New Policy sends MC residents to ER when they fall, whether hurt or not. Any suggestions?

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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.)

26 Comments

I share your concerns. I've dealt with the same thing with my LO. It seems ridiculous, but, so far, I haven't found a solution. I've asked the doctor if we can stop the ER visits just for precaution reasons. Not sure if it's going to happen. I recently read that a doctor can enter an order to not transport to ER unless urgent, but, that might not help, as they consider a fall urgent. What if they are on Hospice? Would they still transport to ER if there is a witnessed fall, with no apparent injuries?

 Maybe, some who know about this will chime in. I'd like more info on it.
I'm bumping this up to see if others have more input.
Stupid policy, not in residents' interests. Needless trips to the ER are costly (to the resident) and disruptive (for the resident).

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!
I agree, policy is expensive; keeps the facility off the hook but costs Medicare a ton of money. If they have 24 hour RN staff, they should be able to evaluate him to determine if he is injured. This also could be in reaction to a local law change as well, so I would check with the adminstrator to determine the reason for the policy. But my question is, could his fall risk be reduced in any way? Would he benefit from PT for strengthening? Does he need a rollator or if he has one, does it fit him properly and does he use it? etc. Not saying you have not already done these things but if they won't change the policy, and you don't want to move him, that might be only option.
Thanks for the suggestions. Dad generally gets around in a wheel chair. He has a walker that he uses occasionally, but he tires out after a short walk. We have tried PT, but it's of limited benefit. It seems that the reason he falls is that he forgets that he is 89 yo and needs a walker or wheelchair. Even when we are with him, he will try to get out of his wheelchair to go somewhere or even to stand when a lady leaves. I really like the facility. The only other alternative would be to send him to a nursing home where he would be belted to the wheelchair (as he was at the day care we used before the ALF).
While I agree these trips may be unnecessary, what if, in fact, the resident fell, hit their head, and then wasn’t evaluated until the next day when by that time he/she may have a slow intracranial bleed and by the next day showing signs of a change in mental status? By then it’s too late, the damage is done. 

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. 
That’s ridiculous policy and definitely a CYA. Talk to the local ombudsman and ask them to intervene. I just saw on the news last night that some insurance company is going to deny coverage for "unnecessary" trips to the er. The goal is to keep people OUT of the er, not fill it up. Tell the AL that it’s their responsibility to keep dad off the floor. I was a broken record at Moms NH and they finally took it seriously and got her fitted for a narrower chair that’s harder for her to fall from among other measures. But don’t assume that he will be belted into a wheelchair in a NH. That would be considered a restraint in NY and not happening. Turn the heat up on them to keep him off the floor.
Erring on the safe side would be a complete no-brainer if all trips to ER were definitely harmless. The trouble is that by the time an elder gets to the stage where stress and exertion are bad news in themselves, and say it might be 'flu season, or say you've got a fat-headed "I'm a senior medical student" (seriously, to my undisguised hilarity one young man did make the mistake of introducing himself to me like that) charged with taking bloods and apparently with Jackson Pollock as his mentor...

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.
My dad’s AL has a fall policy that if the resident hits their head they have to be checked out by the ER. If he falls without hitting his head which he has done as he gets up from his wheelchair and it scoots out from under his butt they check vitals then the resident is on 1/2 hr checks for rest of day.
It's sad but the reality is people sue at the drop of a hat and the MC is trying to protect itself from lawsuits.

I hope you find a workable solution. None of us is made of money.

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