Nursing Home to Hospital

Transfer of Care

Nursing Home staff, Emergency Room & Hospital staff, NH Attending Physician, Resident (Patient),

Mr. F has been a resident at XYZ Nursing Home for the past six years. Prior to this he lived independently at home. He was initially admitted to the NH following a fall at home where he suffered a fractured hip. Following this fall and surgical repair at the local hospital he was admitted to the NH for continuing rehabilitation. During the course of his rehabilitation, Mr. F and his family decided it would be best that he remain at the NH for long term care. In addition to the history of the fractured hip, he has Diabetes, CHF, Atrial Fibrillation and Hypothyroidism.

Mr. F is transferred to the hospital for evaluation of a GI Bleed. One week prior to transfer he was noted to have a 5 lb weight loss and low iron levels. His attending physician ordered a colonoscopy as there was no prior history of his having had one. During this week prior to transfer, and while awaiting scheduling of the colonoscopy, resident was alert and oriented x 3, required stand by assist for transfers, and was independent with eating and bed mobility. Though he did not complain of pain per se, he did complain of “aching all over”. The day of transfer he was noted to have a black, tarry stool, with some bleeding. The Attending Physician ordered ortho blood pressure checks and transfer to the hospital emergency room for evaluation.

Upon transfer the NH provided a Continuity of Care Document (CCD) to the hospital reflecting the resident’s condition, including –

1. reason for transfer – probable GI bleed, black tarry stool, low Hgb, weight loss

2. current and usual vital signs

3. listing of current medications and treatments

4. recent diagnostic results

5. demographics, insurance information and advance directives

As part of the CCD, the MDS was updated to reflect -

6. restorative nursing needs

7. continence status (bowel and bladder)

8. current mental status, sensory impairments and physical disabilities – alert and oriented x3

9. ambulatory and weight bearing status and safety concerns – standby assist for transfers

10. communication level and types of appliances the resident uses.

11. ADL status – independent with eating, bed mobility and dressing, assist with bathing

Upon admission to the hospital and with the CCD, the ER staff was able to review recent and prior labs, medications and vital signs significantly reducing time taken to diagnosis Mr. F and eliminating the potential of duplicating diagnostics recently completed. The nursing staff on the unit where Mr. F was transferred from the ER was able to review the CCD and particularly the MDS section and knew his status in terms of ADL abilities and cognition. Staff was able to provide assistance where needed without being overly intrusive.

During the course of Mr. F’s three day hospitalization GI bleed was confirmed and treatment initiated. Mr. F returned to the Nursing Home along with an updated CCD reflecting the care and treatment he received at the hospital.

Use Case 2

Mrs. L is an 87 year old female who resides in a nursing home. She is alert and oriented, and able to ambulate with a walker. She has CHF, Diabetes type II, osteoarthritis, and renal insufficiency. Two days ago, Mrs. L became progressively more short of breath, requiring additional pillows and raising the head of the bed to sleep. Her ankles became swollen with 2+ edema. Her urine was very concentrated and foul smelling and she was running a low grade fever. On morning rounds the aide noticed that Mrs. L was not her usual self. She seemed exhausted and less talkative. By noon she was gasping for air and was disoriented to time and place. The ambulance was called and Mrs. L was taken to the closest emergency room.

Upon arrival in the emergency room, Mrs. L was transferred to a holding area. She received a chest x-ray and IV Lasix. Her medical record was marked as disoriented to person, place and time. The staff assumed Mrs. L was always like this and failed to attempt to investigate the cause of her delirium. Mrs. L ended up waiting in the emergency room for 6 hours until a bed was available on the cardiac unit. The ER staff had no knowledge of her urinary symptoms over the past several days and failed to recognize the presence of a urinary tract infection-the source of her fever and her delirium. Mrs. L was transferred to the cardiac unit where she remained an additional 4 days on bedrest. No one knew that prior to her admission she was ambulating with a walker and was alert and participating her in own care. Blood and urine samples were eventually obtained and her UTI successfully treated.