Updated on: November 29, -0001

The Two-Midnight Rule: A Beneficiary’s Daughter's Perspective

By Mary Beth Pace, RN, BSN MBA, CMAC
Original story posted on: June 3, 2015

One of the worst things to happen to our elders is when their health starts to steadily decline. I am there with my mother. She is 89 years old and has pretty significant dementia. To an ER that is what they see: an 89-year-old with dementia. I am sure their antennae go up:  Alert, alert, this could be a social admission, and she is hard to care for.

Well, this is the story of such a visit. My mother has her share of medical problems, complicated by her memory issues. She "loops" when she talks, and we can carry on the same conversation many times. It has helped me develop my ability to be patient, and so it helps the other patients that I serve, but it is frustrating at times for all of us. I am one of six children but I am her DPOA and her best patient advocate. Last week she had an episode that landed her in the ER. To make a long story short, she is having some pain issues that we cannot get under control. We have been to a neurological pain specialist, and the new medication was too much for her – she ended up confused, drowsy, and unable to manage her own care. Of course, this raised a red flag to the ER staff. As a matter of fact, the responders thought she had taken too many meds, and the ER gave her medication to counteract that. All it did was take any pain medication she had out of her system and make her even more miserable. OK: 89 years old, suffering from dementia, in pain, unable to really tell us what is going on, pleasant to some, angry to others. Social admission? Placed in outpatient observation and given plain Tylenol and an IV. An MRI was ordered for her; she had not had one yet, but we knew the site of the pain. Oh, and did I mention this was on a Friday?

Saturday morning: MRI was done, and it shows severe stenosis of the L5, S1 with no nerve root impingement. But the physician tells me if she were younger, she would be a candidate for surgery right away. We are not performing surgery on my mom, but we have to get a handle on some quality of life here. Mom was in terrible pain, with no relief, and now nauseated. We could not send her home this way. I advocated for my mom with the knowledge I had of the two-midnight rule. I said to the physician, "if you do not expect her to be discharged today, please write an order for a full admission to inpatient. " Her response? "The physician advisor is going to call me because we aren't doing enough for your mom to justify a hospital stay." Really? We have no handle on her pain, she is now nauseated and has not eaten anything in about 24 to 36 hours, she is unsafe to ambulate due to the pain, and she is here for all of these reasons. We create a plan of medications to see how we can manage her pain. The physician does write an inpatient order, and a consult for pain management. By Sunday morning, one of the medications given to her the day before made her horribly dizzy. The physician came in and made the decision to cut the dose and keep her safe in the hospital one more day. She is still in pain, and unable to walk very far. Finally, thankfully, by 6 p.m. on Sunday she was feeling relief, was no longer dizzy, and was able to ambulate safely with her walker. Did I mention she is in independent living? She needs to be independent again. The plan was for a lower dose of the medication this evening and a return home in the morning on Monday. It amounted to one day in outpatient observation followed by a two-day inpatient stay, all told three midnights. 

Then this happened on Monday morning: I could hear a physician discussing her care with the nurse. That physician was actually the physician advisor about whom my mom's doctor had warned me. Words like “social” and “unjustified” and “need to change back to observation” were being said. I decided to insert myself into the discussion. Understand that I never looked at the physician documentation in mom's chart; I was, after all, her family member, not a hospital employee. I asked a few questions: Did her doctor document how much pain she was in? Did she document that yesterday she was so dizzy she could not lift her head? Did she document that the plan was better pain control and then a discharge home? We were not trying to get a three-day qualifying stay for a skilled nursing facility (SNF), nor were we leaving her in the hospital over the weekend because it is easier. We were aggressively trying to get her back to a tolerable pain level so she could function and experience a better quality of life.

I am not an auditor, and I never looked at her chart, but I do believe I advocated correctly and used the expectation of two midnights for this Medicare beneficiary in the way that the two-midnight rule was intended to be used. 

About the Author

Mary Beth Pace, RN, BSN MBA, CMAC, is the systems director of case management at Catholic Health East Trinity Health.

Contact the Author

pacem@trinity-health.org

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