luck!

  26. Not all nursing homes are the same. Take the time to investigate them and ask around before admitting a family member. Truthfully though most nursing homes are upgrading their medical billing software http://www.medicalbillingsoftwarepro.com allowing for simplified procedures, one stop charting, the options of going paperless. This actually benefits the patients.

  27. A Paramedic who knows says:

    Now does going paperless truly help the Pt? Since now the nurse will have to remember to print us everything for the pt to go the hospital with and you know what we will get it, “Oh well I’ve emailed it or will email it” and the problem then is, we are Health care prof. taking care of the Pt. if we need to give them something on the way we need to know their history and their meds or if it was D/C’d or if they just got it! This is not information that can be taken lightly because, “It’s our policy not to send it” By saying that you just killed the Pt, the one you “Get so close to and love better then family”.

  28. I do especially love when the patient comes with no medical records whatsoever, it makes soliciting a good medical history oh-so-thrilling.
    It’s even better when the patient is sent in for AMS and doesn’t know where they came from, and the EMS didn’t document it either.

  29. William says:

    O.K. let me see if I understand this.
    1) Some (many?) nursing homes are sending substandard or non-existent documentation with their patient transfers to other facilities. (This was the point of the article.)
    2) Receiving ED staff are not happy with this lack of documentation.
    3) EMS personnel are, being the middlemen, blamed by both sides to some degree for this lack of documentation.
    4) Medical Lawyers are “outraged” and “unhappy” with this lack of documentation, but are making a good living from it.
    5) Government agencies, hospital bureaucracies, and other red tape organizations will not hesitate to make further regulations in their own best interest. The result of which is making cooperation between health care personnel of all types more difficult and less likely.

    Please, for the sake of those of us stuck in the middle, lets see what can be done to fix the situation. It will probably take work from us all.
    Family Members – Stay up on what is happening with your elder family members. If something is going on, make sure that you are in the loop and follow up. Ask questions and get informed. If the staff doesn’t like it, your loved one may be in the wrong place. Please remember to be polite if possible.
    Nursing Home Staff – You have an image to work on and you do have to prove that you are equal to other health care providers simply due to the reputation that your facilities have. Take it personally and change your image. It will take time and hard work but in the end Everyone benefits.
    EMS personnel – for non-emergent situations, don’t leave without good documentation. Argue politely if you must, and document if you are stonewalled. Emergent situations are, well, emergent. Get what you can and run.
    ED personnel – Fly the flag when there are problems. Get the problem addressed, but remember that to the rest of us the only difference between a Physician or Nurse in a hospital and one in a nursing home is who pays their check. Their image problem is yours also, so be careful how you go about it.
    Legal and Bureaucratic folks – …, …. Please try to remember that the folks that you are passing regulations for are highly trained personnel and they need room and options if they are to provide quality care to their patients. The more restrictive and regulated they are, the worse the care they provide and the more time and effort they spend covering their collective and individual rears. Time and effort that they could be spending working to the patient’s (your paying client’s) welfare. Your part in this is, optimally, to cull out the negligent, malfeasant, and the dangerous thereby providing a better environment for all.

    Sincerely,
    William

  30. As an EMT in a town with about 5 NHs, we got called to a nicer one and a man had “fallen.” We get there and he’s sitting on the floor. He has syrup on his wrist. Sugary breakfast maybe? I ask if he has diabetes. The “nurses” didn’t know. She’s his nurse, how does she not know this simple little fact????? I couldn’t auscultate a decent BP on him and just palpated it. I told my partner “140 palpated.” Then his nurse, who heard me say that very clearly, asked me what his BP was. I repeated 140 palpated. She had to ask me what that meant.

    First responders are better trained than the NH staff. How is that possible.

    One rehab/NH (again, one of the nicer ones) had a “nurse” that freaked out because a pt had just started breathing irregularly. Me and my partner get there and say “it’s just sleep apnea.” (Yes, we know that can cause health problems) but the nurse just freaked out. By the time we get him on our truck and try to stick him twice he’s fully awake and aware and calls the nurse a crazy bitch. He was trying to nap.

    Our NH calls aren’t billed to the NH, they’re billed to the pt.

  31. [redacted] says:

    I feel strongly that there should be a mandatory form with EVERY nursing home transfer including the patients DNR status, healthcare proxy, emergency contact, PMD, meds/allergies and baseline mental status.

  32. Jen N. RN says:

    So I heard about this blog from a friend and couldn’t resist commenting on it. I work with “gruntdoc” and YES our local NH are sending in MAR’s with the med admin times removed. I mean it literally is a photocopy of the MAR with the times ripped (not even cut!) off the page. Now granted, Ms. Karen, that may not be the case in your area and it sounds like you offer exceptional care to you patients, but the reality is that it is a scary trend here in our area. I too worked in NH and assisted living places when I was in college and I will be the first to admit it is some real crappy work!!!! You fall in love with the residents but through staffing and low pay you become overworked and bitter. Just as in any job there are good people who do the job well and go above and beyond- but lets admit it that the cream of the crop nurses aren’t usually found working in Nursing Homes etc. You (Karen RN) know it and so does everyone else. There are days when I have a NH call and give me a very detailed report on a patient (I truely appreciate it too!) they are sending over and the patient is very sick and needs our care… but for the most part that is not the case. I have worked the other side and I tell you on our end when we are trying to make the best medical decisions for our patients -having incomplete medical records only hurts the residents the staff claims to “love so much.” I mean seriously what is there to hide? And Yes if one of my patients is transfered to another hospital we send all our records!!!! Nurses notes, H&P, Labs, etc…. and if needed we will send old records from previous visits too.

    I recommend you stop making excuses for others in your field. If you are doing everything you can do then why do you have to be defensive. I will keep calling every nurse who sends me the torn MAR’s and requesting a completed record… which as of yet I have yet to recieve!

  33. Incredible! I am a Geriatric physician that has pts in 8 “LTCF” in my area… I am stunned @ the animosity between members of our profession! Yes, I include nurses, paramedics, ED physicians, & attending docs! We are all on the same side, ( with the patient), right? We have what we call a “Transfer Team” that consists of ED DON/ADON, rep from EMS, Facility DONs or ADONs (& occas administrators), Hospital DONs,& Facility Med Directors. Local attending physicians are invited to attend…(yes including the ED’s). This has smoothed our patients’ transition between facilities, allowed us to interact & problem solve together. I insist that all of my pts have a DNR status, POA documentation (which is commonly ignored?!), an Advanced Directive if done, & a “Level of Medical Treatment” form delineating exactly what medical services/care they wish to receive/decline…(Level 0 = Full code/”everything” to Level IV = DNR/Comfort care with no hospital transfer). This documentation is part of my patients admission & I have made it a part of ALL admissions to the facilities where I am Medical Director. This has caught on & most of the facilities @ here follow this practice. Since I have moved to this community (@ 8yrs now) the unnecessary ED transfer rate has gone down significantly-our attending physicians are expected to be responsive to acute problems (we have a triage system for responses),& if we have problems with this we involve the patients & families. LTCFs are held accountable for their patients! They have a difficult & very important job to take care of what I call our “disposable generation” (I won’t go there…), in an obviously hostile environment! We do not need ANY of the hostility to come from “our side!” If there are problems, then there are positive solutions! You can make a difference in your community if you choose… I suggest the American Medical Directors Assoc. as a good source for info or assistance…

  34. A Paramedic who knows says:

    Geridoc; I must say that what you state you have done is admirable and I wish that it would work here or get someone to organize it between all the local hospitals and nursing homes…. actually I would love to do this here but I have a feeling that it would fall on deaf ears (actually if you have any suggestions I’d love to hear them). Unfourtantly it’s more hostility from the nursing home nurses then from anyone else. Just this week I went to take a “hypoxic” Pt from a local nursing home who had returned from the hospital not 45 minutes before. They accepted the Pt and the report from the hospital before the Pt arrived and knew the Pt was on 6LPM O2…why did they sent her back out? Because they can only take pts at a max of 5LPM. Then when I ask for the MAR the nurse refused to give it to me, or any other medical history (and the Pt has dementia so she doesn’t know today let alone herself) stating that the Pt wasn’t admitted t the nursing home yet, even though that very same Pt came from that nursing home and her room just a few hours earlier! This is why we get upset. Oh and that patient, she coded on me on the way in (completely unrelated to the reason they called, apparently the nursing home when she got back the med administrator gave her meds meant for the other patient in the room) and I really wish I had known the Pt was a DNR instead of bringing her back because the nursing home said no and wouldn’t give me her paperwork!

  35. to Paramedic who knows: I hear you @ getting so many people to work together… Ya’ll do get stuck in the middle if there is pt shifting going on between the ED & NH. Since this demented pt had a DNR there should (key!) have been no transferring going on… Sounds like she never should have gone to the ED in the 1st place, then definintely NOT sent back after her return “home!” (Although I will say that I have accepted pts from hospitals that looked NOTHING like we were told in report…) Where was this pt’s family/decision-maker ? If they do not want the pt transferred, then the NH keeps them! The facility is ultimately responsible for their pts & by refusing to give you her med records they knowingly withheld her DNR status! There have been successful lawsuits for “assault” in these pts! (Where are the lawyers when you need them?!)
    Honestly, this is unacceptable & you should make a formal complaint to THHS/Long-term care (# posted in all facilities) I would also ask your Medical Director to contact the Med Director of the facility – this is actually not just a medical (mal)practice issue, but a legal one as well… This woman’s rights were violated!
    Good luck…

  36. If Karen Vradelis would like us ‘ungrateful ER people’ to walk a mile in her shoes, I strongly suggest she walk a mile in ours. I have seen terrible things come out of some of our local ETC/rehabs. Like the elderly gentleman who came in with altered mental status and fever of unknown origin. Soon after he arrived I rolled him over and found a necrotic decubitus ulcer covering his coccyx and part of his left buttocks. The transfer paper work said his skin was intact. Guess where the fever was coming from. The most frightening thing is that he was sent to the nursing home (not ‘dumped’) for rehab after hip surgery. He was a fairly active guy before surgery…rehab bought him a month in the ICU, and his family refused to let him return to rehab, they took him home. He recovered after several months and came in for poison ivy he got while doing yard work. Nobody could believe it was the same guy the ‘rehab’ tried to kill.

    And, just so you know. I worked in a nursing home as a teenager and while in nursing school. Most of the nurses I worked with never took the time to assess their patients, they would push med carts and sit at the nurses station. If I had concerns about a patient they would ignore it (possibly because they had no idea what to do about it). When families would come in the nurses would make a big deal about the resident, all for show, because the residents without family were completely ignored.

  37. Oh boy. Where do I start? Our EMS service and local EDs have also noticed this trend of stripping the med administration times off of the MARs. Am I comfortable with anyone in the patient care continuum seeing *my* patient care documentation? You bet your bippy. So, Karen V, why aren’t you? There is enough detail in my records that I can (and have) sit down with it five years later with an investigator and re-create the entire picture of what happened and what I did during my care of the patient. (An investigator, I might add, who was investigating the death of a patient who was found lying outside the front door of a nursing home. A visitor to the facility had to step over the patient’s body and advise the staff the patient was lying unconscious outside.) We are a not-for-profit 911 provider (not a private-for-profit ambulance service that ‘bills the nursing home’ under a contracted rate), so each and every time we transport a patient for a 2mm skin tear, it most certainly does get billed to the patient’s insurance. Just to educate those who aren’t sure of the purpose of a DNAR, it is a legal document which is completed by the patient to express THEIR WISHES for their future care if they should become incapacitated. I have encountered many a futile situation and if the patient’s wishes are known, I’ve had no problems communicating this to their family members. I have not had *one* family member who didn’t thank me for being truthful with them, and for honoring their loved one’s wishes (NOT the family members’! That’s not what the DNAR says: ‘Uhhh, unless one of my family members wigs out and objects’)I have taught CPR at ECFs and have been told across the board by many that they ‘don’t honor’
    DNARs. My response: ‘If that’s my family member with an advanced directive which you refuse to honor, I will absolutely own you’. As for the perception of ‘Asshat’ EMS personnel, there are asshats in every profession. I’ve had to hit the patient’s call bell in their room in order to drag an ECF staff to give me report, which usually consists of ‘I don’t usually work this unit, and I don’t really know this patient, and I don’t really know when symptoms started/if this is patient’s baseline, etc, etc’. I need that information so that I can complete an accurate patient care record. So does the ED staff. I’ve been called for ‘unresponsive’ patients and of the 3 patients crammed into the room, 2 are sleeping and 1 is trying to crawl out of bed. Guess which one the ECF staff is calling ‘unresponsive’?! We’ve been called, via 911, during a busy shift with many critical patients, to an ECF with 8 staff working, asking us to transfer a patient from a potty chair to a wheelchair because ‘they just can’t do it, she’s too heavy!’ So we stood/pivoted the (under 250lb) patient to her wheelchair while 8 ECF staff stood there, watching us. I also completely disagree with the statement made by Karen V: ” An entire nursing home MAR is simply not necessary in regards to the emergent condition that we have sent our resident to you to treat.” On what planet is it not imperative to know if the patient is getting their prescribed medications in the proper doses and at the proper times?

    So, please. Refrain from the name calling, or I’ll start the ‘I’m rubber, you’re glue’ game. I bet I win.

  38. Jen N. RN says:

    Yup… it is still happening. Happened again on the 3rd. called the nusing home… Which I think I will start posting names on here cause it erks me so…. Anyways… called and had to have them fax it over after arguing with the nurse… Lord help me… How did this people earn the same title as me and get to call themselves “nurses”????

  39. And it continues. Tonight I asked for the full MAR’s to be faxed over, and what did I get? MAR’s with all the times and initials intentionally obscured with a magic-marker.

    Really.

    Embarrassing to all concerned.

  40. Scott_emt-i says:

    I have been lucky in that the nursing facilities I get patients from do put together good documentation for us. However the issue I do have is related; most of the nursing staff does not like to disclose this information with EMS. Many will nicely pack all the medical information in an envelope and seal it up saying that it is for the ER staff. This is the heart of the issue above, non disclosure of critical information from nursing staff to EMS/ED staff.

    I would like the nursing home staff to recognize that often we do not have time to call and confirm or search for information. The patients can wait 4 minutes for their daily meds while you get the information on the patient going with EMS. In general EMS (911 als units) should be used for critical patients only. Please disclose all the needed information, and give a good report to EMS.
    Yes NH nurses have a special skillset that I don’t have, and I would be very uncomfortable with their job. Though I think they need to give EMS a little more credit; we have a very specialized skill set that is much different from them, and we do it anywere anytime.
    We all fit into puzzle of healthcare in different places. We should not hinder each other.

  41. i UNDERSTAND !

  42. A huge pet peeve I have with the NH is that they never ever have their phone number on any of the documentation that they send with the patient. I know that I can look it up but I shouldnt have to. It is like they dont want you to call them to ask about their patients.

  43. nurseexec says:

    As a DON in a FL SNF/Rehab, I am appalled at the practice of removing times from the MARs being sent to you. I am also with geridoc–we shouldn’t be bashing each other, rather, working together to provide the patient with the best care possible. Have you considered talking to the DON at the facility?

    Yes, there are crappy SNFs. But there are also good ones, with positive, caring nurses and CNAs. Yes, there are crappy LPNs, but I’ve met quite a few who could dance circles around some RNs in their sleep.

    Bitching gets us nowhere. I have spent countless hours meeting with ER docs and attendings at our local hospital, and with paramedics from EMS. We have set up education for my staff with both EMS and the hospital docs. They get to come to our facility and see great care, and my staff gets to learn from great professionals. Our returns to hospital have plummeted since implementing the program.

    I spent 12 years as a ICU charge nurse, 3 years in the ER, and 3 years in the OR before taking on my current job. As a DON, I want to be part of a solution, not perpetuating a problem.

  44. A Paramedic who knows says:

    You are right, there are some damn good NH around. Yet, they are very few and far between. If I was to end up in a NH (which I won’t cause those bullets are still cheaper). There has never been a meeting with a NH and ER and Paramedics here, I know I’ve tried. There are some good nurses, but at the same time they’re so busy they can’t see patients! I wish we had more of the good ones like yourself, but they’re hard to find, let alone at what the NH will pay them.

    Also I’ve noticed more and more of LPN’s and CNA’s just don’t understand or care about the patient. Just yesterday I got sent for the “low o2 sat’s” I get there and the patient is fine, with a recent Dx of PNA. I check with my Sat probe and get 99% even after I d/c’d the O2 and the patient talking a 1000 words a min. I told the staff that the patient had PNA and that a lower SpO2 is expected. I even took thier SpO2 and proved that it was the batteries! After all even though I smoke my SpO2 should not be 70%! They didn’t care. This is what we deal with day in and day out and it’s BS and needs to be fixed, but it won’t be. oh well.

  45. I have worked on both sides of the equation and John Harris, J.D. has hit the target. Health professionals – stop attacking each other & attack the corporate greed responsible for understaffing the SNF’s! SNF’s receive $72 billion in FEDERAL funding! That’s our tax dollars. Private EQUITY firms purchase & control SNF’s, maxizing profits, minimizing care. For more information, read my blog
    http://www.healthline.com/blogs/healthline_connects/2007/12/medicare-agency-releases-list-of.html & this article in the NYT
    http://www.nytimes.com/2007/09/23/business/23nursing.html?_r=1&ref=business&oref=slogin
    and make sure you have a plan to for your own “retirement”.

  46. p a boies says:

    this is what you are getting, because that is what those nurse’s are allowed to give you….you need to complain up the food chain, not to the nurses….i work agency, and when i went to copy a MAR to send patient out, i thought the charge was going to faint….alledgedly the hospitals have been trying to crucify the NH for the occassional missed med…..SO, you will no longer get that info…..always remember to think of the unintended sequelae of YOUR actions

  47. nurseexec says:

    JC Jones–the New York Times article neglected to say that SNFs in Florida have the best staffing in the nation–we are not allowed, by law, to “understaff”. Last year, our CNA staffing was actually increased by the Legislature. In my SNF I staff 1 CNA for every 6-7 residents and 1 nurse for every 20. In other states, CNA staffing is still at 1 to 15, and nursing staff 1 to 40 or 50. SNFs are NOT all bad, and using a broad brush to say so is doing the public a disservice.

  48. Paramedic NWF says:

    Well, the practice of cutting out the administration times, dates, of M.A.R.s has ben happening in Northwest Florida for the past 4 years at least. It is exasperating to try and fingure the cause of why a patient may have altered mental status, hypotension, low blood sugar, low blood pressure, in congestive heart failure… get the picture… when the actual date and time of the medication prescribed was last given is removed from the information. For the area I work in, I can relate it to an episode where a poor pt (I am being careful to not provide information to violate HIPAA) was stripped of their rights/declared incompetent, all possessions were placed in someone elses’ care, the patient continued on a downward spiral, edema to the lower extremities, confusion, low blood pressure, borderline low-normal respirations, and swallowing problems to name a few of their symptoms – Any guesses what their problem was? They had a thyroid problem (it was also documented clearly in the H&P) and hadn’t received their medication from the nursing home for many months that was traceable back by using the M.A.R. I pointed this out to the facility who ignored me then brought it to the attention of the pt’s physician’s office so it could be fixed and the pt have what’s left of their health back. I didn’t throw the facility or the doctor under the proverbial “bus” but sought to be a patient advocate. The result, a complaint from the doctor to my medical director (no, I didn’t get into any trouble from the director) to talk with his paramedics about telling a doctor what to do with their patient and M.A.R.s from many of the nursing homes in our area that no longer provide EMS or the ER with the administration part of the M.A.R. What is acceptable today from anyone in the removal of vital health information will come back to haunt those who may have to rely on these same systems for their care or care for their loved ones at some point in the future. How about fixing the problem before you or someone you may love falls victim to the insane practice? Karma can really bite!

  49. PharmaGhost says:

    Doc,

    I understand your concern and you are correct that this nursing home behavior is a problem. I think I know the reason behind the behavior and it probably is due to nursing home policies and procedures in meeting Joint Commission standards for Medication Reconciliation. Joint Commission standard MM.1.10 EP#2 and National Patient Safety Goal #8 address this. Also, on the discharge side there is an additional standard: Provide the Discharge List of Current Medications to the next provider(s) (PC.15.30, EP #1) and to the patient (PC.15.20, EP #9).

    The basic requirement is a list of the patient’s medications is to be provided to the next provider of care. There is no requirement that the list includes the time of the last dose. Depending on facility policies, the time of the last dose may or may not be included. If the nursing staff is incapable of fully completing a form with all the information, the facilities tend to take the short cut approach. In actuality, a full copy of the patient’s MAR meets the JC standard. The medication list doesn’t have to be on a specific form, but facilities don’t want to send patients home with copies of their MARs for multiple reasons, so they have a separate medication reconciliation form for this information.

    It appears the nursing homes in your area, in consultation with their consultant pharmacist, LTC pharmacy policies and procedures, Director of Nursing, and Medical Director cooked up the interpretation of medication reconciliation you are seeing. In order to fix the problem, you are going to need the help of all the ER docs and the group will need to talk or meet with all of the above individuals or directors and recommend that they change their policies and procedures. Of course, you can also contact Joint Commission and report all of this.

    Below is taken directly from the Joint Commission website:

    Joint Commission requirements and recommendations.
    In July 2004, the Joint Commission announced 2005 National Patient Safety Goal #8 to “accurately and completely reconcile medications across the continuum of care.” During 2005, accredited organizations were required to develop and test processes for medication reconciliation to be implemented by January 2006. The requirements of the Goal for 2006 are:

    8a) Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list. [Note: While this safety goal does not require a separate form for the medication list, many organizations have found it useful to develop and implement one or more forms to support the medication reconciliation process.]

    8b) A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.**

    Implementation Expectations for Requirement 8b state: At a minimum, reconciliation must occur any time the organization requires that orders be rewritten and any time the patient changes service, setting, provider or level of care and new medication orders are written. For transitions not involving new medications or rewriting of orders, the organization should determine whether reconciliation must occur.

    On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications* that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with him or her and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists and other caregivers.

    End of JC text.

    It sounds to me like you have a definite nursing issue that needs to be addressed. It is obvious that the nursing homes do not want to send copies of the MAR, because it might show there were doses not given as ordered, and chose instead to cut off the left side of the MAR that lists the medications and send that to the ER. Think of the work required in recopying all of the drugs and the time of the last dose on a separate form when there may be 15-20 medications. It takes too long when a patient is being transferred to an ER by paramedic. In my opinion what needs to be done is that either the nursing home software generates a list of the patient’s medications with a place for the last administration time to be handwritten or the MAR is copied with the admin times covered and the times of the last doses are handwritten on the copy beside each medication.

    PharmaGhost

    -30-

  50. First off, finding and reading this blog made my evening…

    This practice of not giving us (EMS/ER) times on the MARs has been happening in my county at the 3 nursing homes for atleast the last 3-4 years. We recently started demanding the full MARs, threatening to report the facility to the State Board of Health if they wound’t give them to us. Since then we have started getting MARs with times a little easier now. :-)

    DNR/POLST (Physician Orders for Life-Sustaining Treatment) status problem are also the same here. Personally, I love the new POLST forms as they specifically state what should/should not be done for the patient, in great detail. The DNR forms we used to see were fairly limited in their application to our day to day struggles with the nursing homes. We have one facility that has actually told us they can’t use the POLST forms because their a “Skilled Nursing Facility, and that’s not what they were designed for..”

Trackbacks

  1. [...] other nursing-home related madness, GruntDoc has a post about a new practice in his areas of MARs being sent along without the time of dosage on [...]

  2. [...] 27, 2007 in communication The Grunt Doc reports that he is encountering a new strategy when Nursing Home patients are transfer…. They come with the list of medications but no record of when these dosages were last administered [...]

  3. [...] What GruntDoc said about “blank” nursing home medication administration records accompanying patients in the ER is true. [...]