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She was in rehab for 14 days, but started to have skin breakdown, so now the insurance is trying to have her sent to a nursing home (at her expense, since insurance pays for rehab, but not skilled nursing home) the insurance covers 100 days of rehab, but 0 days nursing home. my sister is 64, she is making very slow progress. but the psych medications sedate her.

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Peggy55 has not responded since her post. May have not been able to keep her sister in rehab. Would be nice to know the outcome.
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True. But my experience and the experience of my friends is that such abuse and human rights complaints go nowhere. No investigation, nothing. We must advocate for ourselves and speak out, there is no agency that will speak for us.
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Dear Ibeenscammed, this is a site for support and careing for those who are caregivers or involved with caring for the aging and infirmed, or the aging and infirmed themselves. I do not contribute to debate over issues. Yes, there are abuses in the system and yes people lie. If you have followed my posts you will see all the extreme circumstances I have had to deal with in protecting my mother. My mom has been physically abused not one but twice by home healthcare workers (and the DOH has accepted the complaints as physical abuse, though law enforcement has done nothing), prematurely discharged from the hospital with infections and without medications resulting in her having to be readmitted. I have had to fight with Nursing Homes on treatment and financial matters and stand up for our rights. And, yes I understand medical malpractice claims very well as I have been a medical malpractice ligitation specialist and auditor for 30 years. Yes, the court system is sometimes not as trustworthy as it should be, and certainly a good number of laywers are in bed with one another, but when it comes down to a trial, it is the lay jury that decides not the judge. And, if the judge commits judicial error, there is an appeal process. The judge does not decide. Our healthcare system in America is a mess! I wholeheartedly agree that the elderly are treated very poorly and there are not enough resources for them, at least resources that are not continually affected by government funding cutbacks. And, there are not enough people out there working for the elderly, including family members! We caregivers need to learn the system and learn how to and when to go up against the system on solid footing. It is not just the court system that regulates what happens in healthcare - it is the DOH, various agencies, and indeed Medicare and Medicaid who are on the look out for fraud and abuse of the system. If a complaint is filed with the DOH by a patient or caregiver the DOH does investigate! And, if the institution is found to have deficiencies, they are financially sanctioned and/or required to put a remedial plan of action into place. There is a lot more and little room here. The point is, we need to keep our heads and pursue what needs to be pursued with level heads and accurate information and resources. Peace!
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trying2do... Are you kidding? I've known healthcare workers who lied in court, including doctors. I've seen healthcare workers lie to their supervisors. I saw one steal from a patient and then, when the patient (to her surprise) reported the worker, the patient was assumed to be mentally incompetent and the worker got away with it. The patient had no recourse. While of course the lies and excuses of these workers appear dubious, a judge may believe the medical facility anyway, and not all judges are honest. Many can be bribed. This has nothing to do with emotions but people who are at fault being dishonest about the facts. Judges are working for the state and guess whose interests they protect? We wish they would protect the people but usually they protect the institutions.

If you know anyone who was harmed by malpractice, ask if they got their records. Go look at the records in malpractice and you'll see all kinds of inaccuracies, fudging, missing information that was simply pulled to protect the institution, and other very deliberate errors. Look at ProPublica's study on malpractice. The statistics are shocking to many.

Go watch the movie "Gaslight" and you'll see how workers treat patients in many settings. The United Nations has been alarmed at how elderly people with dementia are treated worldwide, and the USA and Canada are no exception.

While it's the law to act a certain way, there's no guarantee that the laws will be respected and followed. It's against the law to litter, against the law in some communities to not pick up after your dog, it's against the law even to jaywalk in some places. And in every way, "Do no harm" is both ethically and legally binding. Tell me that one is followed!
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ibeenscammed

You tell 'em
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Have you talked to the Social Worker at the rehab. Explain that ur sister is not able to afford her care. They may be able to help with Medicaid.
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Ibeen scammed, venting and anger are understandable, but sometimes not helpful when looking for solutions. There are mechanisms in place to objectively provide data concerning hospital incidents and rehab incidents. If the hospital has an incident report on the fall and there is documentation (which are required) and the patient was on mind-altering medications, then it is a slam dunk. The hospital has an increased duty of care. There are legal tenants that remove the "emotion" and focus on the parameters of the event. By the way, blaming the patient seldom works in front of a jury. Underlying conditions do fairly play a role, but it can cut both ways. The healthcare providers have a duty to take the patient as they find them and ensure their safety and proper treatment. Pressure sores or decubitus ulcers as they are called are not the same as skin tears, which occur from fragile skin and frank abraiding injuries. They might say that patient injured herself hence the skin tears, but that does not account for how they occured, how they were treated, how she was safeguarded and the issues concerning the question of approrpriate medications such that the patient is not able to function well and rehabilitate. Good luck!
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peggy55: There should be a rehab unit of the nursing home. See if there is a wait list for the rehab bed. Some nursing home rehab beds are for Medicare patients and yes, I know that your sister is not on Medicare. How far away is she from turning 65? If she's close to turning 65, she might want to start the application process now.
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Psych facilities are overloaded as it is, and the one thing they do not want is a person who is medically compromised with something serious like sores that could lead to infection. They are super scared about liability. For good reason since the "care" is not good in such places. My friend had a medical issue that saved her hide from being transferred to a back ward.
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Yes, she should be in an NH.
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Contact an attorney. See if you can get her on Medicaid.
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There is no reference to psychosis or any condition that would warrant admission to a psych facility. Indeed, based just on the facts presented they probably would not accept her admission. It appears she needs additional medical evaluation before determining where she would have the best opportunity to recover.
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"Blame the patient" is the norm in malpractice cases. Expect them to go to extremes to avoid admitting fault. What I have seen is re-diagnosis to something else, with the claim that it was "underlying" and have that explain away all your sister's injuries as if her new "illness" caused it, never them, never. The doctor is always right and they act like gods on high.
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I thought Medicare paid for a certain amount of days in a nursing facility. I just read there are certain circumstances. If ur sister doesn't have money, Medicaid should pay. The social worker at rehab should have explained this to you. I agree, that maybe things should be checked out concerning the rehabs part in all this and the hospital.
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So sorry for these hardships! Two separate issues: What kind of injury did your sister have when she fell in the hospital? If she was injured it is a compensable event (grounds for a claim) as the hospital has a duty of care to your sister to prevent her from harm/injury, particularly if she is on balance altering/sedating meds. You can use this to your benefit.

As for the rehab facility, skin breakdown can happen from numerous causes (e.g. dehydration, malnutrition, underlying disease like diabetes, failure to turn and position, sitting in wet linens or undergarments, etc.). However, skin breakdown is not considered acceptable complications in that setting. (Trust me I have handled medical malpractice litigation country- wide for 30 years). And, if she goes to a NH the care will likely be worse. What kind of rehab facility is this? A glorified nursing home? Does your sister have any other underlying medical conditions? Was/is your sister bed-bound? Has she been receiving physical therapy? WHat has the rehab facility done to rehabilitate her and improve her conditioning? Blood work? Adequate hydration (dehydration can lead to slow progress and lethargy, as well as skin breakdown)? What have they done to evaluate her medications so that she is not so lethargic? I would shoot back a letter to the rehab facility and the Rehab Social Worker (that is their job) and indicate that this is not a safe discharge and that rehabilitation services are now in question.

With that said, the insurance company will likely say that is not their problem. The coverage under the policy does not exempt for medical negligence. Does the insuranc policy provide coverage for 100 days per event, or per year? And are you still in the same calendar year? You need to see what the policy says. Meantime, the rehab Social Worker should be able to help somewhat.

It is hard to give specific help without knowing more about your sister's condition. But, if you bring her back to the ER be sure she is admitted with the complaints of skin breakdown at rehab, failure to thrive and medication induced lethargy requiring evaluation. Her blood work may help out with figuring this out. You want to be sure that this comes across as newly developed problems to avoid any disclaimer of coverage for pre-existing condition that fell under the first 100 days of coverage. You need to really let the ER doc and triage nurse know all the medical concerns. If you take her back to the ER (where she fell) for evaluation of the skin breakdown, psychotropic medications that are impeding her rehabilitation and her general status, then that is a new and separate "event"/condition and a new diagnosis, which insurance will have a hard time excluding for. Be sure to tell the ER doc that she initially fell there at their hospital, which necessitated the admission to rehab. ER docs are generally good people who really don't like to hear that the people they patch up end up in worse shape after they are transferred. ER docs can really be helpful sometimes in directing the course. Insurance will have to pay, likely she will be admitted for evaluation of the medications (and with the potential lawsuit exposure for the initial fall) and they will treat her, provide PT and then be responsible for a safe discharge. The Care Managers at the hospital will help with that. Even if your sister has to go to a NH for a short stay, the Care Managers will be able to set up financial assistance for that. They can't move a patient to a facility when the patient cannot pay, without providing assistance. Seems to me, your sister's treatment and condition need some real attention and that is not something Nursing Homes are geared to do well!
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Never tried this...if she is ill, made worse by the care she did or did not receive, perhaps a visit to the acute care hospital (E.R.?) to be re-evaluated and her condition documented by a second opinion might help the insurance company see the error of their ways. E.R. is a covered expense, especially test for infection from the pressure sores. If it were my sister, I would fight for her like you are.
So, calling an ambulance?
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Insurance companies will do anything they can to avoid paying. There is no reason why your sister has to be moved to LTC. Just because she started having skin breakdown is not a reason for the insurance to stop paying. I'd fight that tooth & nail. It is not the insurance company that should determine her level of care---that is determined by the physician & rehab facility. I would think that it is illegal for an insurance company to stop paying for treatment & have her moved to LTC at her own expense. If she is not ready for LTC, she shouldn't be put there.

However, it is a MAJOR problem that your sister started having skin breakdown after 2 weeks in a rehab facility. That is a state reportable incident & should be reported as such. All you have to do is tell the rehab facility that you are going to be contacting the state to report your sister's skin breakdown after 2 weeks (in order for skin breakdown to even occur, a person must be in the same position for extended periods of time---over the course of 2 weeks, if she is in rehab, she should be getting exercises that move her around to keep her from being in the same position for long periods of time.) and how insurance wants to move her to LTC at her own expense.

Was your sister in the hospital at the time she fell while on Depakote? Why is she on Depakote & how long has she been on it? If she can't function taking Depakote, it would probably be a good idea to change the medication to something she can tolerate.
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If one has "complications" from a med, that med is usually discontinued due to side effects. Depakote is a nasty drug primarily used for seizures. Does she have seizures? If not, why is she on this drug? I would seek a second opinion from another psychiatrist and move her to a psych hospital which would be covered.
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Did a discharge planner tell you it would not be covered at at Skilled facility? If she is at an Acute Rehabilitation facility and not able to do 3 hours of rehabilitation a day they move them to a skilled facility that has a rehabilitation room and give them OT PT and speech if needed at the skilled facility. Insurance will usually cover skilled care minus the time in Acute Rehabilitation for 100 days if her progress is slower. If they told you that she is going to skilled and not covering it then you and your sister need to understand why. it could be she is choosing to participate or she needs more time to heal to be able to participate. Sit down with the discharge planner and hear what they say. there are times to fight and there are times to go along. Be authentic and share how you feel in a healthy way. I alway find that showing my vulnerability and asking someone for their professional expertise as if it was their family member gets them into their heart and they will do what the can do within the systems that they operate to help you.
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I've had my sister home with me when she can't walk. She has seizures and brain damage. Instead of having her go to rehab after a hospital stay that weakened her, I requested having her come home with me and having therapy come to my house. This was cheaper and my sister recovered faster in her own environment. It is a lot of work. I bought a baby camera for $70.00 at Meijer that lets me see her and talk to her when I am in another room (from my phone) so I can still get things done around the house. If she is on depakote for seizures, make sure she is seeing an epileptoligist neurologist rather than a regular neurologist. They can better control meds and therefore seizure activity. We found Vimpat more effective with depakote. Also, request a script for barrier cream if her skin is breaking down. If this is too much for you, you can always take her to the nursing home as a last resort. She is very fortunate to have a caring sister like you. God bless you both. I am praying for you and sending you big hugs!
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I knew someone in that position. Clearly this is iatrogenic, right? The Depakote harmed her as did the previous facility's negligence allowing her muscles to atrophy. It is gross malpractice in my opinion. They are well aware that if a person doesn't use their muscles they can lose a lot of muscle tone. They should not have left her sitting or lying in the same position, and it's their responsibility to get her up and walking so the atrophy doesn't happen. The side effects of Depakote are also known and documented. The fact that they are sending her to a nursing home is only cover-up for the damages they caused. The cover-up is very common since no one wants to admit fault. Their aim is to prevent a lawsuit. I'd get a lawyer if I were you.

When I didn't have the money for a lawyer and was in the process of trying to find one, I faked it that I had one (or was waiting for a callback) and actually that scared the heck out of the offending party and they backed down.

I had good results calling the attorney general recently. You will get action. Don't settle for their claims that they are doing an in-house investigation. A real investigation is external.
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Skin breakdown, as in pressure sores? That would imply that she is not making any effort to even reposition. If she is on a hoyer lift, she is definitely nursing home ready. So sorry.
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oh sorry, misspelled, she had complications from her Depakote and fell, then was unable to get up, and the hospital MD's determined that she needed rehab to build up her muscles, after 14 days still needs assist to get up to walk with walker,
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