I’m not sure most people understand how important each role plays in a healthcare setting. My most recent experience is a journey my uncle experienced beginning the middle of September.
While visiting my parents and my uncle on Sunday, my dad said my uncle wasn’t doing very well. He slid off the bed twice the day before, and my dad had to pick him up off the floor. Even though my uncle is what some people will consider “feeble,” he was completely independent with all activities of daily living, showering, preparing food, driving, managing his checkbook, and paying bills online. He was even a community ambulator without an assistive device.
This particular day, and the events that followed, were concerning to me.
When I went into my uncle’s room, he was attempting to get out of bed and was barely sitting on the edge. He complained of left leg pain. He was unable to stand or sit, and he was barely verbalizing anything. We lifted him back into bed, and I took his blood pressure, 220/197. We called the paramedics, and they reported that my uncle was in atrial fibrillation. Atrial fibrillation is something new for him.
After 8 hours of assessments by multiple healthcare personnel in the emergency department, he was admitted. He was clearly hallucinating and confused. The next day, I arrived at the hospital looking for the results from the Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA) that they attempted to do the night before.
Unfortunately, my uncle was confused and combative and was not participatory in any Magnetic Resonance studies. Therapy was not in to see him at all on Monday, and the nurse reported that they would start tomorrow.
The Real Diagnosis
Jumping ahead to Day 3 of his hospital stay, the nurse came in to care for my uncle. I asked the nurse if they received the results yet from the MRI and MRA because we had not heard anything. The nurse informed me that they did have the results from the MRI, which confirmed that he had a stroke in the right cerebellum area of his brain. The nurse also said that my uncle coughed when taking his medications, so speech therapy was going to come in and do a bedside swallow exam.
On hospital admission Day 4, to my surprise, my uncle was sitting up in bed more alert and oriented. I asked him if he knew where he was, and he did know the name of the hospital. I also asked him if he knew why he was in the hospital, and he said for therapy. I then explained to my uncle that the MRI that was done confirmed that he had a stroke. I asked him if he had any questions, and he said no.
The neurologist walked in and asked me if I knew the results of the MRI. I told him yes, and he proceeded to tell me the extent of his stroke, and they were determining the cause. He said that the atrial fibrillation most likely caused the stroke, but they were waiting for the MRA results.
Later that same day, the cardiologist visited and informed me and my uncle that there is no evidence of atrial fibrillation. He said that my uncle has been in normal sinus rhythm with no evidence of atrial fibrillation since he came into the emergency department. The heart monitor continues to confirm no atrial fibrillation. The cardiologist said that he feels atrial fibrillation was a misdiagnosis. The plan was that they would continue to keep him on the heart monitor 30 days post hospital discharge, to see if perhaps he was going in and out of atrial fibrillation.
Physical therapy (PT) and occupational therapy (OT) continued to see my uncle in the hospital for the remaining days, and the planned discharge to a skilled nursing facility (SNF) was set for Saturday. My mom and I toured two five-star facilities listed in our area on the Medicare Care Compare website. I also reviewed the most recent nursing home survey results. The SNF of our choice would not accept him as a patient. Our second choice did accept him, and he was admitted.
The Care Conference
During his stay at the SNF, I found it very odd that the PT and OT interventions were not what I would expect to see for a stroke patient. I started to question my mom to see if anyone from therapy met with her. There had been no communication with her, and she was there at the SNF for 8 to 10 hours daily.
I asked her to speak to the social worker to see when they were planning on having the care plan meeting. The care conference took place on Friday, six days after his SNF admission. During the care conference, we learned that therapy was planning on discharging my uncle home on Tuesday, just 10 days following his admission to the SNF. The social worker explained that my uncle’s insurance company will not pay past Tuesday. I asked what insurance they are billing under, and they proceeded to tell me the Medicare regulations for therapy coverage in a SNF.
Now, you may be laughing at this because I am a Corporate Compliance Officer certified in healthcare compliance. Nonetheless, I listened to her explain the regulations and then I said he has Medicare, so it’s not the insurance company that is cutting him, it’s the facility. I then stated and asked the question, ”You’re telling me that his condition no longer requires the skills of a nurse or therapist after Tuesday, right?” And they said “yes.”
The Director of Rehab provided my uncle, my mom, and I, a thorough update on his progress. I asked if OT had trained him on safe and effective showering and I was informed “no.” I also asked if my uncle received any cognitive retraining, and I was informed that his diagnosis didn’t support cognitive retraining. I then asked, since my uncle is returning home in a few days, wouldn’t it be a good idea for him to be trained how to take a shower safely and effectively? The Director of Rehab informed me that she will ask the Occupational Therapist if they could work on a shower before he returns home. I then explained to the social worker and their Director of Rehab that my uncle had a stroke, and I would expect more therapy involvement to work on his underlying impairments that are still present. The Director of Rehab informed me that his primary diagnosis is not a stroke, but a heart condition. I explained to her that the Atrial Fibrillation diagnosis was not accurate, and that the neurologist confirmed the MRI revealed a right cerebellar stroke. She disagreed with me and said that the information in the record is a heart condition.
Highly annoyed, I could not wait for my uncle to be discharged home. After the care conference, I asked my mom if she was planning on obtaining my uncle’s medical records from the hospital. She said she already did! I was happy to hear that for sure. My uncle was discharged home, with a Home Health diagnosis of Atrial Fibrillation. The same inaccurate documentation the SNF received from the hospital is the same documentation the SNF sent to the Home Health Agency.
Play Fetch!
Question for you: If a family member tells you that their loved one had a stroke and you, as a care provider, had no evidence in the medical records from the hospital of a stroke, would you explore the validity of that comment from the family member? Would you call the hospital and ask for the MRI results?
Outcome
Let’s look at this misdiagnosis journey. The diagnosis of a Right Cerebellar Stroke never made it in the medical records sent to the SNF, nor did they make it to the home health agency either. My uncle’s care pathway did not meet his condition. At the time of SNF discharge, my uncle’s condition absolutely did require the skills of a therapist! The care team missed an opportunity to deliver five-star care excellence to a fresh stroke patient!
- He never learned safe and effective showering techniques in therapy at the SNF.
- He did not have compensatory strategies for short term memory loss, and as a result, requires care from my mom and dad.
- He is not able to drive. He did not renew his driver’s license and his car has been sold.
- He needs reminders to drink fluids and to take his medications.
- He no longer can pay bills, manage his checkbook, and prepare his own meals.
- His quality of life is nowhere close to what it should be.
As a care provider, I see my uncle’s case not as a diagnosis, but rather, a once independent man who is no longer independent. My uncle was the perfect stroke patient, with excellent rehab potential, and an appropriate comprehensive therapeutic clinical pathway that met his needs would have benefited him tremendously.
Never underestimate what a family member brings to the table.
The SNF is not 100% to blame, of course. Our industry health information technology failed. It failed then and it is failing right now as you are reading my story. It must change!
If we had medical records that crossed the care continuum lines, the SNF and home health teams would have had at their fingertips, immediate access to my uncle’s hospital records, his MRI results, the cardiologist’s report, and the neurologist’s report….everything.
I read the entire 632 pages of my uncle’s hospital medical record. All throughout the record, Acute CVA was the admitting hospital diagnosis, “Acute Infarct in the Cerebella’s artery territory,” to be exact.
On the PDPM side of things: Atrial Fibrillation vs. CVA…I wonder what his BIMS score was in the SNF. Think about the SNFs missed revenue opportunities. Oh well, I threw them a bone…. they must not like to play fetch.
For a copy of the full story, please contact Gina at gelkins@fprehab.com