Mom is in a SNF for physical and occupational therapy. It is suppose to be a short term stay. How do we have her discharged?

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It has been 27 days. The facility has not developed a care plan with any measurable goals. We have not had any follow up from the doctor, the nursing staff doesn't follow her medication schedule, the meals are always cold and under cooked, and have refused her snacks and water. Mom is 80 years old, recovering from double pneumonia and has made a huge improvement in her physical strength and outlook on life. I have requested the purpose and goals for Mom as well as progress updates, but all my requests have been ignored. They do not know my Mom's physical abilities prior to getting sick, don't believe what we tell them bout everything is does daily, prior to illness. In the afternoons, after her therapy, we sit together while she pays her bills and balances her checkbook. The PT and OT have said they think our goal of discharging Mom in a week is realistic and that she has made such progress, they are impressed by her positive attitude, willingness to try everything they ask of her, and her physical strength is amazing. But, they also said, unfortunately, it is not their call to make.

I want to know if we can request the facility to begin the discharging paperwork, even if they do not agree and if we do discharge her against their recommendation will it affect Medicare's payment for her care?

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While out of town my mom fell and broke her hip, was taken by ambulance to hospital in which X-ray was done and the ER doctor said there was no break and released her, she was in able to get into car due to pain and could not walk I had to call for ambulance to transport her to my sister home thirty miles away. Unable to get a dr to see her for four days she suffered with pain and unable to walk, on the fourth day she saw a one dr and insisted for an MRI to be done which showed a break and she was admitted to a hospital and surgery was done the next day.
Question can I get the first hospital to be responsible for ambulance rides since they misdiagnosed her?
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Both my Ils and my mom were in rehab, and we had weekly meetings with the care team. Insist on one.. I mean INSIST if you have to. And the entire care team. Have your concerns written down so you dont miss any or get sidetracked. Cold food is a big no no..missed meds are an even bigger one. Be a b*tch if you have to be, but INSIST on this!!
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Garden Artist is right on.....good choices and if she needs more in patient therapy she can be transfered to another facility of your choice if they have an opening. If you need a Patient Advocate to help look one up in your area, if involved they must stop any discharge plans until there is a independent review. Normally the mention of one will send them in a tail spin as they know they will be looked at very closely, all documentation. You do the same keep notes for yourself.Sounds unfortunately like most of the places these days, and yes there are some great therapists and terrible admin and vice versa.......Unfortunately a very large company bought out the majority of medium and smaller facilities and I along with several nurses I know are noticing the same poor care in way too many cases! Best of luck with your mom and do what needs to be done to get her the best care!Whether in patient or home care.
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While visiting my sister out of town mom fell and broke her hip which she had to have surgery she was discharged and went to a skill nursing facility for rehab, she has Alzheimer's we are not happy with the facility her tray is delivered, food cold and they do not assit her in feeding they leave her in bed and wet or sitting loose in a wheelchair, I have POA on her can I request her to be discharged and brought to my sister home and receive therepy? Will Medicare pay for home therepy which I need to get her stronger so she can travel with me back to our home?
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27 days without a care plan? Call the ombudsman.

It is entirely possible that this place has excellent therapists and sub-standard administrators!
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Also make sure the Home Health agency will provide Durable Medical Equipment she will need for transitioning to home ADLs. Be aware the new Medicare Competitive Bidding process should in no way delay delivery of DME . If she has to use her part B she will be on the hook for 20% of Medicare approved amount; HHA should provide as part of their providing care. Make sure you know what the doctor orders so the HHA will can cut services ( PT, OR or home health aide ) to less often than doctor's orders state. In many areas they now get paid under prospective payment system so less services = more $ in their coffers.
Medicare does not require improvement. Not losing abilities is reason enough to continue HHcare.
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Sounds like your mother is getting better from the therapy, notwithstanding poor management on the part of the facility.

You do have options:

1. You could find another facility and request a trasnfer for continuation of her therapy in a facility, or

2. You could ask her doctor or the facility doctor to script for home care.

Given the description of the cold food and other issues, my inclination would be to talk to the doctor who scripted for her rehab, presumably one of the doctors who treated her at the hospital.

Assuming she has some assistance from you or siblings at home, ask that doctor (or her regular treating physician) for home care, but find a home care agency first. Some hospitals have their own home care divisions. Make a list of your goals, your mother's conditions, and ask how they would plan to help her continue on the road back to health.

Most likely they'll tell you that they can't determine that until after an evaluation, which is generally true. But their attitude and tone of voice when they respond can be indicative of what kind of cooperation you can expect from them.

Ones that get huffy about being questioned should be crossed off the list. Ones that patiently explain how things work are candidates.

The reason I suggest this is to establish up front that you have goals you want incorporated into any care plan. Some agencies, especially when there isn't a strong family presence, set the goals themselves. You need to make sure that they know you'll be involved and that they'll be working with YOU and your mother on your mother's care. I've met a few from agencies who are so convinced of their superiority that they dismiss any family contribution.

After you find an acceptable agency, tell the rehab doctor your mother is ready to move on to home care and ask for a discharge.

Don't just leave AMA and jeopardize Medicare coverage.
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Since one is under no obligation to accept physical and occupational therapy, Medicare isn't going to refuse to pay for what's happened so far.

It sounds as if "it's worked" though, since you say your mom has gotten stronger. Yay!!!!

The nursing home where mom stayed had a Discharge Nurse. See if your facility has the same and talk to her. I can't emphasize enough that you would be wise to ask the DN to set up some home healthcare for your mom. It's a wonderful thing. And free. The PT and OT will transition her into her home; make recommendations for things that will make your mom safer and enhance her life.

The long and short of it is that your mom can discharge herself any time she'd like. That assumes you agree with her. If you didn't, they'd probably ignore her requests.
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Call the ombudsman if they are not responding to your requests got clarification of her status, progress in therapy and potential discharge date. Do you have POA? Are HIPAA forms signed? You probably should be talking to the hesd of social work and/Director of Nursing, not the doctor affilisted with the facility.
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