For some reason, they won’t let patients go to the facility as outpatients. It’s not set up for that. She will still get rehab at her own continuing care facility, but only three times a week instead of six times a week.
^ and does your mother qualify, as mine did, for 40 visits( I think ) for PT and OT to come to her ? So possibly your mother could maintain a similar level of PT?
Wheels within wheels. Mom called today and said they told her she was being released. Yay! But then it transpired tht she thought she was being released right now. When my sis arrived to visit her, she was sitting by the door thinking she was about to go. Although the communications from the facility have not been perfect, I’m pretty sure nobody told her she was leaving today.
Then the director of the facility called, but she won’t talk to me because I’m not on the HIPAA forms, so I have to wait for other sis to get back from a meeting.
But it looks like the facility will be working with us for the discharge, which is great.
We will find out how much PT and OT Mom qualifies for. It should be a lot. We were worried that if Mom was released AMA, we couldn’t get the PT/OT orders, but now I’m hoping that issue is resolved and the facility will cooperate and get Mom what she needs.
Wishing you a smooth transition. I think that the benefits of having your mom be back in her apartment with assistance far outweigh the possibility of further PT progress. Good decision, she will be happy!
Ay ay ay. Just when we thought we’d be able to get Mom out, we had this meeting with the staff of this rehab facility, in which they explained to us that the nursing supervisor asked Mom, and she said she wanted to stay there, and they were looking out for her interests and couldn’t discharge her.
I should remark that right after this meeting between Mom and the nursing supervisor, my other sister came to visit Mom. Mom was sitting by the door with her coat, expecting to be discharged from the rehab center right then and there. She was glowing with happiness that she was getting out. Now, I am certain that the nursing supervisor did not tell Mom she was being discharged, but the fact that Mom is confused enough to think she was on her way out indicates that she is not capable of making this decision.
So Sister One and I talked it over with Mom. She wants to go home right away: when we told her that the staff had told us they’d have another meeting about her discharge two weeks from now, she gasped, “Two weeks!” She was thinking she’d be out in a couple of days. She also wants to stay at the facility in rehab until she can walk (which will be never). Undoubtedly the staff can pick and choose what she says to suit their needs. Mom told us that we should make the decision… but we are not allowed to make the decision.
I don’t even know how to proceed. We can’t even discharge her against medical advice, because they are saying that she is competent and she wants to stay.
I left a message for the NJ Ombudsman for the Elderly. They’re supposed to call me back.
You are working so hard for your mom Cardinal Fang. Big, Big Hug.
Wow, @“Cardinal Fang”! Sounds like so much stress for you and your family. I’d be very concerned about that facility! Hope you get the Ombudsman and can resolve this promptly–it’s already caused you and your loved ones way too much time and stress!
I have to say that the facility itself is fine: kind staff, skilled therapists. But whatever they call it, it’s actually a hospital. And I don’t see why Mom should be in the hospital for months and months, when she could get care at home.
Cardinal Fang maybe there is a compromise mom stays another week and they have a review? The acute rehab where my mom was for seven weeks- conducted weekly reviews. You can ask for those medical reports, which may be helpful. The actual physical therapists reports of goals and attainment were very helpful to see in writing what their stated objectives were, and how mom progressed.
Yes, it may be a great place, but I’d be very unhappy about a place that naked it so tough for patients to leave, where adequate supports are available and family clearly wants to have mom moved.
They told us they’d do a review in two weeks. They dragged their feet about getting us the medical records. It took a week and we eventually had to pay $17, but we got them today, and although in the meeting the staff was unable to explain to us what the concrete goals for Mom were, the goals were clearly and specifically laid out in the record. They never would give us any time frame, but lo and behold the goals were for two weeks and eight weeks. I don’t know why they couldn’t have shown us these things a month ago when she was first admitted.
I am so mad.
I think it was a good idea to contact an ombudsman. Who on their, (rehab. facility), staff determined that your mom is capable of making informed consent? How and when was the evaluation done, request a copy of the report asap to discuss this with the ombudsman. Arrhg…
Good question. We didn’t ask who in the staff determined mom is competent to consent. We have her medical records. Nobody did any evaluation to determine she is competent.
Does she have a diagnosis of dementia? Is there a conservator or guardian?
We went through this when FIL wanted to leave rehab. They told us they could not keep him against his will. He has no diagnosis in his chart, although it would take you 3 minutes to determine he is incapable of informed consent. In his case, his CHF got worse and he went back to the hospital and then back to rehab, and hasn’t put up a fight about being there again (yet).
CF, sounds like your mom will agree to whatever anyone suggests, and that it will take a sustained effort to get the facility to start working through your sister with HIPAA authorization and POA instead of around her. I assume they deal with a lot of pushy greedy unreasonable families, and they haven’t yet decided whether you are in that category or not. Since they hold your mother’s welfare in their hands, it’s up to you and your sisters to firmly, steadily, and non-threateningly charm them into working with you.Then you can go back to the hotel and drink if you want to. Really best to avoid a fight if you can help it, fights get ugly and help no one.
You mentioned she will not be able to get back to walking. Was she walking before?
No one wanted to talk to us about it (and the BIL with POA and HIPAA authority didn’t press it), but the speech therapists were doing a lot of cognitive evaluation.
I would be livid. I hope the ombudsman is able to help.
I’d make the next call to a lawyer.
I’m nervous that if we have her declared legally incompetent they’ll say she can’t live in the independent living part of the facility.
We’ve heard from several other people, including her doctor, that it’s difficult to get them to agree to discharge someone.
I would say the greed is on their part, not ours. We acknowledge that it would be cheaper to let Mom stay in the rehab with Medicare paying than to hire aides and therapists at her expense, but we value her quality of life.
^cardinal fang- first kudos for all you are doing for your Mother’s happiness. Patients need advocates.
Curious, do the PT’s state, in the medical records, that their goal is for your mother to be able to walk?
Really? Why? I can’t think of anything that would get the rehab center more defensive and oppositional than calling in a lawyer. I get that CF’s family and the rehab center have different ideas on what is the best course of treatment for Mama Fang. But lawyers? That can only stretch things out, and CF’s whole point is that her mom has little quality time left.