(Poorly) Skilled Nursing Facilities

[SafetyPro]

RANT ALERT!

OK, I just need to vent. Had a call about 3 AM at our SNF that was all to common. Toned out for a male PT age 94 with difficulty breathing. I had the ambulance, so respond, and walk in to find the patient with severe, rapid wheezing respirations. Ask the nurse what's been happening, and he tells me the PT has had an O2 sat in the 70s since that afternoon! So, they started him on oxygen...5 LPM via cannula.

So, preped our O2 kit for 15 LPM by mask. Took his O2 sat...was about 75%. Put the O2 on him, and surprise surprise, it came up to the 80s before we got him on the gurney (and we were hustling) and was in the 90s by the time we got him in the rig. Dropped back down again during transport because we had to suction him several times, but they had him back up in the ER. BTW, he had a HX of pulmonary edema.

I get so freakin' PO'd at this facility, because their response to any respiratory distress is 5 LPM (or less!) by cannula. I can't count the number of times we've come into that situation, and on every single one we've seen a marked improvement in the PT when we start them on 15 LPM by mask (shocking, I know).

I also love the fact that he'd been in distress for a little over 12 hours before they decided it was an emergency, and woke us up.

OK, got that off my chest. I'm just a little cranky this morning...calls at 11:30 PM, 3 AM and, oh yeah, our dispatch toning us out at 5 AM and saying "Sierra Madre Fire, disregard, accidental activation." just after I'd fallen back asleep.

Thanks for listening.

[Chimpie]

LOL Chris. Maybe it's time that your medical director and their medical director have a little chat. I'm sure their SOP's state to do 5 LPM-canula. Maybe he can persuade them to go to a non-rebreather when it hit 70% or something. I don't know... just throwing out suggestions here.

[MMiz]

Working BLS, I understand how this happens. Being that our company sends ALS rigs for "Major incidents", the BLS rigs get called for the BLS Nursing Home transfers.

I've learned which nursing homes can and cannot be trusted. At the worst ones, they'll ask for a BLS rig non-RLS, and the crew will arrive and start CPR. The best NHs will be on top of the situation, have the vitals done, and the patient being attended to by RNs or LPNs.

Don't your calls go to a QI board? 100% of those type of calls would go to our QI board, and that person reports directly to our medical director.

Another day in EMS <_<

[rescuecpt]

Slip a note to the pt's family telling them to sue the nursing home for negligence if he ends up with dementia or brain damage. That'll make the nursing home change their policies real quick (I wish we could do stuff like that!).

My gramps had CHF and the low O2 sats caused dementia that he never had until his edema started becoming worse. The hospital actually had him on PPV to try to help bring his sats up (while conscious).

[Luno]

Yeah, the death camps, uh, I mean Skilled Nursing Facilities, hmmm, called for Resp. Distress, CNA had just placed a NC on the pt prior to the call, when BLS arrived, had to remove the NC from a pt with lividity, yeah, DRT, gotta love the death camps.

[PArescueEMT]

wow... 5lpm. I'm impressed. At least they know to use a cannula. I've walked in on 2 lpm via nrb
talk about CTD. Report from RN was Pt's sat was at 78 so they put him on a mask (coming from a concentrator.) One BVM, D cylender, and NPA later, the patient was back at 98%.

After that call is when I found that they were only allowed to give 2 lpm without orders from the Pt's PCP. that may be where your problem lies.

Good luck.

Zak

[PArescueEMT]

I got another "wonderful" facility.

70 y/o M CAOx0 responsive to painful. P:110, R:28, B/P:???/?? (to low to get) L/S: Rails throughout, Expiratory wheezing upper, SpO2:94% on 2 lpm via N/C, Cap Refill:<2 sec; PE: Generalized Edema, no extremity control. G-Tube with thick dark green puss aspirated (over 300cc in 1 day) with a recent cholycystostemy (is that spelled right?)


Who can guess what the dispatch was for. MedicStudentJon is not allowed to guess.

[MedicPrincess]

Umm..."General" Sick Call?

[ffemt8978]

Non-code transport?

[MariaCatEMT]

ummmmmmm.....SOB?

[rescuecpt]

Cardiac arrest??? LOL - I've had "cardiac arrests" who RMA (Refuse medical assistance) when I get there...

[Jon]

Originally posted by rescuecpt@Dec 27 2004, 08:08 AM
Cardiac arrest??? LOL - I've had "cardiac arrests" who RMA (Refuse medical assistance) when I get there...
I had a friend who got a signature for consent from a code. Well, he was P.C.L. on arrivial, and coded in the bus, they worked him, and he didn't make it. Anyway.....


Jon

[PArescueEMT]

Would you believe "Altered Mental Status"

Vitals given to our dispatch were all perfect.

On that run tho, I actually had a Train stop b4 the crossing and wave ne through.

[Jon]

Originally posted by PArescueEMT@Dec 28 2004, 06:24 PM
Would you believe "Altered Mental Status"

Vitals given to our dispatch were all perfect.

On that run tho, I actually had a Train stop b4 the crossing and wave ne through.
Strange things happen with you. Also, you sure you didn't stop to see the new wheels SEPTA just put on that Silverliner II?????? :D :rolleyes: :lol: :lol:

[SCEMT-B]

I see this more times then I want to here in South Carolina. I work for a private company here and we're contracted with almost all the SNFs in three counties. First off I'm a basic out here. I can't count how many times I've been called to a nursing home for a non-emergent transport to the ER and its not. Two weeks ago I got a call for just that because someones sodium levels where high. Thats all the information my partner andI where given. We get there, the guys in the hallway in a wheel chair. The guys barely breathing and white as our gourney sheet. The guy had been puckin his guts out all day and apparently is walking up and down the hallways all the time. We loaded and went withit. After we got him into the ER the doc came out to us and asked us why we brought him in. When we told him he asked us to come in. The guy was flippin out and we all had to restrain him. I just don't get SNFs. :angry:

[emtchicky156]

I've worked both ends of the spectrum as an emt and a cna in a snf. I've had many times where I know the pt NEEDS to be seen NOW, but the RN/LPN decide to just watch them over the next shift. I've come onto shifts where the nurses supposedly just checked the o2 bottle the pt's been on for the last two shifts and says it's full and wonders why the pt's o2 stats have dropped, so I switch the bottle and they come up again amazing I know. I had a pt fall c/o neck and shoulder pain and the nurse walks in makes sure there are no obivious deformites to the hips and procedes to stand the pt up, two days later the pt is taken in for xray and had a slight neck fracture. I understand that these people are not trained in ems, but they should be able to do the basics (vitals correctly, know when the pt needs o2,correct assesments). I can only hope that one day things will get better.

[Jon]

Originally posted by emtchicky156@Mar 2 2005, 10:30 AM
I've worked both ends of the spectrum as an emt and a cna in a snf. I've had many times where I know the pt NEEDS to be seen NOW, but the RN/LPN decide to just watch them over the next shift. I've come onto shifts where the nurses supposedly just checked the o2 bottle the pt's been on for the last two shifts and says it's full and wonders why the pt's o2 stats have dropped, so I switch the bottle and they come up again amazing I know. I had a pt fall c/o neck and shoulder pain and the nurse walks in makes sure there are no obivious deformites to the hips and procedes to stand the pt up, two days later the pt is taken in for xray and had a slight neck fracture. I understand that these people are not trained in ems, but they should be able to do the basics (vitals correctly, know when the pt needs o2,correct assesments). I can only hope that one day things will get better.
My most memorable nursing home call was in New Jersy (Which has an intresting prehosital EMS system, but at least the state recognizes that a transport truck isn't any different than a 911 truck, and treates them as such) I was on a 3 person crew (funky staffing - my partner didn't show, so I was thrown in as Lift assist)

I was a EMT, not im Medic school yet
My two partners were female, one a PA student, and one a Paramedic Student, both mostly finished their training.

We were all EMT-B

We were sitting ACROSS THE STREET from our most often called nursing home, all sleeping at 3am, when our dispatcher calls on the radio and wants an ETA for that facility with a patient in Resp. Distress with a SPO2 of 76%.

I say we are 1 minute away, and we pull the truck across the street.

I am Paperwork boy - I stay at Nurses station doing my paperwork while my partners assess the patient.

The Patient was on 2lpm O2 via N/C, only in the Left nostril (right prong was aimed at eyes - cold eyball syndrome). pt supine in bed, rales and wheezing throughout on auscultation. SaO2 mid 70's.

Pt. moved to strecher, in high fowlers and placed on NRBM. 2 minutes later, as we are walking off the unit we use their pulse ox again - 89-91% range - the nurse looked and said "how did you do that." My PA student partner pulled her aside and said, "well, we SAT HER UP, and PUT HER ON MORE O2"

I understand that most nursing homes around here cannot change O2 delivery method or rate without Dr's order, but I think it should be part of the protocol for sending someone out with a low sat or S.O.B. (which the doc approves anyway)is that the doc orders high flow / higher flow after the decision is made untill EMS arrivial.

Anyway.

Jon

[CodeSurfer]

Originally posted by PArescueEMT@Dec 26 2004, 02:06 PM
I got another "wonderful" facility.

70 y/o M CAOx0 responsive to painful. P:110, R:28, B/P:???/?? (to low to get) L/S: Rails throughout, Expiratory wheezing upper, SpO2:94% on 2 lpm via N/C, Cap Refill:<2 sec; PE: Generalized Edema, no extremity control. G-Tube with thick dark green puss aspirated (over 300cc in 1 day) with a recent cholycystostemy (is that spelled right?)


Who can guess what the dispatch was for. MedicStudentJon is not allowed to guess.
PCL? :P

[SCEMT-B]

This being a common one here I'm taking a shot at low o2 sats :blink:

[TTLWHKR]

I could go on for hours about the poorly skilled workers in Nursing Homes. Especially the night shift. You know they don't check on the patients regularly. Most* cardiac arrests are right at meal times, or medication time (I feel this is the only time most are checked on), very rare to get a call late at night unless they were watching the patient close.

The Golden Hour, this doesn't exist there. Just this week I ran a class 1 respiratory at a N/H. I asked when it began "about noon" (meal time-who knows how long before then), it was now 4AM. Why didn't you call then? "He has a DNR". Yeah, that means we don't do anything when there is nothing to do. We can reverse this condition, you need to call when it starts. "Well, we were hoping he would pass on". HOPING? WTF is wrong with you...?

:angry:


I strongly dislike, to the verge of hating nursing homes. There are some really good ones, but the bulk are bad! I've seen things that have made me want to beat the staff out of their utter stupidity. :o

[Jon]

Originally posted by Blueeighty8@Mar 3 2005, 10:27 PM
I've seen things that have made me want to beat the staff out of their utter stupidity.
MODIFIED O2 Therapy?

[Jon]

Had it last night on what the Nursing home had called in to the ED quote charge nurse "they said this was a BS change in mental status."

Myself and PA Rescue took to the hospital Facility had requested (8 min. travel) instead of the closest (5 min travel) because of similar times. Then the Facility said to go to the sam hospital system as their first choice, but the one that was 25 min away. We said No, you smoking something?

Called in with 2nd pressure being 76/50, 1st was 78/44. Said 4 minutes out with Change in mental status that is SEVERLY HYPOTENSIVE. Ran Class 1 in BLS bus.

What scared me and PA Rescue was no palpable radial, regular but VERY weak carotid, and muffled lung sounds, Pt. responsive to pain (this on demented Pt. who normally walksaround and talks somewhat coherently).



Just venting.


Jon

[TTLWHKR]

Originally posted by MariaCatEMT@Dec 27 2004, 07:55 AM
ummmmmmm.....SOB?
Went to a nursing home on 5th-Due EMS (4 companies scratched b/c the facility thinks EMS is free for them), Asked what the problem was...

Nurse said "SOB on the 4th floor again". Went to four... Nursing staff had to look up a room b/c nobody was with the patient :huh:

I asked when the problem started, "Last shift the SOB started complaining of chest pain". Did you get orders for oxygen or albuterol? They asked why? For his Shortness of Breath.. "He doesn't have shortness of breath" Then why did you call for an SOB patient? "Oh my gosh, that was a joke, we meant Son Of a B*tch; the CNA that called it in must have thought we were serious". Walked into the patients room, finally after they found out who the patient was. The bed was empty, cleaned, and all his effects were gone. I said "Do you people even know what the hell your doing?" They said "That's not our job..." Obviously you don't know what your job is anyway.

The patient charge sheet said "Patient began having severe SOB and chest pain, TOD 21:30. Morning shift should make necessary contacts." The patient had died the night before, and was already taken away by the funeral home. They were supposed to call the family, but called 911 instead. So we know that they did all of this with out ever checking on the patient.

[ffemt8978]

WTF?!?!?! :angry:

That facility needs to be visited by some state inspectors and lose their license.

[TTLWHKR]

Originally posted by ffemt8978@Mar 11 2005, 11:56 PM
WTF?!?!?! :angry:

That facility needs to be visited by some state inspectors and lose their license.
They get fined all the time, don't know why they're still in business. I've made several calls to various state agencies myself, from pay phones -in a deep voice; so I couldn't get slapped for possible HIPAA violations.

Personally, sometimes I want to get out the roll of spare O2 tubing and either whip the staff. How they got to be in the business of caring for those who need "24 Hour Continuing Care", I'll never know. But I bet that they only check on people at shift changes.

Walk into a room, patient is blowing bubbles b/c the staff didn't know if they were allowed to suction or not. Just makes me so angry, but what can we do, other than pass along word at the ER? Anything else we'll get slapped with a go**amn privacy act violation.

[Jon]

Too true.

[SCEMT-B]

I could have used that spare tubing today ^_^