Inappropriate Discharge and What Happens
Speaking up is very important, as the following stories illustrate.
Esther R. was seventy-six years old when she went into one of the big university medical centers in New York City for a double hip replacement. She went through the surgeries without a hitch. About one week after the operations, the doctors transferred her to the rehabilitation floor. There she went through a series of physical therapies to improve her range of motion. She also had occupational therapy to practice using a commode. After two weeks the rehabilitation team decided it was time for Esther to go home despite limitations in her ability to stand, sit, and walk.
The internal hip prosthesis is a ball joint attached to a shaft made of surgical steel. Steel is harder than bone, especially in the elderly. Therefore, the patient has to be very careful not to exert pressure on the steel shaft because it will break through the wall of the femur. When people sit or squat as one would have to in using the toilet, they exert outward pressure on the steel shaft. The lower they go, the more force there is.
In preparing her to go home, the nurses should have told Esther that she needed a raised toilet seat with armrests to guard against sitting too low when using the toilet and to aid in slowly sitting and rising. The rehabilitation team members should have also recommended that Esther not go home without a home attendant who could assist her with sitting on the commode. No one told her this basic information, and the discharge planners never made any arrangements. In the end, this world-class medical center with a world-renowned rehabilitation department did a wonderful job in replacing the hips and rehabilitating her to functioning level. However, they failed in the process of discharge like most other hospitals. The attending doctor wrote orders for a home-care nurse to evaluate Esther's needs outside of the hospital, and no one responded. The discharge planner should have picked up the order and referred the patient to a home-care agency.
On the day of discharge, Esther went home via ambulette in a wheelchair with her seventy-eight-year-old sister. The equipment vendor delivered a raised toilet seat without armrests. When it was time for Esther to use the toilet, she had no one to help her. Her sister was unable to offer any assistance other than rolling the wheelchair into the bathroom. Esther stood up, turned herself around, and sat down hard on the toilet seat. At that moment she heard a loud cracking noise and felt terrible pain. Her sister at least was able to call 911. The paramedics came, lifted Esther off the toilet, placed her on a stretcher, and brought her back to the medical center. The steel shaft of the hip prosthesis broke through the bone on both sides.
The saddest part of this scenario was that the accident was avoidable. This is true for many accidents. It is simply a matter of doctors, nurses, and therapists giving serious thought to what will happen after a person leaves the hospital. Everyone who took care of Esther either knew or should have known what would happen if she sat too low and/or too quickly. Unfortunately, they did not convey a warning to the patient. If they had, she would have insisted on going home with an attendant.
If you or your loved one is being discharged, be sure that your nurses have evaluated your current health-care needs and anticipated potential health problems and complications.
A few years ago, a social worker at a Manhattan hospital referred Barney, a sixty-eight-year-old man, for ambulette transportation and home care. He had a fractured right femur, which he had sustained when a taxi struck him down while he was crossing the street. The social worker told me that Barney lived on the fifth floor with no elevator. She said he had to leave the next morning, so there would be no time for me to go to the hospital to do a discharge assessment. She also told me that he only needed help in going up the five flights of stairs. So I arranged for an ambulette with two men to bring Barney to his apartment and for a nurse to meet him there to do an in-home assessment.
The next morning I got a call from Barney's next-door neighbor, Robert: "Are you the nurse that is going to take care of Barney? He has your telephone number.
- I have assigned one of my nurses to go see him this evening. Is there a problem?
- Well, he is sitting on the fifth-floor landing and cannot get into his apartment.
- What is the problem with his apartment? Did he lose his key?
- No, it's worse than that. There is a lot of debris, and he can't get the door open wide enough to fit the wheelchair.
- Where are the ambulette drivers?
- They left".
I got in my car and headed downtown to Barney's home. When I got to the fifth-floor landing I went inside his apartment. This was a three-room railroad flat with every room filled to the ceiling with trash. A narrow pathway led to the bedroom, and there was a tiny amount of space in the kitchen for the stove, refrigerator, and table with two chairs. There was also a narrow access path to the bathroom. It was obvious that Barney could not stay there. Besides the fact that he could not fit through the door, we could never get anyone to come in to take care of him. He was in a precarious situation because he could not survive very long in this predicament.
I called Beth, the social worker, to tell her what was happening. "Barney cannot get into his apartment because it is filled with all of his trash from the last twenty-six years. When his wife died, he stopped cleaning house."
Beth became angry. "He never told me anything about that.
- Can I send him back to the hospital?
- The hospital will not take him back because he has no medical reason to be here."
As flabbergasted as I was, I did not argue because Beth was referring business to me. So I arranged for another ambulette crew to bring Barney to the local YMCA hotel and booked him into a room. Then I got one of my vendor agencies to send a home attendant, who sat with Barney through the night. Afterward I contacted Disaster Masters, a cleaning service company specializing in sifting through mounds of trash, to preserve the valuables and throw away the garbage. Fortunately, Barney had credit cards and some money in the bank, so he was able to pay for everything. If he had been penniless, I would have arranged for him to go to a nursing home after an initial trip back to the hospital emergency room.
So who was at fault here? Certainly Barney would have been better off had he told the whole story. But the social worker did not do an adequate job of assessing Barney's ability to receive care in his home. She blamed him for withholding the facts about his apartment. However, had she engaged him in a detailed discussion about where to put everything and whether the wheelchair would fit through the doors, she would have realized there was a problem.