The Memory Care ALF where my father is living recently changed their policy to send any resident who falls unwitnessed to the ER, whether it appears they are hurt or not. Prior to this, when a resident fell, the nursing staff would notify the family and the PCP, evaluate them, and monitor them over the day for signs of head injury. If all seemed well, the resident would continue their daily routine. Now, they go to the ER regardless of any evidence of injury. My father is 89 yo, with moderate mixed dementia, and bad balance. He falls a lot. In the 6 weeks since this change in policy, he has been sent to the ER 3 times, where he can't answer the doctor's questions, and confusion is increased. So I have had to take off from work to sit with him while he is treated for nothing more serious than a skin tear. And of course there is the co-pay for the ER and the copay for the ambulance rides. Does anyone have suggestions for how to get the ALF to change this policy back to the old policy? Dad was living there under the old policy for 7 months, and all was well (although he did fall often). (The nursing staff also thinks it's an unworkable policy.)
Maybe, some who know about this will chime in. I'd like more info on it.
It is, of course, an a**-covering exercise. It avoids the possibility of angry and litigious family members demanding to know whether their fallen loved one was immediately taken to the ER, and ensures that the facility can always answer "yes, of course, our policy is for all unobserved falls to be followed by ER examination."
Get together with senior staff members and other residents' families and seek further discussions with the policy makers. Best of luck!
Granted, the ALF is trying to avoid a lawsuit and rightfully so. What else could they do? Even if they had a RN 24/7 they couldn’t assess an intracranial bleed and an RN would prudently most likely send them to the ER for an evaluation. I know I would.
It is wishful thinking to assume staff in those facilities can watch every resident to prevent them from falling. That’s not going to happen. Unless the family private pay a “sitter” to watch the person and even that doesn’t guarantee it.
This scenario is just another “learn as we go” scenario as people are living longer and more seniors are placed in long term care centers. It’s damned if you do, damned if you don’t. One solution would be to have the family document in writing when their Senior should be sent to the ER but I am not sure anyone would or could take liability to predict these situations.
As a RN I wouldn’t be comfortable assessing a person and deeming them to be injury free. I would send them out for evaluation. It’s not my job to diagnose.
What a dilemma. And I agree with everyone above as these trips are costing Medicare a lot of money. Plus I am hearing that county governments are now charging families for unnecessary use of ambulance services. But realistically no one can predict an injury by an incomplete evaluation, especially if the person is not familiar to the RN.
There is a risk that a trip to ER might be the first step on the slippery slope. I guess it partly depends on the reliable quality of your local ER.
By the time things started getting silly with my mother and we'd have been up and down the road to the hospital all day long...
Broken limb, actual blood, obvious stroke - ambulance.
Fall resulting in bruising or "oddness" - take to ER.
Fall, nothing to see but not happy - call for advice.
Fall, explained, no worries, no nearby hard or pointed surfaces - watch at home.
The ALF should quite rightly, I totally agree, exercise an abundance of caution. And any RN should quite rightly refuse responsibility s/he isn't confident accepting, I also totally agree. But this ALF seems to be safeguarding itself at the expense of its residents, and it isn't costing those residents nothing. I'd argue.
I hope you find a workable solution. None of us is made of money.
If he were on Hospice they would not transport. Hospice becomes the "911" call. They would have someone evaluate or they would just make note of the call. But to transport to the hospital becomes a double billing nightmare and the patient would have to go off Hospice to go to the hospital then be readmitted to Hospice upon discharge.
Another possibility if religion is listed on his papers change the religion to Christian Scientist, no ER transport. But this would not work if he is taking any medications as they would also be discontinued.
Another possibility. If you spoke to a lawyer and signed a release holding the facility harmless and an order were submitted by his doctor stating that you are refusing to allow them to transport to the ER. Or refuse to allow them to transport until they have contacted you to get approval to transport. Not sure if all the lawyers would be happy with that.
I don't know if that's for the UK or just for England. Technically, Wales, Scotland and Northern Ireland run their own (still national!) health services, but it may be that the NHS LA covers all of them. If it's the whole UK, that's for c. 70 million people; if it's just England, it's c. 55 million.
I think individuals are the same, really, in terms of feeling aggrieved and wanting something for it... I suspect the major difference is the number of jury trials of civil cases - the still quite paternalistic English legal system wouldn't *dream* of doing that with negligence, though it does for certain other civil matters like defamation - leading to settlements which are spectacular to the point of fantastic.
Also English people are brilliant at grumbling to no purpose. It takes quite a lot to make them sue, they'd rather just go home and feel sorry for themselves.
We do have some disgraceful law firms which advertise on t.v. and in the press soliciting claims for things like personal injury and mis-selling of financial products. Until, oo, I think it was the 1990s, lawyers were forbidden to advertise at all; and it is still seen as a mark of dodginess.
Hmm. £14.6 million was awarded in 2015 to the family of a boy born with cerebral palsy as a direct result of useless midwifery and obstetrics, to judge from the article. But that sum won't have been punitive, it will be actuarial - I think that's probably the other main distinction between the US's and UK's civil culture, here the courts' focus is still on restoring the plaintiff to the status quo ante as far as possible, there isn't the same emphasis on punishing the failings of the defendant.
Care homes, I haven't researched but I'd say, have to be utterly abysmal even to get reported, let alone sued. There is a hangdog, despondent attitude to standards in elder care that makes me froth at the mouth periodically. It isn't that I want to see more claims, it's that I wish people wouldn't be so bloody apathetic - and that they'd recognise that it is up to them to do something about the problem, if they care.
I think our employment tribunals might do brisker trade than the States'. I assume so because the government, last year or the one before, was trying to reduce it.
With things like train crashes, and the appalling Grenfell Tower fire, there have been moves to get prosecutions for corporate manslaughter but no convictions yet, I don't think (though watch this space with Grenfell; people are very upset indeed). Which leads me to reflect that if we're going to take these things more seriously, maybe we should be looking not just to the US but to China. They don't bankrupt their miscreants. They hang them.
JoAnn29 raises a good point--if the fall was not witnessed, there is no guarantee if he hit his head or not. A head bump IS ALWAYS CONSIDERED A MEDICAL EMERGENCY.
The same works for her bed. They put an alarm on her bed, so it goes of when she gets up. They can get to her and assist her or she'll hear the alarm and lay back down and wait for help.
They really aren't allowed to strap anyone in, since that is a restraint, but, if they can undo the belt, it's not considered a restraint. At least not in my state.
Of more concern to me is that they are sent alone. Who is going to watch them while they are at the hospital? What is to stop them from wandering off or leaving? Who is going to answer the right questions? Our mother is VERY hard of hearing, so even if she could explain what happened or what issues she might have (more often than not she cannot do that), she might not even hear the questions! She'll often say she is fine, but later may complain of something.
For more recent falls (she usually has more of a tumble than a fall) they have reported it to me and monitor vitals for a day or so. I do understand their concerns, but if someone had an uncomplicated simple witnessed fall, this should be a decision for the person who has medical POA. The best you can do is inquire WHY this change and what you can do, if anything, to limit the ER trips. As someone else said, damned if you do, damned if you don't - and unfortunately it applies on both sides! Think of how litigious people here have become - the slightest issue, hire a lawyer!!! We are not all like that, but how can a facility know? They do need some CYA....
Couple of ideas on being proactive since it looks like the ER might be coming up. Even aside from that MC policy, people call 911 all the time, and things cascade from there. You didn't call 911, you didn't want medics, but you are now stuck with the ambulance bill for $700 and the ER bill too.
1. Find out what ER they would be taken to, whether there other ER choices available, which one do you prefer for insurance/whatever reasons, can you put the preference in their records. Where does her doctor have hospital privileges?
2. Find out about the ER/hospital policy on being held "for observation" instead of being admitted. Medicare will not cover non-admitted "observation". You get an enormous bill. There may be a law/requirement that the ER has to notify the patient and get a signature before holding them for observation. All this is good to know in advance.
3. See if there is a way to get their medical records at or online with the hospital/ER, so that the ER people can access them. Something like "Forgets to use walker, falls occasionally" is what I wanted for my mother as a starting point, because they get a million tests when the ER staff are trying to rule out every possibility. (Didn't get it because their ER computers could not access the facility's records).
4. Find out the MC policy on dentures/glasses/hearing aids going with the person or not. Where is this going to be written down? The hospital lost my mother's dentures and claimed both (1) They didn't know she even HAD dentures in, and (2) Since they were missing, then they had never been there to start with because it was not written down.
5. What is the policy for an unaccompanied patient to ER? Your question is a good one. Some places have a patient advocate. Then, how do they get discharged and returned to their MC residence?
6. I learned to check what the ER/hospital staff wrote or prescribed. They are busy, the shifts come and go, the elder is confused, and opinions can get written down. Then everyone treats the opinions as true. Not sure how to put this tactfully, but those very young doctors seem to be inexperienced with the elderly.
7. A confused elderly person easily gets hospital delirium. (If you're not familiar with hospital delirium, google it).
Also I started taking notes on everything said in phone calls or conversations with ER personnel, with names and phone numbers. Because it is busy, stressful, and you can't remember it later.
1) The idea of transportation other than an ambulance makes sense. A trip for $10 is certainly a lot less expensive than an ambulance ride (and the latter might be needed for use elsewhere if there has been a serious accident justifying it).
2) Would it be possible or practical for people prone to falling to wear some kind of protective helmet? I seem to have a vague memory of seeing someone with one a few years ago--perhaps something like those that kids and others wear while riding a bicycle.
Just taking one point - how do you fall out of your chair at dinner? Oo, lots of ways! Overbalancing, for a start, and once you build up a little momentum nothing's going to stop you. Solution? - Carver chair, a dining chair with arms. Will that stop them? Yes, until their sense of overbalancing causes them to try to get up, which they can start but not control, and once up - over they go.
Or, take the number of falls that happen - and make families very angry and upset - while the person is being accompanied by an aide or caregiver. HOW???
Well. Because the only way to prevent the fall is to have the person you're assisting bound in closely to you, his hip against you, your arm firmly around his hips, he holding tight to you, so that you're the world's best three-legged race specialists. Otherwise, if the unwary/untrained aide believes that by holding the person's arm she'll be in time to "catch" any stumbles; or if the person seems to be walking fine and doesn't need more support; the opportunity is there for the slight tip off balance, the build in momentum, and the only way is down.
If you have one-to-one care and the person is unable to move around unaided, you may prevent falls from standing. But not from sitting. You cannot tie the person down, that is a Deprivation of Liberty and will get you into serious trouble (don't even ask, because the people in charge have no sense of humour). And once dementia is a factor, the person will get up. She will promise she won't. She will appear to understand and be willing to comply. But you cannot believe a word of it. Turn your back and she'll be up and off like a little jack-in-the-box and it's another fun evening in the ER.
I would like to see falls prevention made a key part of basic training. I would like all staff in facilities of all types made to watch a skilled Physical or Occupational Therapist, and then made to practise and drill until correct handling becomes second nature. I cannot tell you how many other types of health care professional I have seen hold onto elders by their upper arms and think that's going to do the trick. It's a nightmare.
But it is still true that no matter how much you pay, and no matter how many people you have in the room, falls will happen. I can only share my tearful frustration with you.
After they reported mom having pain in the throat and ear (not constant but after a few times they contacted me), I took her to see the doctor. The doctor kept trying to ask mom questions - between hearing issues and not even wanting to go or being able to express the issue, she finally told the doc her throat hurt. Doc says get chloraseptic - she has a cold. I had NO confidence in that, and now know that no one will ever get near mom with chloraseptic again! We got back just in time for dinner and I got to observe the reported issues: refused most of the food, complained of pain under the jaw and even gave up her beloved chocolate covered ice cream bar after 2 bites. This was NOT a cold. Although by the time I could look up the symptoms (pain at mealtime, under the jaw, enough that she would ask for pain med and go to bed, but fine in the morning...) AND get an appt with ENT, the issue had gone away (lasted about 3 weeks) After describing the issue, he checked her over, said no blockage at this time, but agreed that was probably what she had - blockage in a salivary gland. It can be minimally treated and can go away on it's own, but it can also become much worse. You know your LO best and it would be best if YOU take them to the doctor or ER (get ALL the details when picking them up.) However, this could lead to daily hospital trips!!
So, ER or no ER? Falls could happen when no one is looking and although there might be enough injury to cause problems later, it might not be apparent. If not one saw them fall, how would anyone know they need to be checked? If they fall when observed, it is probably best if a family member who knows the person well can check them and take them to be checked out if deemed necessary. Just sending someone to ER, especially with no observable injury and no one to describe the fall or possible injury, would be pointless. The first few tumbles mom had, they sent her off to the ER. The last one, even with a small cut from her glasses (not broken), they treated and monitored. I'm okay with trusting their judgement at this point. Clearly if someone is falling often, there are issues in the place or your LO needs to be in a place with more staff. Generally there are not enough people to watch over everyone one-to-one, so you have to pick your facility wisely or hire someone to be your LOs daily monitor.