Trouble "negotiating" with-P's assisted living place to pay for her IV antibiotics--sue?

[TerryJ2]

Arrgh!
Cousin P was bitten and scratched by her cat in early Dec.
It got infected.
The nurses were alerted by S, from Visiting Angels.
They put antibiotic cream on it and bandaged it.
It quicky got out of control, turning red and spreading and hot to the touch.
She told the nurses to call the dr.
I called after she went home and asked the nurses to call the dr.
They left a msg and he blew them off.

We took her to the pain mgmt dr last Monday for her chronic tailbone pain. He pretty much ignored the tailbone and looked at her leg and told us to get her to a surgeon and get an xray asap.
After she rec'd emergency antibiotics at the ER, I told the asst living dir of nursing that I wanted them to pay the bill.
The rest is in the correspondence below.

*****
Good Afternoon Terry,

I wanted to touch base with you as I promised regarding the investigation with Ms. L’s cat bite and its subsequent treatment.

We have documentation that the bite was reported the evening of 12/18. T immediately treated it and notified Dr. L asking for an antibiotic and treatment order. He responded and provided an order for a topical antibiotic daily. Documentation from the 18[SUP]th[/SUP] and 19[SUP]th[/SUP] reveal that the bandage was changed and antibiotic applied per order, with only slight redness and no fever. On the 20[SUP]th[/SUP], it was not changed as she was documented out of facility. (this was the day of the pain management visit and subsequent ER visit) Worsening seems to have occurred quickly between the 19[SUP]th[/SUP] and the morning of the 20th as is a potential complication with a cat bite. I spoke with Dr. L at great length on the 24[SUP]th[/SUP] regarding his treatment plan. It was not appropriate to place Ms. L on a systemic (oral) antibiotic due to the risk of progressive insensitivities (MRSA etc) on the 18[SUP]th[/SUP] and thus he placed her on a topical antibiotic as was completely appropriate at the time.
Dr. L acted quickly and prescribed the appropriate treatment on the 18[SUP]th[/SUP]. The nursing staff performed the ordered treatment appropriately on the 18[SUP]th[/SUP] and 19[SUP]th[/SUP], documenting on the condition of the bite. On the 19[SUP]th[/SUP] it was documented with redness but no drainage or fever suspicious of possible systemic infection.

On the 20[SUP]th[/SUP], she was seen at the urgent care and the ER.

Based on the above, there was no delay in service or inappropriate treatment regarding the cat bite in the 1.5 days of its treatment here. Per the documentation, the facility staff acted appropriately and followed all MD orders. The MD did prescribe a topical antibiotic. I did notify Dr. L that you had some questions regarding his choice of treatment and he asks that you call him with any specific questions you may have.

The bite is showing signs of healing and continues to improve. Dr. L’s number is ...
Thank you and have a great evening!
***

Terry,

In addition to the previous email, I spoke with Q and we recommend that if Nipper is proving to bite – you may want to consider a different home for him. I know that Ms. L loves him and he provides companionship for her, however I would hate for one of his bites to cause serious health complications to her or another resident/staff member should he get out inadvertently.
I’ve not known Nipper to bite before now, and maybe it was just a one-time occurrence. I will certainly let you be the judge of that, but we, as oversight at the facility level are just concerned that if it does happen again and we have knowledge that he has done it before; we certainly could be held responsible. If you would like Ms. L to keep Nipper, it is very important that she does not let him out even inadvertently. Certainly you can understand this.

We just want all of our residents safe and happy. Your thoughts on this?

Thanks!


*****
Dear C:

Thank you for your investigation into Mrs. L's cat bite infection.


1) Dr. B, pain management specialist for H, looked at the infection and said that Mrs. L should be immediately seen by a surgeon or specialist. He asked whether M had nurses and doctors and why they hadn't done something other than topical antibiotics.

This was the same question asked by Dr. MB atPatient First, and asked by the ER physician at M.

In addition, Dr. MB said that it was "Too late" for oral antibiotics.

Clearly, the fact that Mrs. L was out of the building that morning was of little consequence because the infection had gotten out of control before then. The point is that Mrs. L should have been given oral antibiotics over the weekend, if not earlier.

If you would like to talk to Dr. B, his number is .
If you would like to talk to Dr. M at Patient First, the number is .

2) I agree that something should be done about the cat. I had already begun investigating new homes for Mrs. L's cat, Nipper, and also the option for declawing him. I have an appointment for blood work at C Animal Hospital next week, and a consultation with the veterinarian in regard to either declawing or re-homing Nipper.

Sincerely,

*****
Terry,
I will make sure to pass the below info and contact numbers to Dr. L and have him call you. Perhaps you speaking with him may help to answer the additional questions you have.
***

 

[DaisyFace]

What a mess!

I find it ironic that a cat named "Nipper" was not known to have been a biter. Nip = Bite.

 

[witzend]

I take it that the cat is a resident companion? I'd contact the nursing home director in writing and explain that they have 24 hours to get your Aunt on IV anti-biotics and to continue to comply with any and all other directions her personal physician gives in regards to this infection. Make sure that they understand that because you have sent the letter by registered return receipt (about $3.00) you will know when this 24 hour period has expired, and that you will contact their licensing authority if they don't comply. No reason to sue, just utilize the resources that are already there for you.

 

[svengandhi]

Doesn't her medical insurance cover the IV antibiotics? I would assume that the staff at the facility could administer it which cuts down the cost as a visiting nurse is not needed.

If this was a cat other than her own, I would be pushing the facility to reimburse for any costs not covered by insurance.

As far as suing, what are the damages? Is it the cost of medicines not covered by insurance or co-pays, was there pain and suffering over and above what a normal cat bite might bring? Please don't think I'm unsympathetic. My H was scratched by a cat and almost died from cellulitis so I do understand. I do think that unless a doctor is willing to testify that the treatment rendered by the facility was improper or deviated from appropriate treatment standards that a medication mal suit is impossible to win. I also know from my experience that a cat bite can turn nasty quickly even if it appears to have been okay just a short time before. My H's arm went from looking like he had a healing mosquito bite to being swollen to twice its size with red hot streaks in just about 2 hours. I think a law suit would be hard to win. Think carefully about what you want to accomplish. If it's to pay unreimbursed expenses, I would ask for that and maybe settle for half of them because it was her own cat. If you want to keep her there for her remaining life, you may just have to compromise as long as there was no permanent lasting damage to Ms. L beyond having to be on IV antibiotics for a time.

I love cats (it was not mine which scratched H) so I think Nipper should be rehomed. I think declawing is cruel.

 

[susiestar]

To help clarify details, Terry posted about this back when P went into the pain doctor then the urgent care and then the ER (all on same day) where she was admitted and given IV antibiotics. She actually had 2 threads about this problem - one for the cat behavior/rehoming and one for the medical issues. The threads were started on Dec 21.

Here is the medical issue thread: http://www.conductdisorders.com/forum/f10/cousin-p-er-cat-bite-yesterday-51778/

Here is the cat behavior/rehoming thread: http://www.conductdisorders.com/forum/f10/need-cats-experts-51776/

This is a situation that you NEED an attorney to help with. in my opinion the staff were hugely neglectful and they need to be held accountable. Get copies of P's medcal records from that day at the urgent care and of her entire hospital experience. If at all possible, ask those docs to document that they told you that she needed to see a surgeon because it was left way too long.

Do NOT let them bully you or sweep this under the rug. They were grossly negligent and P could have DIED. I had cellulitis a few years back and every doctor and nurse I saw said that I wouldn't have survived another twelve to twenty four hours with-o iv antibiotics. I almost lost my leg and that would have been complete removal because the infection was on my upper thigh.

PLEASE do not let them get away wth this. their excuses about audits and other patient's havind crises that day do not in any way change their responsibilities to P, not in the smallest way. If they can only handle 2 patients wtih urgent problems, then they should only have two patients. Just like it does not MATTER how expensive a needed accommodation is for a child wth an iep, it does not MATTER how expensive it is to have enough staff to properly care for patients before, during, after and between emergencies.

You have had almost constant problems with P's care at this facility. Go back through your threads about her and any records/journals/etc... you have kept to see the magnitude of these problems and the toll they have taken on P. in my opinion it now shows a clear and consistent pattern of neglect, though a judge may not see it as clearly. Make a timeline of problems. Then write down all the details and what lead up to the problem (if anything), what staff did/didn't do, how it impacted P, etc.... Take it all to an atty and see if you can get help.

PLEASE look into the elder abuse laws and the nursing home oversight/elder abuse prevention organizations in your state. in my opinion much of this and of the runnng out of her medications, etc... is due to neglect. I shudder to think how they would treat P if you diid not visit so often and take such an active role as her advocate.

Get Nipper out of there. Today. I know it isn't fun, but you cannot retrain this cat. You smply are not there enough and P cannot help with it. If you can't or don't want to take him to your home, find a shelter for him. Yes, I DO hate to think of the cat being put to sleep, but it is irresponsible of you to keep that cat with P. You KNOW that the cat causes serious bodily harm and yet you continue to allow him to stay there where he is basically unsupervised and untrained. P is so very vulnerable and sometimes we must do what is right to protect someone even when they hate it and cry and rage about it. The home is going to claim that it couldn't be that big of a deal because you would have removed the cat if it was.

Get the cat out. Now. then get an attorney. Unless/until you sue and/or report them for elder abuse, they will NEVER change how things are handled.

Also invest in a decent quality camera and take photos every time P has a sore, injury, bruise, etc... Include something to provide scale like a ruler or quarter etc... and if the camera does not have a time/date stamp (or you are like me and cannot figure out how to work it, lol) then put a newspaper in the photo so that the date is showing in the photo. Cell phone cameras have their uses, but often they are low quality and nt nearly as helpful as those taken from a halfway decent camera - esp if the photo is ever enlarged to show details that are harder to see at normal size.

 

[TerryJ2]

Camera ... hadn't thought of that! Thank you.
I have an appointment on Tue to get Nipper blood tests to make sure he's healthy enough for declawing. However, I think it was a Tasmanian devil approach, where cats pretty much wrap themselves around an arm or leg with-all four paws and then bite, too. My cats do it too, but gently.

I spoke to P about it and she said if the health dept said Nipper had to go, she'll move back to NY. Right.

Nipper ... yes, how ironic. However, it can also mean drinking. Soon to be my nickname ...

 

[DammitJanet]

Terry, you could put a camera in your cousin's room that would take pictures every so many seconds. It is really a hunting camera that they attach to a tree and it shoots pictures in both daylight and the dark so it would capture everything going on in her room. It takes stills and videos but doesnt have sound. I dont think you would need sound though. Images are good enough.

As far as everything else other rehoming the cat..all I can say is I think sven knows the most about medication mal suits because she is an attorney. A practicing one.

 

[Hound dog]

Ok. I'm going to have to play a little bit of devil's advocate here since I've spent a lot of time working in such places. But first I have a question........... Is Dr. L employed by the facility or is he your aunt's private physician?

Now here is the devil's advocate part:

1. A cat bite can get nasty fast, even WITH proper treatment, in a young person......in the elderly you can blink and just a common scratch can get nasty, so imagine what a cat bite can do.

2. If she is stating the recorded nurses notes properly (and I'm sure she is because to do otherwise would be just plain stupid), then treatment was reasonable and per doctor's orders. Facility staff cannot issue medications without a doctor's direct order to do so. And trust me, if a doctor doesn't think he needs to it can often take moving heaven and earth to get him to change his mind, and often he won't. Regardless, no order means staff's hands are tied.

If anyone is to "blame" it would be the doctor, not the facility. And even had he ordered oral antibiotics, there is no guarantee that the infection would not have continued to fester and still had the same result. It would be next to impossible to prove that had she received oral antibiotics she would not have had the same result. Perhaps with a different sort of injury, but not with a cat bite, and not with your aunts advanced age.

Personally, I don't see a reason to sue. I think it would be a costly dead end. You might, however, want to nail the doctor down as to why he didn't come and inspect the wound personally to assess whether or not ordered treatment was working or if additional treatment was required. Based on his answer, you might want to seek out a new doctor.

 

[TerryJ2]

Hound and all,
this is a facility doctor. The last one was fired for similar things.
Part of the problem is that the nurses are the dr's ears and eyes, and he has to trust them and listen to them. Either they were too passive in their request or he was too defensive, or both.
He is part of a visiting physicians group and is hired and paid by this assisted living facility.

Any ideas?

 

[TerryJ2]

Oh, and I don't really want to sue, sue. I mean, I just want them to pay the bills for urgent care and then the ER. But I may have to sue to get it. I really think that had she been given oral antibiotics, she would have been better.

 

[Hound dog]

Hmm. I'd look into finding aunt a private physician. Seriously.

I can't speak for this facility, but I've worked in such like places that I can tell you that in all of the ones I've worked in staff docs hoover. Nurses can't do squat with them, they don't want to be bothered. They want to take their pay for being facility doctor, do their rounds (however often that is), and get on with their own practice or whatever. There are, of course, exceptions. I haven't met any personally, but I'm sure there are. In facilities I worked in clients with private physicians had less issue with medical problems. Know what I mean?? (if for no other reason than doctor gets to know them better)

P is in assited living, not a nursing home environment. I'm going to guess that is going to muk up the waters because the accepted level of care is MUCH lower than a nursing home setting. How much it would muk it up I dunno. But it is not the same as a nursing home or hospital setting. (it would also depend on her level of required care)

I just don't think a suit is going to do you any good. And I am certain you'll not get them to pay for a darn thing without one because that would be an "admission" of guilt. Not gonna happen. So you're gonna have to decide is a law suit for cost of medications and care worth the time, trouble, and cost of a suit you're most likely not going to win?

Of course you can consult with a lawyer. But if it were me I'd be finding a private doctor instead.

 

[TerryJ2]

Hmm. Well, P's mental clarity is better (she actually remembered a ph conversation from last wk!) but she is frail, still a fall risk, and not getting any younger. She also suffers from mental illness (Major Depressive Disorder, Anxiety, etc.) and has had several TIAs and progressive dementia. She's not quite ready for a nursing home. Sigh.
I just hate to have them continue on like this with-o being called on the carpet. I don't want to be a thorn in their sides for no good reason. I want to see real changes. I have to give myself some time to think.

 

[DammitJanet]

Oh she isnt in a nursing home yet? I thought she was. What about a rest home which is the step right below it? They live in a family home but there are nurses on staff and she would have her own doctor. They also have community meals fixed for them daily. That is the care Tony's grandmother was in for her entire life. She never got to the point of needing nursing home care because she went into the hospital and died before going into a nursing home.

However with your aunts dementia she may qualify for the dementia wing of a nursing home before actually needing the care of a nursing home. Might be something to look into. However one of those other nursing homes I was talking about on the other threads...the Methodist one...actually has assisted living cottages on their grounds. I find it so very hard to believe my little town has a better selection of homes than you can find...lol.

I have told Tony I want to go into one of those little cottages soon....lmao. Im just waiting a few more years. 60 sounds good.

As far as payment for her medication, isnt it covered under her insurance? She has to have met her deductibles by now for everything by this time of year and I am sure you have her on some type of Medicare Advantage plan which would pick up her extra 20%. She might have a copay but if it falls under part B, it should be less than if she is in the donut hole.

 

[TerryJ2]

Yes, they would only have to pay the deductibles and anything else not covered. Easy as pie and not worth the fight on their part. It is the symbolism, the idea, that I'm after.

This place is part of a trend, where each facility has several layers of care. There are 4 levels for a regular apartment, each with-its own cost, of course. The highest level is the dementia unit upstairs. If the person is more physically disabled, they move to a bone fide nursing home.

I've got my work cut out for me this year.
And I thought my New Year's resolution was just to clean my office ...

 

[svengandhi]

Terry -

Your relationship with this facility seems fairly adversarial. Again, I think you might want to explore other options in your area. If Ms. P has friends at this place and has bonded with any of the workers, you might want to try to make it work here.

I repeat that I don't believe that a lawsuit would be viable in this situation. It would be almost impossible to say whether or not oral antibiotics would have prevented the infection and doctors have reasons why antibiotics aren't just routinely given. Resistance is one valid reason, another is that antibiotics have their own side effects. If an elderly, frail person developed diarrhea from antibiotics, that could lead to dehydration and another entirely different set of problems.

Doesn't the facility have an ombudsman or patient advocate who could mediate this for you? At my aunt's ALF, there is a poster with that information on every floor. If the law in your state doesn't require such a person, contact the oversight board and discuss it with them. First, figure out what you really want. Is it the money for the co-pay and deductible or out of pocket expenses? Is it that you want the facility to apologize and admit that you were right all along? Is it both or some other reasons entirely? Have it clear in your mind what you want before you call. IF it's legal in your state, record the calls you have with the facility from now on.

My aunt is in an assisted living facility and I have our family PCP visit her every couple of months. I only rely on the facility doctor for emergencies and they tend to overreact here because they've sent her to hospital twice in 3 months for things I'd never have taken her in for.

Good luck.

PS - Janet, Thank you.

 

[TerryJ2]

Yes, they do have that. I saw the poster in the hallway. Good idea.

 

[DammitJanet]

Is she on a medicare advantage plan? Well I have no idea how they work for being in an assisted living facility but I would assume medications are medications and would just fall under her part D. I know that IV antibiotics fall under part B. (God knows I hate knowing this much) Once you reach your $200 dollar whatever they call it, then you have that 20% but if she has any type of advantage plan then that should take care of that. I think there is also a medigap program too but I dont have a clue what that is for but it might be for assisted living...I just havent looked into it because I am also on medicaid and dont need it.

Honestly if I was having this much problem I wouldnt be looking at attorney's, I would be looking at changing facilities. I dont think you are going to be happy until you feel comfortable with the care you are getting. Now no place is going to be perfect. They cant be because P isnt going to be the only patient. Even hospitals are understaffed these days.

 

[witzend]

Again, contact the state NH licensing board.

 

[TerryJ2]

I'm hoping to meet with-the dr today. He is in-house.

 

[TerryJ2]

Met with-the dr today.
He was supposed to call me, and was told I was in the bldg, but nada.
Caught him just as he was packing up files and a laptop to go home.

He was stubborn as a mule.
Said he followed protocol.
Period.
I told him that the infection was out of control when the nurse called him, and he said he trusted the nurses (he must play chess; that was my next move) and that everyone followed procedures.
I told him what the outside doctors and ER said and he shrugged his shoulders, said he was sorry it all happened, but she's fine now, and that I should call him directly next time, but be sure to tell the nurses that so it doesn't look like I'm going behind their backs.
I said that I had done that with-the other doctors (he's the 4th dr) and I felt like I was doing everyone else's job. He responded something to the effect that this is typical for the venue, across the board.

I am checking out other assisted living places and nursing homes.