LVN in SNF goes behind family's back and orders antibiotic for hospice patient. Has she broken a law?


Has anyone else experienced this? This is the same LVN that argued with us when FIL was placed on hospice. Now MIL is on hospice, she came down with an upper respiratory infection and LVN told doctor that family had approved antibiotics to treat chest infection. The medicine was ordered, picked up and administered without notifying family. Has she broken some kind of law here by taking it upon herself to make the family's decisions? I don't know if they would have chosen to treat of not, they were never given the option.

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I'd go with stupidly deliberate. You know my mom had a high option BCBS as my dad was a fed. Well the fed BCBS is most excellent and covers way more than other BCBS policies with no-copay either. Anyways when mom went into NH # 1, it was via Medicaid pending (she is mid 90's and just flat outlived her money) but until Medicaid is done, her Medicare was billed for whatever they paid (or rather didn't pay LOL) BUT her BCBS was billed for most of the medical services (like PT, OT, specialized nursing) as BCBS fed pays a really high reinbursement rate and covers a huge amount of services. Well, once she got on Medicaid (6 months later), her BCBS got suspended. Was done within 60 days. Not canceled but "suspended" as that is how the fed policy works so that later if need be it can be reinstated.

Anyways, NH # 1 had major changes and issues and was not the NH it was initially when mom moved in...3 adminstrators in less than 1 year, the med director got removed from the gerontology practice and from within the medical school program... Just a clusterF waiting to happen. Moved mom within the year and a couple of months after accepted by Medicaid& BCBS suspension done. Moving her was super easy too, although I had to wait like an hour for her blister packs of medications from the nursing station but I wasn't leaving without it. Told them that mom was going to pee on the floor if we had to wait longer too. That moved them to somewhat faster than glacial. But I digress.... NH # 1 business office took forever to update and deal with billing. I sent them a couple of registered mail letters that BCBS change was coming too during the Medicaid Pending period as a cya for me. Well BCBS did a claw back to the NH for all the monies it had paid out by deducting it from other BCBS $ to them. Big butt difference in $$ too. Billing was some kinda mad and billed me for the difference. Yeah sure I'm right on that, lmao. Mom was already in new NH # 2 and there was nothing they could do. If you take Medicare & Medicaid, you agree to accept as payment in full whatever the reinbursement is. If too low, then too bad. You know, you should get a BCBS statement of services paid on a regular basis and it will have the date of service, provider paid and the code. BCBS in my experience is some kinda detailed and accurate. If BCBS overpaid the facility, they will do a clawback.

Stark is pretty fun detective work. Find out who the holding corporation(s) are for the NH. Then look for the names of the companies paid by the NH then cross it with your Sec of State corporate database. If there is overlap in ownership or relations in ownership, then Stark can come into play. Federal offense too.

I bet UAW national has someone who is the point person for BCBS, you may want to find out who that is. Good luck.
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igloo572, I am still concerned with the nursing home. The new DON that disciplined the LVN has left, supposedly LVN and billing person and asst DON had something to do with her departure. I will do some reading up on Stark law. My most recent battle with them is over MIL's bill. She had unusually excellent insurance that covered her nursing home (room and board) during hospice. I had the most difficult time getting them to believe she had the benefit. Such a mess, no time to write the details of the local billing person's incompetence. She sent me a bill for June- for over $4,000. I ignored it at the insurance coverage had been verified. Local biller had the nerve to tell me they were billing that for me as "a courtesy". I told her that their contract with BCBS says they MUST submit the bill- not me. I told her they will owe me once May and June are paid by BCBS. She said I had to pay in advance for May and June. I explained to her that a Medicare facility can not bill me for services that are covered by insurance. She doesn't hear a word I say. She has lowered the amount "I owe" by over $3,000. since they received the April "hospice boarding" check from BCBS.

So annoying, in the end, once BCBS finishes paying, they will owe me about $1,000. yet they want me to pay another $1600. in the meantime.

This is the same billing person that told me BCBS had denied the coverage to her over the phone. BCBS told me they didn't even have a record of her calling them. It is difficult to get the coverage verified. You have to be persistent with BCBS when you call and make them look carefully at her policy for the "5th level of care" not many people have it, it's an old UAW benefit.

You have to wonder if LVN and these staff standards are conspiring and why? Keeping the bed full would be one reason. Why demand I pay upfront for something they know her insurance will pay? Reminds me of the Pharmerica scam that they pulled initially. Are these ignorant actions or are these deliberate actions?
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Oncehated - our condolences for your losses. Are you still perhaps thinking about if you still want to deal with the irregularities with the nursing staff and the NH? If that LVN is still there and NH ownership is the same, they are going to do the same to others. WIth your MIL being gone, no worries on anyone at the facility causing repercussions towards your MIL. If you have the fight in you or are just cut out for it, you can request a Stark Law file be done on the NH and the hospice.
The CMS (Centers for Medicare & Medicaid website - it's the federally maintained clearinghouse on all things M & M) website has info on Stark reporting. IF there was any Medicare or Medicaid $$ spent, then Stark can be done and it is pretty serious. If you think there is any overlap in ownership or relations in ownership of any ancillary vendors (from laundry, to pharmacy, to contract labor nursing staff, OT, PT) who get any Medicaid or Medicare $, then Stark comes into play. And it can't be fluffed off, like a facility will do to residents family.
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orangeblossom5 and dljbohsix, Thanks for your kind words and thoughts. I do hope that our difficulty can help other people who find themselves in a similar situation. My MIL was quite ill and had been on hospice almost 2 months. Her digestive system had basically stopped working. At the end her bowels were moving regularly (after all the de-impacting that was a relief) she was eating, even was feeding herself again, but nothing nutritionally was being absorbed. She was always hungry and always losing weight. She had been a big lady, the weight loss was steady over the last two years. She originally weighed over 250 pounds and last month weighed 118. For a lady of 5'11" she was thin and getting thinner.

She could showtime till the end. Didn't know who I was on my last visit but enjoyed drinking sprite (2 cans!) and a lemon pudding cup. During her last visit with her son. I prompted her that someone was here to see her and she showtimed like a pro. Had no idea who he was, she inquired of him, "how's your family?" and made appropriate generic responses to his news. She could still respond correctly to directions like raise your arms, how are you?, etc. I have been told that some people with vascular dementia do retain speech until the end, she did.

Two weeks ago she had an unusual two days in a row where she was like her pre-dementia self. Way, way back self. We took advantage of those days to place calls to her family - she knew who they were and spoke to them as thought they had just spoken yesterday. They all had trouble controlling their crying as they spoke to her. She and I watched tv together and she laughed at the appropriate times - she hadn't been able to really understand tv for the last year and a half. She had been a dedicated tv watcher all her life, too bad that the one thing she did enjoy daily in her life was taken from her. The first day she asked if I would bring her some new clothes like I was wearing, I brought them the second day and we hung them where she could admire them and we showed them off to the SNF staff as they came through on their rounds.

On the third day I arrived full of plans for who we would call and I thought I would take pictures of her in her new outfit. We hadn't taken any pictures of her since she had gotten so ill.

She was dressed in the clothes we had hung out, but she was not "there" anymore.

She ate twice the usual amount for breakfast the day she died. During her last hospital stay I would watch her vitals on the monitors. Sometimes her blood pressure would go so, so, very low. Vascular dementia seems to run some body systems on some days and not on others. Her kidney numbers would jump around. I suspect that she just slipped away in her sleep when one of her systems was down.

Passing on the same date, one year later- really has thrown me for a loop. We had just toasted my FIL's life a few hours earlier noting the anniversary of his death. We toasted him with a beer named "Arrogant Bastard" - -he would have loved that choice. We hadn't mentioned it to her yesterday as it would have distressed her. Most days she thought he was still living and she had just been talking with him. Her Mother's Day helium balloon is still floating in her room. She had spent a lot of time looking at it as it wavered over the bottom of her bed.

That's it folks, I am sure there will be some family stuff coming up as we try to gather her children for a double memorial.

Thanks again for the responses.
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I just saw where your M-I-L passed and a year to the date from her deceased spouse. I also found strange things like that happened a lot?
I realize she was very sick and now 'No more suffering'
I will always wish you and yours well.
I also agree with OB5 this may help others with similar issues. I am all for better Hospice Education.
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Dear Oncedhil: I have just come upon this thread, and with the sad news you just delivered, can only offer my condolences to you your and your husband. I believe the protocols you described will be useful information to others who may encounter the types of situations that you did, so thank you for sharing your experiences.
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dljbohsix, thanks for keeping the story in your thoughts. My MIL passed away this evening. Today is the anniversary of her husband's death. Just doesn't seem possible that she would pass away one year later on the same date. Thanks so much for responding.
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Dear OnceHD-I-L
Yes you had every thing in order and quite well! When I worked along-side Hospice, all went well. My biggest problems came from the Aides. They were always begging me to do more! I could understand that more as they really had hands on the be-loved patients a lot.
There are still a lot of problems that Instruction needs to be given to many Nurses.
Patient and Family wishes should be followed.
Sometimes I would get somewhat up-set with families, that was keeping their loved one at home and still working with Hospice. (That is done a lot in this area)
But even some 'Family Members' can really get into trouble with the Hospice Patient they are caring for.
Some of these would end up at our facility because they were in so much pain. The family member/members had the 'Mindset' that their loved one would get addicted to the pain medicine and only give a little of it?
It is then hard to get the correct dose for the patient from Hospice and the Nurse.
Your story is in my thoughts.
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Yes, dlj, it had all been decided and laid out in the meeting between my husband, hospice and the SNF. My MIL was put on comfort status for medication to treat her vascular dementia and my husband clearly stated that any other conditions would be decided by him on a case by case basis. While on hospice you can be treated for other conditions, you can't be treated for the condition that has qualified you for hospice.

An example is a UTI or bronchitis, those things MIL can be treated for if my husband agrees. Vascular dementia has given her the terminal diagnosis.

To update - the local pharmacy has flagged her file that no one may pick up meds for MIL without the authorization of my husband.

I met with the DON, asst. DON also. This week no one is trying to cover up that the LVN did this deceptively. They all said that she had not told any of them about the antibiotic, which is unusual in itself. They found her action to be deceptive, they believe us that this was an effort to sabotage the hospice status. The LVN was scheduled this week for remediation hospice training. That action satisfies my husband.

Yesterday a question came up regarding a new treatment. The LVN spoke with the doctor, he gave her a possible med that could be ordered if my husband wanted to treat, the LVN called hospice who okayed the med and referred the LVN to my husband for his decision. That is how it is supposed to work.

This is a delicate subject for many people. People on both sides feel quite strongly. We do understand that the LVN has very strong thoughts regarding hospice and is willing to act on those personal beliefs. The new DON does not support the LVN's sabotage, the old DON did.

This is my husband's family's decision, the LVN has no right to interfere. Hopefully this incident proves the point to the new DON and they will keep a better eye on this LVN in the future now that they have seen that we were telling the truth.

I do understand that the LVN has dedicated her work life to helping elderly people live and enjoy their time on this earth. She is exactly who you want taking care of your parent in a SNF. Well, until she decides that she has the power to make decisions that are not hers to make.

Truly its the same mentality as a medical professional that decides to sabotage a family's desires that everything medically possible be done for their elderly loved one. My MIL's thoughts on this matter were quite clear in her directive. Some people want everything possible done for them, some people don't.
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I worked with Hospice on my floor for years. Yes there have been changes in their ideas. At a time NO medicine to make one better was given, but now they do give Antibiotics in some cases, as they do radiation to stop pain. (they do not approve feeding tubes and life support means.)
When I needed something for a Hospice patient I only had dealings with Hospice and never a doctor.
I really did not realize how big the devide was between Nurses on these issues. I thought most of us felt the same, but in surveys it shows some nurses (no matter how sick the patient want to go beyound the scope to help them live even a short time longer, and many times in misery?
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