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Hi Everyone
My 95 yo Mom ended up in the Emergency Department last evening after a fall resulting in a very swollen ankle and quite a goose egg on the back of her head. She could not walk or bear weight due to the ankle pain.


They admitted her as I was quite adamant that it would not be a safe discharge back to her home when she cannot ambulate.


I spend a lot of time at her house but do not live there. She has an Aide 3x per week for ADL assistance, meal prep and housekeeping. She does sleep alot and has experienced a significant loss of her short term memory in the last yr. She does not drive or cook...I have removed the stove knobs as well as installed hand railings and other safety features and a bedside commode. She ambulates with a walker or cane when she remembers otherwise she can furniture surf as we have strategically placed heavy furniture to assist her in navigating the first floor of her home. I also have 2 cameras in place to keep an eye on her when I am not there.


Five years ago she spent 3 mo in rehab recovering from a major stroke. She worked hard to regain mobility and strength to baseline. It was nothing short of a miracle. So she has the drive and desire to do what ever it takes to heal. That and the fact that she is sweet as pie keeps me in her corner fighting for her to age in place.


My hope is that she can return home after a rehab stay bringing her back to ambulation. So....am sure most of you know where this is going at this point!


It is an ankle sprain not a fracture...negative for UTI...CT of head and neck is negative as well. Consequently no medical reasons for the required 3 day hospital stay to qualify for a Medicare paid rehab stint.


We have started the spend down for Medicaid but she is not there yet. At this point Social/Discharge says she is in Observation status & they will continue to search for an in patient qualifier but it doesn't look promising. They can't even tell me if her CDPHP Plan F will cover this maybe up to 3 day hospital stay if she doesn't convert.


Please advise as I search through previous threads on this subject. I know its a nightmare many of you have experienced.


Thanks in advance for any advice to help me through this!

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I would fax a letter to the Joint Commision this AM.

I would also get in touch with the patient rep asap AND mom's doctor if s/he has admitting priveleges at that hospital.

Inexcusable. But very usual.

And if it makes you feel any better, I had my mom doing PT on a fractured hip (they assured us that it wasn't broken). It was.

It was the PT who finally figured that out.
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lucyinthesky Feb 28, 2020
O Barb...it's just so heart breaking. And to think it's going to be us on the receiving end of the broken Health Care System in the not too distant future.

I've been mulling all this in my head over and over as I am putting the timeline together. Please let me know if you have any buzz words or key phrases I should insert. And I haven't even told you guys the half of it!

PT OT and I almost ambulated her yet again after the repeat x ray showed a fracture! We were discussing it and thankfully the RN overheard us and intervened saying to PT don't you know it's fractured???? And the worst part NOBODY EVER took ownership. PT said well that's your government at work to which I said YOU ARE BOOTS ON THE GROUND...YOU NEED TO DO YOUR JOB AND READ THE CHART JUST LIKE THE RN DID!!!!

Got the impression from the multiple requests to meet with the Patient Representative that that's their way of getting a jump on my complaints. Forewarned is forearmed...would not surprise me in the least if they are busy altering and deleting documents. Hey at least I am forcing them to work a week end!

I asked for her hospitalization records prior to discharge. The Resource RN said they couldn't do that. I said I have the Patient Bill of Rights right here in my hand....would you like to read it? Of course I walked out empty handed...I didn't have time to track down yet another apathetic Admin and tell it all again when Mom was almost out the door.

My poor Mom ...thankfully she doesn't have a full understanding of it due to her profound hearing loss. Did I mention she was an OB RN at this very same hospital for many years? She delivered several of my friend's actually. Back then sometimes the Attending didn't even show up....he didn't have to...the boots on the ground knew what to do..

As I sit here holding back the tears ....I think I now have a sense of what it's like to be a parent ..... I could never have children. My Mom is my precious child. As hard as it was to care for her at times I really miss her right now.

Last week Mom needed an RN home visit to re-certify for her at home care aide. Long story short RN didn't know how to work the handheld BP or O2 Sat equipment...got some wacky results and wanted to call 911! Mom was pretty lethargic as the Aide had just left and she now had to deal with yet more questions and fussing around. I tried not to laugh too hard as we had just discussed Moms DNR. I said no...she'll be up in an hr or so looking in the fridge! Then RN wanted to call Moms Dr....I gave her the # and said go ahead!

I can only hope that she could go that peacefully...after her caregiver visit with me here...she loves her caregiver. But not like this...as a result of a cluster of errors...

I know how lucky I am that I was able to leave Mom for hours at a time....lucky to have a pretty full life of Yoga, hiking, cycling, skiing and the theater. I did have to give up travel but I made lemonade out of lemons rediscovering the beautiful bucolic setting where I was born.

Am grateful today for AgingCare☮
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I'm sorry Lucy you and Mom are going through this. Its still not clear to me, why isn't she Medicare rehab eligible? And why do they think Mom will be safe and be able to rehab at home? Have you asked if she could stay there and transition to LTC Medicaid?
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lucyinthesky Feb 28, 2020
Thanks Bill

I don't get it fully either. Mom not only fell thru the cracks ...she was pushed thru the cracks.

I think from day 1 she was ear marked to not"meet" In Pt status to then qualify for a Medicare funded Rehab due to her age. As we know age really is just a number.

If they "find" everyone a diagnosis Medicare will frown upon that and reduce reimbursement to a hospital that is statistically approving more Rehab stays than they should. There are monies"to be shared" at the end of the year. Its called a shared cost of services. All hospitals will get a check at the end of the year for saving with respect to theses services. It's a numbers game figured out by actuaries to fatten the bottom line.
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It's fractured???????

They mis-read the initial xray? And they won't admit her? I think you need to talk to the Patient Advocate office at the hospital. Now.
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lucyinthesky Feb 28, 2020
Yes....it's a distal fib and tib fracture...so fractured on both sides of the ankle! Aggravated by ambulation of course.

Ortho casted it on Wed with instructions of no weight bearing for weeks.

Can you imagine being forced to ambulate on a fractured ankle by aides and your very own daughter?

I met with the Director of Nursing, the Resource RN and the Hospitalist without much satisfaction. My every complaint was met with an "OK" by the Hospitalist. I stared him down and said "Not OK" to which he replied "all right." I then said "not all right either." I thought any minute someone was going to yell "Candid Camera!"

I had actually met with the DON day 2 as Mom was with out a drop of water in site one morning and she was left in the same position in a chair for over 8 hrs the day they put the cast on. Just found out today about the Medication error. Everyday I walked into a "WTH?"

The DON encouraged me to speak with the Patient Representative but at that point I was exhausted and Mom was being discharged never having achieved In Pt status. Figured I had nothing to loose when I said neglect was mandatory report able as was malpractice and that I'd rather have the next conversation with NYS and Joint Commission.
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Is she being encouraged to walk on the sprained ankle? Does she have a boot on it, or is she using a kneeling scooter? Sprains are supposed to be elevated, iced and rested, yes?

RIGHT NOW, LTC is what she needs, because she can't ambulate and can't be alone.

Where I come from, SNF/LTC's do PT and other therapies as ordered by the doctors. She needs therapy to maintain and develop her upper body strength and to maintain her overall strength and balance.

I don't see a downside to signing her into LTC right now.
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lucyinthesky Feb 24, 2020
She "walked" over the wk end 6 times pushing thru the pain with most of the weight on her good side. She made it about 20 feet once. Treatment is elevation and ice....no boot....she wouldn't be able to manage a scooter.

Ambulation happened over the wk end as I was on site to make it happen. I brought her exercise/stretch band from home to do some upper body strengthening and am doing deep breathing with her as well.

Today was a completely different story with a whole new team of nurses ancillary staff and Hospitalist. ..didn't recognize a soul.

They did not walk Mom at all today! They transferred her to the recliner and that was that. I waited 3 hrs for the Hospitalist and that same 3 hrs to get Mom re-positioned! Hospitalist said not sure about a Failure to Thrive DX and no to a repeat ankle x ray. He did do the most thorough exam I have seen since admission tho.

Much to my surprise the Case Worker who has threatened me daily that Mom will be discharged and is still not Medicare Rehab eligible didn't "magically" appear soon after my arrival!

Mom was exhausted so I just left after we got her back into bed. She worked hard both Sat and Sun. My dear sweet Mom needed a day off.

I attempted contact this morning with Office of the Aging as she has a case worker with no call back yet. I called the Admissions person @ the LTC/Rehab Mom will go to. I met her last Nov when Mom stayed there for a Respite week ....no call back from her either.

I did hear back from Mom's PCP who was on vacation last week....she Emailed me to "hang tight ....they have to figure it out" which is exactly what MSTRBILL advised. Heard back from the local Fire Chief that they would indeed assist Mom back into her home whenever. No call back from her Elder Attorney yet either.

It was a relief to not be confronted by the Case Worker today. I'll have dinner with Mom...the coast should be clear of any Case Workers by then!

Tomorrow is another day. Thanks to all for your continued support and advice❤
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Week End Update:

Mom is pushing thru the pain and has ambulated 6 times over the wk end achieving a distance on one occasion of 20 ft. With the walker she sorta hops on her sprained ankle.

Am still campaigning for that Medicare funded Rehab Stint. Will ask for the Failure to Thrive DX today. Am praying it works.

Her wk end RN said they were looking for LTC for her? What would that look like as I dont want to sign her in for LTC? Or will I have to and after successful ambulation with PT which is on site sign her out?

This facility houses both LTC and Rehab.
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I would start to be proactive to find the best nursing home for her now and get her waitlisted. Get her in before complete spendown or she will be stuck with what is available. One year to complete spendown should suffice. There are some places that have multiple levels of care where she can start in assisted living then age out in the facility. If you choose assisted first, you will be surprised with the available activities to keep her socially engaged.
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lucyinthesky Feb 21, 2020
Mac
Not much available in my area. There is a low rated LTC nearby and unfortunately thats where she might end up for Rehab if she does miraculously convert to In PT status over the week end. There are a few other choices some 25 miles away.

This afternoon she is back to her happy talkative self. Shes reading the staffs badges and calling them by name...all with out glasses BTW..telling them the weather report....wishing them good days....shes joking with the nurses and they are joking back. Its a joy to see! Clearly the overall pain from the fall has eased up considerably.

I kept telling everyone she was in pain and not herself.. In fact I mentioned to the Hospitalist this morning that she has that look of pain on her face hoping he would x ray her pelvis as Barb suggested but no dice.

And then there it was...the age comment....maybe shes just old. To which I replied yes she is but she can come back from a sprained ankle. The hip might be another story.

I sure hope he is on the week end to see my real Mom. Not going to hold a grudge as he really has been awesome....I might have ended up with a Dr with the ageism attitude from day one.
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Have they xrayed her pelvis?

My moms broken hip didnt show up on the first set of xrays. There was a nice poster, DeManBro, whose mom ended up with fractured verterbrae; the hospital thought she was "faking" the pain.

Keep advocating!!
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lucyinthesky Feb 21, 2020
Barb
No they have not xrayed her pelvis. Will consult De Man's post.

It could be her knee as the swelling there has increased.So what xrays and further testing should I ask for today???? Radiology is not my field...need all the help I can get.

A GF says an MRI is in order. Dr did say no to that yesterday with regards to her hip.

I feel like I am the DR! Based on my daily assessment of Mom I ask the nurses to have the Hospitalist to come see me and I show him where her pain is and without much of an exam by him at all he follows my instructions!

Whats wrong with this picture? As long Doc keeps listening and I get advice from everyone here maybe its all good.

Thanks Barb...am even more distraught now with no answers and Mom now inactive for 4 days...they heard crackles yesterday. :((
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Sounds like mom needs Assisted Living community. There would be someone to check on her, someone to help when needed. Or depending on how poor her memory is a Memory Care wing of an AL community so that she might be able to start in AL then transition to Memory Care if needed.
OR
It sounds like she needs to have caregivers there more than 3 times a week.
either option would be a way to spend down so that she is eligible for Medicaid.
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lucyinthesky Feb 20, 2020
Here's the latest: Ankle swelling is down considerably but she is still in a great deal of pain when that leg is moved and during transfers.

4 people basically pick/haul her up from the lounge chair w dangling legs and sit her down on the bed then place her legs together up onto the bed. Does anybody know what kind of transfer this is called? Is it a transfer? It is scary and extremely painful for her .

And away she goes to Radiology as we have now xrayed her spine due a history of back fractures as well as her hip....all negative and the pain persists.

PT did a more intensive exam isolating the pain to possibly her knee and will try again tomorrow to weight bear/walk and see want happens. Poor Mom is so tired of answering the same old question a 1000 times of "where does it hurt" that she doesn't even know anymore. She knows it s not her ankle so much anymore and says she hurts all over.

The xrays and PT eval were requested by me based on my assessment and exam when I get there after she has been moved to the recliner.

If I were not there none of this additional testing would have been performed despite the fact that they transfer her from the bed to the recliner and are aware of this pain.

Still in the same boat...no medical reason to convert to in patient status.

Because Medicare is the primary Insurance they govern the 3 day rule with required DX to convert. Her CDPHP is supplementary and therfore secondary insurance.
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I agree. Mom needs to be in LTC. I think she is passed a AL but if she has the money, thats an option.

I applied for Medicaid for my Mom. I had 90 days to give the caseworker all the paperwork required. Cash in her insurance policy and prepay her funeral with it. And place her in a NH. I stared the process in April. Placed her in a NH on May 1st paying privately for May and June. ($18,600) This took Mom under the $2k cap needed. I confirmed with the caseworker that he had all the paperwork needed and Medicaid started July 1st.
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lucyinthesky Feb 19, 2020
Thats great JoAnn....and it may come to that in which case I have your example to follow!

Just one more chance :))
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Some insurance companies are waiving the 3 day criteria to allow people to get needed rehab. Can you contact her insurance company to find out if her policy waives this? What might be a sticking point is her classification as being under observation, not inpatient.
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lucyinthesky Feb 19, 2020
Will do! Thats a great idea....good to be informed going forward.

Here is the update since my post: The Hospitalist decided to treat her empirically for a UTI with IV antibiotics hopefully necessitating a 3 day in patient stay and thus triggering the Medicare Rehab stint.

I explained to him that the ED obtained a stinky stinky stinky dark yellow cloudy urine specimen only to be rejected by Lab Staff for a labeling issue. The subsequent specimen obtained after hydration in the middle of the night was negative but the optimum specimen is first AM void. He palpated her tender tummy and HEARD me! Yay!

At least she is not being sent home today unable to ambulate as the Case Worker threatened this morning.
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Is your mom a candidate for AL or LTC? You may need to have this discussion with the facilities you visit. I'm not sure how much Medicaid pays for AL in your state, but they probably will pay 100% for LTC. FYI you should get her placed in private pay in a great facility that accepts Medicaid recipients. She cannot be kicked out if they do, but please know that in most facilities a Medicaid room means a shared room. My MIL is in a great facility on Medicaid and she gets all the same care and attention as the private pay. She just has to share a room. As others have advised, don't wait for Medicaid approval to place her, since there can be waiting lists for "outsiders". I wish you success in finding a great place for her!
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worriedinCali Feb 19, 2020
Medicaid doesn’t pay 100% for LTC, they pay whatever amount is left after your income has gone to the facility. In every state.
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IMO, she needs to be placed now as a self pay, thus spending her money down, after that Medicaid can kick in.

Living in a home is not the end of the world, most adjust nicely, my mother for instance is happy, glad to not be alone 24/7. She has also made many new friends, her age, very helpful as she can communicate back & forth on her own level.
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lucyinthesky Feb 19, 2020
I hear you Dolly.

Mom spent a week in the only LTC facility in our area last November for Respite and really liked the people and the food especially the ice cream. Other residents loved her and she loved the attention as they were always looking after her. It was heart warming.

When I picked her up she was laying in her own excrement and hadn't had the 1 shower I requested! And this after saying hello to 1 RN and 2 Aides just chatting away. They even stole the oversize plastic Boscovs shopping bag I brought her clothes in with! Appalling!

I won't bore you with the stopped up toilet and angry red peri anal rash she came home with. And yes this will be the rehab she will go to if approved.
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She needs to be placed in some care now, and the social worker can help you with that. Be honest about her assets; they will be gone soon enough with placement and she will have "spent down".
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lucyinthesky Feb 19, 2020
AlvaDeer

I feel like Rehab is the best opportunity now to PT her ankle back to baseline.

Am not at all confident in the Nursing Care at the only LTC facility in my area but the Rehab Department is excellent.

And maybe what u all are trying to politely tell me is that a 95 yo has a slim chance of recovering. I hope you are wrong but I do know you could be right in which case I will concede.

Al tho I have not contributed much to Aging Care lately I am here taking it all in from you wise and generous folks. The gift of the time you all took to reply is melting my heart.
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The hospital needs to find a facility for her to rehab at. The medical bills she is accruing and will accrue will help with that spend down to Medicaid. So sit tight, let the hospital keep working to find a facility and go from there.
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lucyinthesky Feb 19, 2020
The Case Worker essentially bullied me this AM saying Mom will be discharged & if I want her to go to Rehab I was on my own and we would have to come up with $10,000 up front for an out of pocket stay.

That is kinda laughable to me now as I was advised 5 yrs ago post stroke to spend down just in case. I did some home improvements all to her benefit and now she is almost spent down leaving no cash for a private pay starter LTC or even a Rehab stint.

So I think what you are saying is: Refuse the discharge....insist on Rehab & go from there? It makes sense.

Bottom line tho she is willing to put in the work to heal from an ankle sprain which seems like a walk in the park compared to the work she put in post stroke and I want her to have that chance to be with her kitties and birds.

Thanks Bill and all who came to my rescue. Please read the update above...I may get my wish afterall!
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