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

The ER trips are more than likely a "better safe than sorry" policy. If someone falls and it is not looked at by a doctor, they can possibly be held liable. With a little tumble, observed, perhaps best not to go the ER route, but at the least they should call the responsible party and let them decide (including YOU should check your LO, not just take the call and brush it off!) The problems with sending someone with dementia off to the ER are many - will there be an aide with them to prevent wandering? - will they be attended to asap? - is the person even able to express any issues they have with the doctors and nurses (or EMT)?

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.

Rosemary I found no aspect of care more stressful than the falls risk. I had only my mother to care for, one-to-one, 24/7, and the ways she found to fall turned my hair white.

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.

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.

D yourself a favor. Do not change policy. My mother was found on the floor by her bed. Never taken to hospital "just looked over". It wasn't until the girl who does her nails came back from vacation 7 days after noticed obvious problems and stayed she needed a hospital. She had a subhemotama and us now dead. The neurologist, as well as staff were more than shocked she was never brought tib the hospital.... and now we are broken. Coroner, DA, attorneys are now all getting involved.... there is no amount of money that can bring her back..... and that's all I want.... it may seem so "trying" or "frustrating" to be constantly called.... nut be glad you are. And talk to the staff. All residents have a "care plan" and those plans are always adjusting and changing to meets the person's needs. Especially in "frequent fall" situations.... and find your local support group for children of parents w/ dementia etc.... each person has experienced so much, I'm sure a.lot of what you are, and they all have answers and tips for eacvh situation..... good luck...

Two thoughts come to mind:
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.

Yay! That’s great! Way to go...

Good for you, Weary418! Your actions probably saved a lot of expense and hassle for a lot of people.

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.

Hi-
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.

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.

Our mother has a very good BCBS policy in addition to medicare, and so far they have covered the trips to the ER via ambulance (of course insurance companies are always looking to cut costs, so that may eventually go away!) The first few falls they sent her to the ER (I was called first, but I was away from home and was not close enough to transport her myself.) In our area they also have "transport" vans - much less expensive than an ambulance, especially where there is no visible injury that needs immediate attention from EMT. The hospital is very close, so the one time they used it, it was only $10 (not covered by insurance.)

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....

Weary, you said in one post that your dad forgets that he needs wheelchair and/or walker and gets up and then falls. My LO did that too. She would get up out of her wheelchair and hit the floor AND she would get out of bed, forget she couldn't walk and hit the floor. What helped her A LOT was a belt alarm on her wheelchair. It doesn't keep her in the chair. All she has to do it is unsnap it and an alarm goes off. She is able to unsnap it, but, when she hears the alarm, she giggles and snaps it back. So, it works to keep her from getting up unattended. If she did try to get up, a staff member would be coming to assist her after hearing the alarm go off.

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.

A lot of elders will resist the walker. I found my mother "ditching" her walker anytime someone wasn't looking. Perhaps this facility HAS had lawsuits and changed policy for protection. To avoid paying each visit, you may want to consider changing Medicare Supplemental policy.
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 main word here is "unseen". Residents have to be sent to the hospital if they hit their heads. Since no one witnessed the fall, they r not sure if resident hit his head.

£1.49 billion in the year to March 2016, is the figure for NHS payouts on claims for negligence. The NHS has its own litigation service, the NHS Litigation Authority. In 2017, the reserve it recommended was £60 billion.

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.

We have several people in this forum from the UK, Canada, and Australia (among other places)--is the situation similar in these countries, or are people as litigious as in the US?

If you do not want him transported to the ER there might be a few things you could do to "get around" this new policy.
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.

This is sad but the ALF are concerned about lawsuits against their facility and have instituted this policy to protect themselves from suing families. Unfortunately, we are a suit crazy population. Good luck about getting them to change their new law.

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.

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.

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.

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.

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. 

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).

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.

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'm bumping this up to see if others have more input.

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.