Hospital vs. MC (warning: graphic description of injury)

psg712

Yesterday morning I got a call from MC that they had called 911 to transport mom to the ER. The MC staff found mom sitting on the floor with a "bad cut" on her arm. When I asked if they were sure she needed the ER, they told me she would need stitches. When I asked if I could take her instead of sending her by ambulance, they told me that the ambulance was on the way.

So I met her at the ER. "Needs stitches" was an understatement! She had fallen against her dresser, must have caught her arm on the corner of the drawer handle (metal) on the way down, and ripped a huge flap of skin and tissue out of her forearm. All the way down to the muscle. She was literally covered in blood, head to toe, and it took the ER team a bit to examine and make sure there was nothing else cut. Just one small slice on the inside of her hand. They did numerous xrays and a CT of head and neck, since the fall was unwitnessed and of course she couldn't tell them if she bumped her head or anything else.

After all the tests, a tetanus shot, and repair of the injury, she was cleared to return to MC. This time I drove her back. She had a prescription for an antibiotic, Keflex, and Tylenol for pain, plus instructions for daily dressing changes. MC staff welcomed her back and were very helpful in finishing getting her cleaned up beyond what I was able to do at the hospital.

The issue arose today when I went in to check on her. The med tech informed me that they can't give her the Keflex since this drug can have cross-sensitivity to penicillin (she has a penicillin allergy). The hospital provider and I had discussed this yesterday, noted that she has received a related IV drug in a recent hospital stay without adverse reaction, and decided to proceed with the Keflex. MC med tech said no way. She then admitted that mom had been given 3 doses of the Keflex before they realized the cross-sensitivity. So now they will not give her any until she is seen by the facility PA tomorrow.

They also will not change her dressing until tomorrow. The aides are not allowed to change dressings. It must be changed by a nurse, and this facility doesn't have a nurse except during the week (unless the health director, an RN, happens to be the admin on duty for that weekend). So no inspection of the would till48 hours after the injury.

So much for hospital discharge instructions. I plan to be there when the PA and the nurse see her tomorrow. I want to see the wound and address the antibiotic issue. Any thoughts on this type of situation, where an acute care provider makes a recommendation that MC facility policy won't support?

M1

there is 10 percent cross reactivity between penicillin and Keflex and the fact that she had already received three doses without problems is sufficient to keep giving it. Some folks like to create drama where there is none. But I wouldn’t sweat it , waiting until tomorrow to sort it all out should be fine. Sorry that has happened, we had a similar bad fall in June

Anonymousjpl123

I am so sorry she had a bad fall - very, very scary. I am that surprised re: MC response. They just don’t seem to always have the medical/care flexibility i would think they would. I think you being there tomorrow will help. Hopefully her wound is healing ok, with no infection. Like M1 said she already received three doses which is good.

I had a similar drama when my mom was planning for surgery a year ago. She was not supposed to take a medication starting one night before the surgery and I had to move heaven and earth to get this ok’d at the MC.

I think they really are limited in terms of what they can do. Sending my very best energy for your mom’s healing. This sucks.

psg712

Thanks for the info and encouragement. I don't want to make a bigger deal than it needs to be. I really do appreciate the staff at her MC, and I could see their genuine concern for her when she got back from the hospital. If the fall had happened on a weekday, this would have been easier to sort out. It just seems that policy is pretty immovable when it comes to the actions of unlicensed staff. I get it, standardization helps with safety. But really, Anonymous, they couldn't hold one dose of a medication per the surgical team's instructions? Seems a bit ridiculous.

housefinch

What a nightmare. Seems like 3 doses without a reaction = she’s ok taking the Keflex. And the dressing changes—-I know how these situations go—-“it’s not in my scope of practice” etc…. I’m sorry you and your mom are dealing with this situation. Hopefully someone can update her medical record to note she can take cephalexin/cefazolin (the IV version). But hopefully she won’t have more ER/hospital visits for a while.

NizhoniGrrl

My mom was told at rehab by someone that she must not be allergic to penicillin anymore because she has been taking Keflex with no adverse reaction. There is a lot of confusion about these two drugs but I think the current understanding is that an allergy to penicillin does not automatically mean that you will be sensitive to Keflex. She sounds like she is fine with it.

psg712

The facility PA and health director (RN) agreed that the Keflex was probably fine, but the PA decided to switch her to Levaquin anyway to avoid the pharmacy conflict. Oh brother. But I got to see the wound when they changed the dressing. It is healing well, considering the depth of the injury.

They decided not to follow the ER recommendations for daily dressing changes. Since there was no drainage and no appearance of infection, they think that unwrapping it daily will be more exposure and also encourage her to mess with it. It does seem like "out of sight, out of mind" has applied so far ... even with a bulky dressing, she doesn't pay it much attention.

Here's another minor eye roll: the facility PA is ordering home health nursing to come out for dressing changes and wound assessment. I saw this coming, having seen similar situations with other residents there. I could do the dressing myself, but I will be out of town this weekend and I want someone to be responsible for assessing and documenting. Plus the location of the wound on the upper inner forearm makes it necessary for a second person to position it while the dressing is being done. Mom was none too pleased about her arm being touched yesterday, and I had to do a lot of reassurance and distraction to get her through it.

M1

Levaquin can have way more side effects than Keflex including diarrhea and confusion. I’d suggest a low threshold for requesting they stop altogether. What she has had is probably sufficient, especially with ongoing dressing changes.