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?).