What happens if Mom or Dad insists on Leaving the SNF?

Nobody wants to be in rehab. But that doesn’t mean that rehab isn’t necessary sometimes, and it doesn’t mean that rehab is bad. It just means that people value their privacy (which isn’t available in SNFs), and they want to be in their own homes. It’s normal.

So I view this in three categories:
People who want to leave, and are able to care for themselves.
People who want to leave but cannot physically care for themselves.
People who are too confused to care for themselves (dementia, delirium, intoxication, mental illness)

People who want to leave, and are able to care for themselves.
SNFs are not prisons, and SNFs are not allowed to prevent cognitively intact people from leaving – doing so is false imprisonment. Patients who are “cognitively intact,” —meaning that they are alert and oriented, can understand their medical condition, can understand the reason that they have been admitted to a SNF, and understand the risks of leaving—have the right to leave. It may not be a great choice for them, and it may result in them getting sick or injured, but they have the right to make their own decisions, even if we don’t agree with or like their decisions. Sometimes they are perfectly capable of caring for themselves and have plenty of resources available at home and really don’t need rehab.

Administrators will discourage them from leaving citing “liability” (which is nonsense), or they will threaten that Medicare won’t pay for their care. The Medicare threat is wrong, and the threat is specifically prohibited by Medicare regulations and is reportable to the department of health. Administrators and physicians will refuse to write prescriptions for patients who elect to leave “AMA” (Against Medical Advice). This is also specifically prohibited by Medicare, and is “patient abandonment”, which is illegal. It is the Administrator’s responsibility to assure the safety of the patient as they leave the facility (assisting them out the door, and even helping them into a car if necessary).

Medicare regulations require that the patient’s bed be kept available to them for 24 hour even if they leave against medical advice, so the patient can get home, realize that they have made a mistake, and then return. Their re-admission cannot be declined, even if the Administrator is unhappy.

“You have to sign these AMA papers!”
No you don’t. AMA documents are legal documents that indicate that you are taking responsibility for leaving, and that you are leaving facility against medical advice. The facility wants you to sign these papers to demonstrate that they did everything that they could to explain why it is better that you stay, and absolving them of responsibility if you get sick or hurt. Ideally you should sign the papers after they have sat with you, explained everything that is in the papers, and then have you sign to prove that you understand the risks you are assuming. But you are not required to sign the papers, and signing them is not a requirement for exiting the building. The papers are often wielded by frantic nurses or administrators as patients are exiting the building. By the time that happens, they have already missed opportunities to sit with the patient and address their concerns.

People who want to leave but cannot physically care for themselves.
Again, as long as patients are cognitively intact, they are aloud to leave. If that patient is at high risk of injuring themselves, then it is the obligation of the SNF physician to make sure that the information is clearly explained, that the patient understands that risk and is willing to assume that risk, and that the conversation is documented. If all that is done, again, the patient is legally allowed to leave, even if it is “Against Medical Advice.” It is the ethical and legal obligation of the SNF to make arrangements for the patient to leave safely: equipment should be ordered and delivered to the home, Visiting Nurse and outpatient therapy should be arranged, the patient’s doctor and family should be notified, prescriptions should be written or called in to the pharmacy, and the patient should know that they can come directly back if they realize that they have made a mistake.

People who are too confused to care for themselves (dementia, delirium, intoxication, mental illness)
This is the trickiest category. Patients who are not cognitively intact cannot legally make the medical decision to leave the facility. It is not uncommon for patient’s with dementia or who are mentally ill to insist on leaving. These cases require the intervention of the senior staff and physician to talk the patient down, address their concerns, and convince them to stay. In some cases, medications may be warranted to protect the patient or staff from injury. The quandary is that SNFs are not legally able to physically restrain a patient, so if a patient is successful in exiting a building then police or EMS may need to get involved to pick up the patient and take them to the Hospital, where different restraint laws apply.

Patients have the right to a Day Pass
A surprising number of nurses and administrators don’t know this, but patients have the right to leave the facility (with family or on their own) and then return. Medicare Regulations specifically state that patients may attend doctor appointments, meals, church, or social occasions and then return to the facility for continued care. The physician simply writes an order for a “Day Pass.” If a patient is unaccompanied by family, it is wise for a facility to provide an escort to assure the patient’s safety.

The patient is required to return to the facility before midnight in order to keep their bed and prevent being discharged. A physician or facility that refuses to allow a day pass without specifically documenting verifiable reasons why it would endanger the patient, is violating Medicare Regulations.

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