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I told the nursing home social worker that I intended to take my mom home a couple weeks ago, but the charge nurse told me this evening there was no discharge plan for my mom. I spoke with her Hospice social worker as well and nothing has been done.


I told the charge nurse this evening that the place was not fit to leave my dog, I would be taking my mom out whether I have their permission or not and she should pass that information on to whom it may concern.


First I'm told the hospital is sending her to the nursing home for 20 days of rehab then after she is in the nursing home I'm told she doesn't qualify for rehab and she's a permanent resident from day 1. Then they tell me she will be in a private room but the other day the move a roommate into her room. They tell me my mom is okay with her roommate but when I visited my mom this evening she was pissed. I took my mom a phone but couldn't call her today, when I went to visit the phone was unplugged. They needed 2 oxygen concentrators, 2 power beds, 2 power recliners 1 television and 1 cable box. They told me I would have to bring her a different kind of phone because there are no available outlets to plug anything else in. They left her a big monster cup of water that she isn't strong enough to lift then they complain she isn't drinking. I asked them several times to bring her a smaller cup. Tonight they gave her corn for supper even though I've told them 3 times she has severe diverticulitis, no corn, peas, seeds, nuts, etc. The other night for movie night they gave her popcorn. Later my mom's roommate started screaming at me to shut up so the nurse told me I was going to have to leave because I was aggravating the situation. The other night when I was there they forgot to take her to supper, they moved really fast to get her something to eat when I called their attention to it.


She was on Medicaid Waiver for home care, I spoke with her case worker and she can get more hours if she returns home and I have a new home care agency to help out. The only things changed with her is she has different meds and she is on oxygen. Since Hospice is for my mom, not me, I will put up with them coming in her several times a week if they are helpful, but if they don't want to help with her in her home, they don't have to.


I really don't care what I posted about before, my only concern now is getting my mom out of that hole they call a nursing home.

I'm sure you've heard the saying that the definition of insanity is doing the same thing over and over again and expecting different results.

Haven't you already danced this dance with the home health care agency? Didn't you complain bitterly that you couldn't live with the last arrangements that happened when your mom was home? Not enough hours of coverage to allow you to work, but not enough paid hours for you to earn a living?

Didn't that same agency actually *threaten* to report you to APS when they showed up to your mom's home and she was "alone" because you were outside mowing the grass?

What do you think is going to happen once mom is back home? And honestly. how much more help do you think the Medicaid people are going to give you when you once again find yourself overwhelmed and burnt out by mom's needs and you tell them mom needs placement in a facility? Do you not think they're going to remind you that she WAS placed, but YOU insisted she be released back to your care?

Sorry, but at some point we all need to look at our own behavior and ask ourselves honestly if we're being reasonable or not.

Do what you want. But be prepared when things don't work out the way you want them to, or the way you think they *should*.
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Reply to notgoodenough
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From an earlier post: "I had to put my life on hold, give up my job and my apartment to come live with her because she refused to go to assisted living"

Then a hospital stay. You didn't want her to come home. You were totally burnt out.

That was May. It's now June.

And you want to bring her home?

What do you really want?

It sounds like you want Mom cared for but are being blown around by your feelings like a changing wind.

Stop and think.

Would the current SNH do if some of the issues are improved? Find out who to speak to & speak to that person - politely discuss the settling in issues.

Or will you start looking for an alternative SNH?

Maybe you really want to being her home & want to start research care agencies for round the clock at home care instead?

Work out what you want first. Then make plans.
Communicate your plan to the current staff. See if this helps.
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Reply to Beatty
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This is very sad. Not all nursing homes are good. We have some that are absolutely horrible in our state. Others are doing an adequate job.

I have been very pleased with hospice organizations in our area. If you are not satisfied with your hospice situation, I would look into signing on with a different organization.

If you can’t do home care, look into other facilities too. If you have decided to do home care, I hope that you will find the best care available. Wishing you and your mom all the best. I am so sorry that you have gone through these difficult circumstances.

I had an issue when my mom was in rehab too. I spoke to the DON and social worker to file a complaint. I would encourage you to do the same. They should be reported to help prevent the same situation from occurring again.
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Reply to NeedHelpWithMom
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Usually those joints have a social worker that can give you some semblance of help.
They can help set you up with oxygen, a bed if needed and help you discharge her.
That place can't be trusted to keep her healthy and you have to get her out of there while she is still somewhat healthy. Don't wait very long--get her out of there.
When you get her home, her attitude will probably change for the better and she will be motivated to improve her health. How badly does she need oxygen? Can you work on that?
Learn everything from the home nurses.
It's a long hard way, but knowing you saved her life makes it worthwhile.
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Reply to ThomasY
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I would advise looking around for another facility if you don’t like that one. Read the posts that me & all other burnt out caregivers ..caring for an elderly parent with dementia at home. Fighting with the staff & threatening them won’t help you or your mother. You will need 24/7 care for your mother at home. Your mother being on oxygen will be very challenging & needs to be closely monitored. My advice is to not take her home. This will be a big mistake. Hugs 🤗
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Reply to CaregiverL
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My mom was in a NH after hip replacement. She'd been sold a totally different scenario than the one she got. She had a roommate--who obviously had been there for YEARS. The room was small for one person, jam another one in and you have no room to move around.

It was dank, smelly and you could ring for an aide all day and nobody would show up. She fell out of her wheelchair almost immediately, YB and I found her lying on the floor, crying. 7 days post op and she's supposed to wheel herself to meals---she couldn't do a wheelchair transfer for love nor money!

When asked WHERE was the lovely single room she'd be PROMISED and PAID for? Not even in that particular facility!

OS showed up. Gave everybody heck and simply took mom in her car to a facility a few miles away that she had scoped out. She also paid the difference between the gross home and the lovely one. $25 a day!

Your mom is not a prisoner. With Medicaid, she does have fewer options, IMHO, but still, basic decent care should be the standard, not the unusual.
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Reply to Midkid58
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The nursing home is dragging their feet and giving you the run around about the "discharge plan" to take your mom home because they want her to stay. Time is money as they say and nursing homes want a person in every bed.
It sounds to me like your mom is probably not a difficult patient. Nursing homes love people like that and don't want to see them go.
If the hospital said she's getting 20 days of rehab, then she is. The nursing home is probably pulling their classic scam which is billing Medicare for a rehab stay (which Medicare pays for) and then billing Medicaid for residential custodial care. They only get caught in this scam if someone's family checks up on it with Medicare and Medicaid. You can find out easily from Medicare and Medicaid exactly what they paid for and should.
The nursing home pulled a similar scam like yours on my father. Only I caught them. He was approved for rehab by Medicare and his secondary insurance. Then they said it wasn't covered anymore and started shaking me down to cover his cost in cash. I checked with Medicare and his supplemental insurance and they were still paying. I was intimidated by them and paid. Then I found the information out. Luckily I had time to stop payment on the check. Stay in touch with Medicare and Medicaid and look at every statement. I'll bet anything the nursing home is playing both.
Back to your problem with getting a discharge plan for mom. You tell the the admitting social worker and the head of the nursing department that they have 48 hours to prepare the discharge plan for your mom. When that time is up they either have it ready and if they don't you take your mom out.
Nursing home administration has a way of making family, even ones who have legal POA or guardianship over a person, believe they have no right to decide their loved one's outcome. You have every right. Give them the 48 hour notice, then pack your mom's stuff and take her out.
Keep in mind you don't work for the nursing home. They work for you.
You're also smart to keep an eye on hospice too and you won't be easily talked into everything they say either. Good luck.
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Reply to BurntCaregiver
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George, you do not have to have Hospice. Signing papers only gave the NH the ability to set them up for you. If you have changed your mind then cancel them. They will call to set up admitting. Tell them then you have changed your mind. If its going to upset Mom then it will not be a help. You can always get her PCP to order it when you feel she really needs it. All Hospice will provide is an aide to bathe Mom maybe 3x a week. A nurse will come maybe 3x a week to check vitals, etc. But should be on call 24/7. You will be taught how to give any meds. So, if this is not what you and Mom need, then cancel hospice.

If ur taking her home this will not apply, but you should be talking to the dietitian. Tell her Mom cannot have certain foods and they should be abiding by her diet. This should have been discussed with you upon admitting.
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Reply to JoAnn29
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You probably need to familiarize yourself with what hospice does and doesn't do. They aren't caregivers, so if you think that's what will happen, it won't. A nurse will visit weekly (or more often as needed), and they'll provide a bath aide plus all the medical equipment, including a bed -- all paid for by Medicare.

You should get your ducks in a row with hospice to arrange the transfer of equipment and services to your house prior to moving your mom.
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Reply to MJ1929
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SGeorge24 Jun 7, 2021
I know hospice is useless, only good for billing my mom's Medicare. All they are going to do is get my mom all worked up when they try to bring in a hospital bed. She isn't going to like it one bit when someone shows up unannounced at random times several times a week, but it's what you have to put up with since hospice was already started. If I could do it over again, I would have never signed the papers.
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I assume you have the legal authority to move your mother? I'm wondering who signed the admission papers, when my mom moved to a NH the admission process was long (over an hour) and I signed enough forms to make a book.
Do as Countrymouse has advised and write out all you concerns (use bullet points and keep it short), then in a separate letter give formal written notice - I believe 30 days is commonly asked for but there should be details in your contract (To avoid getting an unexpected bill it wouldn't hurt to have somebody with legal training to read that over).
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Reply to cwillie
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I'm so sorry you and your mother are experiencing this. Write it all down. Submit formal complaints - especially about basics like absent or inappropriate food. Do that anyway. Never mind whether it's good enough for anyone's dog, just keep to dates and facts.

Your mother is not a prisoner, she can leave if she wants to, you can take her home.

That said, it would be sensible a) to be ready for her; b) to have your back-up in place first. Have you been able to speak to your own case worker or anyone with authority at the nursing home over this weekend? Staff on duty aren't really in a position to support a properly managed discharge, so if I were you I'd spend time on the phone first. It won't make much difference if your mother has to wait for another day or two.
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Reply to Countrymouse
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