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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.)

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.
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Reply to Sunnygirl1
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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. 
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Reply to Shane1124
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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!
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Reply to Countrymouse
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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.
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Reply to dogparkmomma
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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.
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Reply to wi57twin
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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.
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Reply to rocketjcat
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Thank you all for your comments and suggestions. I've written a letter protesting the new policy directed at the local Executive Director, and my father's PCP has written a letter expressing his preference that Dad not be sent to the ER if there is no indication of injury, and offering his services if they want a reviewing physician (rather than the ER). So far, no response from the ALF. If these are ineffective, I will reach out to the other families (I know my father is not the only resident who falls) to try to organize a group protest of the policy.
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Reply to Weary418
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I took my husband out of an A/L because of their “must go” to the hospital policy, but keeping him home is untenable now. His dementia is escalating.

I luckily found a small home with only 16 rooms and they only take care of people with dementia. He isn’t in it yet, but because it’s small, what I’ve been told, they know the patients, know they can’t do much for themselves, and they are escorted to the restrooms and watched closely. If this is not just talk, I’m hoping smaller is better.

I asked about their fall policy, and they do a body check and patch up if needed. The problem with the many trips to the hospital are the unnecessary tests. What nuclear waste are they injecting into our loved ones to do these tests? How many times in a couple weeks would we want a brain scan done? How many chest X-rays would you want to keep getting when nothing is wrong? Pelvic MRI’s? What the heck was that for anyway?

Once an A/L gets a policy, usually dictated to them by insurance companies, the patient suffers. They could hire more help to keep a better watch but they don’t, and the patient goes off on a gurney.

Good luck with the protest letters.
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Reply to Rosemary44
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Update. So I sent my letter of concern to the Executive Director the ALF and my father's doctor also sent a letter saying that he would prefer that Dad not be sent to the ER unless it appeared that there was an injury or other underlying condition that would benefit from ER services, and that he (the doctor) would be available for medical consult. Dad has fallen twice since then. Once he was sent to the ER, in part because he had a nasty cough, which was treated as pneumonia and with diuretics. The second time, he appeared unharmed, the nurse did a thorough exam and consulted with Dad's physician and opted to not send him the ER, but checked in on him every 15 minutes for the next day. The ED later came up to me and said that she was very happy with the arrangement and that my father's doctor was very responsive. So far so good.
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Reply to Weary418
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Further update. They now call the EMTs for any falls, and call me. If the EMT thinks the patient should be transported to the ER, they will call me and we can discuss why at which point I can refuse service if I think that's warranted. The last two times Dad has fallen, the EMTs said that there was no reason to send him to the ER, dressed any skin tear, put him back in his chair, and went on their way.
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