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83 yo Mom entered hospital after ER discoverd AFib. Also wanted to rule out pneumonia. First X-ray indicate next two were fine. We had issues with the hospital. They said one or two weeks of rehab due to her being in hospital for two weeks. First meeting isn't until May 12. She has been in rehab for a week. After signing papers the previous week for admittance, we have meet only the RNs and CNAs. Checked medical record as everyone says won't be here long and others saying she doesn't really need to be there. Medical record does not have admitting md note on expected length of stay. She is having difficulty with the food and with some rather loud pts. We were told we would be invited to all team meetings and nothing kept from us. I thought team meetings had to be weekly. She wants out, we are willing to continue to reside with my parents until mom is back on her feet. What do we do?

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Thanks for all your answers and suggestions!

Geewiz- sorry I was not more clear. My Mom does benefit from PT, OT is not geared for her needs. All OT covers at this facility is dressing, hygiene and something else I forget at this time. PT is extremely helpful for anyone coming out of ICU especially with almost two weeks in ICU.

I did research on the Internet for Medicare. There are guidelines that the admitting doctor into an Intensive Rehab Facility has to put an expected length of stay into the medical record upon the preadmission physical. Unfortunately the SW said they never do this which is out of compliance with Medicare mandates. Any of the RNs should have been able to share this information with us

If a patient leaves Against Medical Advice the insurance company be it Medicare or private can refuse to pay for the patient on the exact same thing the next time around.

Intensive rehab is to be three hours per day per Medicare mandates unless there is a good physician reason that has been charted. She was barely receiving two, most days received one. There was no orders to counteract the Medicare expectation.

Team meetings again mandated are to run 15 minutes for each patient each week. They aren't chit chat sessions,bare bones facts and move on. Many don't need the full 15 min,and a few may need more. This is also an expectation of Medicare. It is of paramount importance for caregivers and family members to learn the jargon used in order to keep the day flowing for the professionals involved

The facility has agreed to release my mother. They will set up in home health until she is ready to do outpatient physical therapy. She was receiving no respiratory therapy though some of the excercises do cross over which is very good.

My parents are 82 and 83 they chose the DNR order as they do not want to be on any type of life support if something should happen. Unfortunately they didn't understand that this would mean no CPR. If in a facility there is a DNR order, the facility must do everything they can to keep oxygen going to the brain. When my Dad had some medical procedures that required anesthesia, he did revoke the DNR for those procedures. This allowed the anesthesiologist to correct any errors in administering the anesthesia. But my family does not believe in a body being medically preserved. We believe we should be allowed to go when it's our time. Everyone of us is an organ donor, some have made arrangements for the nearest medical school to have the remains.

The rehab facility my Mom is in has great RNs and CNAs. Most are very experienced with geriatrics. IMHO to discount their experience and knowledge would be akin to discount the meteorologist saying batten down the hatches. The Doctor is also fantastic. She was the first medical professional since this all began who directed all questions and answers directly to my mother. She will set up the appropriate orders for post admission care. Unfortunately we were told the home health agency cannot come in until she is released from the rehab facility. So now we wait until next week to see about grab bars which she never wanted before...

Thanks again for everyone's help and input, it's very much appreciated!
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There should be a facility SW or discharge planner to talk to. We always have family meetings formally every other week in our acute rehab, but a lot of adult places do not do that and just staff everyone in a couple minutes once a week and MAYBE have some one get bak to you. They should be able to talk to you about goals of the stay and what needs she has to be able to go home safely and with the best chance for imrpoving anything that can be improved, and staying out of the hospital as long as possible.
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Ombudsman is independent of the hospital and usually pretty objective. AMA means "against medical advice" and can create both billing problems and trigger a report to APS (adult protective services), who may send someone for a home visit to be sure everything is OK.
Moltroub, make sure you talk to the Discharge Coordinator and the Social Worker as well as the attending MD. You said you will stay with her until she is on her feet. That could be months. READ all medical reports and test results. Ask about home health care for her, at least a visiting nurse, unless you have enough training and equipment to listen to her lungs, check BP and HR, O2 sat and temp and weight and keep a log daily.
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1) Get a doctor with hospital privileges to give a second opinion, stat. Ask him if he will discharge her.
2) Call Medicare, ask if they will pay her hospital if she leaves AMA.
3) Transfer her to another hospital?
You need more information from an expert. DaveFM seemed to know, but can anyone explain why Medicare wont pay the bill if they leave AMA? Is this something new or the hospital's policy to make idle threats? I sincerely need to know because a neighbor leaves AMA often.
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Ombudsman, is that the same as the patient's rights advocate, independent of the hospital?
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Had this happen to me once. I faxed the Doctor and sent a fax copy to the nursing unit (I called and got that number). I said that they were holding my relative against her will and to release her immediately. I said that she was accusing them of kidnapping and false imprisonment. Boy, the let her go so fast there were wheelchair skid marks out the front door.
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Have you called and asked to meet with her care team? Or asked to speak to the Director of Nursing?

When mom was admitted to a rehab that we thought might become her permanent placement, we filled out a financial disclosure form in the discharge office of the hospital. This is standard operating procedure, I believe, and probably shouldn't be interpreted as the facility being interested in her property. Facilities need assurance that there are resources for the period after Medicare payment.

Don't ask your questions about discharge to the RNs and cnas. Go to the front office (on a weekday, during business hours) and get your answers. If none are forthcoming , you go to the ombudsman.
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Moltroub, I am confused by your info as you say she doesn't need rehab, is fully able to ambulate and do the activities of daily living yet she has a DNR. Aside from that, my personal experience with one rehab my mom had --- she was in the hospital for a mini stroke. After 3 days they sent her to rehab. She was 92 and otherwise healthy. She wanted to go right home but we did do the rehab scene. Rule of thumb, a week of rehab for each day of being bedridden (full or mostly). At least this is the measure we were given at the time. After a week, she was doing more than what the therapists expected and she wanted to go home. The rehab had a lot of extra beds! They thought she should stay. We talked with the staff and had her released without the AMA designation. BUT, she was returning to independent living in a secure environment all tailored to seniors and aging. It might not have been the right move if she had to return to a house with stairs and no way to do shopping etc. My sister stayed with her for 2 nights just to be sure and my Mom was right, she did just fine at her own place. Consider the circumstances and meet with the director.
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Oh and she is in for Pneumonia Rehab but has no access to Respiratory Therapy. She is receiving PT and OT. She doesn't need the OT as she can dress herself, complete hygiene which is basically all they cover at this facility. We believe she can get Home PT or do Outpatient PT just as easily.
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Thanks DavelFM! We do understand AMA relating to full out of pocket cost. We are concerned that since Medicare will pay 20 days full and 90-100 days at 80% we are getting the Admin run around. They were very interested in the property my parents own. We are at a loss of how to get the Rehab/Convelescent facility to let her come home as no one has met with us in the week she has been in rehab. All we get from the wonderful nursing staff is that she shouldn't be there or she shouldn't be there long. We are not receiving any feedback from Admin.

We're new at this and expect will become more experienced rather quickly it seems. We don't understand how to get Mom out. She is cognizant, able to communicate, lucid, able to walk and do hygiene by herself. Because of liability issues, the facility has her call when she goes to the bathroom. She mostly does but like all facilities, they are understaffed for pt needs to be met immediately. So Mom doesn't always call. We had t bring the DNR paper in being told by law, they have to put it at the door. It's not there.

Where do we find the laws that explain what a facility is supposed to do and in what time frames? We reside in NC.
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Every year, thousands of Medicare patients who spend time for observation but are not officially admitted find they are not eligible for nursing home coverage after discharge.

suppose the answer is observation. Then what do you do?
Medicare doesn’t require facilities to tell patients if they are merely being observed

If you or a family member land as an observation patient and think you should be admitted, it’s better to act sooner than later.

Patients leaving the hospital for a nursing facility after an observation stay pay the full cost out of pocket.

"If you do find out that the person is on observation status, do what you can to get it changed at the time. Get your doctor to go to bat for you."

Get the person discharged by the doctor. Do not leave against doctors orders
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