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I live in Nevada and originally had my mom living with me in my home during the pandemic. She had a stroke 10 years ago, is unable to walk, unable to transfer herself, is incontinent, and has diabetes that requires insulin. I wanted to get her into some sort of care facility so she could have caregivers with her at all times because she would occasionally fall while transferring or get low blood sugar. She was also alone most of the day once my partner and I went back to work.



I spoke with everyone possible: her doctor, the state, and various facilities about our options, especially because she would need Medicaid. It seemed that with her on insulin, group homes wouldn't accept her unless she switched to oral medication. If she stayed on the insulin, she would need a skilled nursing facility to care for her. The Medicaid applications for group home and skilled nursing are different, and I was under the impression that a doctor/hospital had to do the one for skilled nursing. Her primary care doctor suggested dropping her off at the ER at a time when she was medically fine during the pandemic to be able to get into a skilled nursing facility. I held off on that, because...pandemic. So we went the group home route and tried the oral medications.



The oral diabetes medication they put her on (metformin) did not agree with her at all. It basically wrecked her gut--constant diarrhea and vomiting led to severe dehydration and malnourishment which led to a hospital stay. She recovered back to her baseline normal after about 3 weeks in the hospital and 3 weeks in skilled nursing rehab, all while being back on her insulin.



They then discharged her back to her same group home, after I raised concerns about the diabetes medication causing problems for her. They put her back on the metformin and suggested hospice care when she got back to the group home. I thought that was incredibly strange because she was at her baseline normal (mentally coherent with very mild forgetfulness, physically limited but able to sit in her wheelchair and wheel around the house).



Within two weeks she had RAPIDLY declined. The metformin caused the severe GI issues again, leading to the same dehydration/malnourishment problem that she had the first time around. Hospice was trying to convince me that it was her "natural decline." They informed me she had severe pain in her hips and started giving her strong pain meds. I said I didn't want her on strong pain meds all the time and only as needed. They ended up giving them 3x a day, every day. I let this go on for about a week and then stopped hospice and took her to the ER because none of this seemed normal.



In the ER they discovered the source of her hip pain was a bed sore that had become infected because the group home was not repositioning her regularly. She also had a severe UTI and bladder infection from a catheter that hadn't been changed in a very long time. She also developed a blood infection. They put her on antibiotics for the infections, but her appetite hasn't fully recovered. She is still very weak and is experiencing delirium. The doctor says that this is her natural state and that she's declining naturally, referencing that she can't use her legs as evidence (she hasn't been able to use her legs in over 4 years btw).



Now they want to discharge her back to the group home. I'm upset because the group home was NOT caring for all of her medical needs. The Medicaid application we have pending is for home-community-based care, not long-term nursing home care. I believe that she needs that nursing home level of care at this point and that it will be unsafe to discharge her to a group home. In her current condition, she needs 24-hour care. But we can't send her to skilled nursing because she doesn't have Medicaid already for that, but you can't get that kind of Medicaid unless you are referred and admitted. I'm at a loss. I don't want her to go back to a place that can't care for her properly.

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I also wanted to add that my mom is only 68 years old, and loves playing on her tablet and iPhone, and video chatting with her friends. She was NOT on death's door before the group home let her get to this condition. I'm very reluctant to go back to group home/hospice, but they are making it seem like that is my only option at this point.
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Myownlife May 2022
Oh wow, I am 68. And I am looking at returning to work ( nurse ). I just can't imagine your going through this with your mother so young. I just googled and this is the website to report unsafe conditions at a group home in Nevada. https://dpbh.nv.gov/Reg/HealthFacilities/dta/Complaints/Health_Facilities_-_Complaints/
Are you your Mom's POA ? Or guardian? I would speak with everyone, the dr., the nurses, the social worker/case manager at the hospital and tell them you REFUSE to have your mother discharged to this group home due to unsafe conditions which you have reported. (right after you report them). Play hardball, and refuse. Also is there a DNR on your mom? (do not resuscitate) Is this something you do not want? You can refuse that as well. And Hospice is different nowadays. It can be something to get extra services and assistance with help, and can even later be discontinued when your mom is doing better. It doesn't necessarily mean it is "the end". Just get more info. on that.
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You need to tell the Social Worker that it is unsafe to send her back to the group home. The records show Mom is not being properly cared for. I am actually surprised oral meds are being pushed once she was on injections. My Aunt oral did not work for her so she had to change to injections. Maybe things have changed because that was long ago.

I would look into Mom being transferred to LTC with Medicaid pending. Having a bed sore means neglect. It needs to be cared for by a wound care nurse. I would say since the group home doesn't allow injections then they don't have at least an LPN on staff.

Be aware that when you place Mom into LTC, you turn over her SS and any pension to the LTC. Medicaid should retro back to pay for their share of her care.
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JuliaDade May 2022
Apparently, Medicaid-pending does not exist. Nursing homes will not admit her without guaranteed payment, but the hospital won't keep her for the 3-6 months that it takes to get Medicaid approval. I'm really at a loss of what to do, and I can't seem to find anyone who can help me. I've talked to Aging and Disability Services, Department of Welfare, social workers with the hospital and nursing homes. I'm just at a loss. It seems like my only choice is to send her back to the group home where she will surely decline even further and most likely die. I'm just so upset.
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Yours is a beautiful write up of a dire, dire situation.
I can only suggest that this is an unsafe discharge. To send a 68 year old with severe insulin dependence, bedbound from strokes, and now having a BEDSORE (which I hope was reported to licensure board for the prior facility who apparently didn't even know it exists? Licensure can be taken for this) that is nonhealing????
This is not only an "unsafe discharge" but it is almost a death sentence. I would make that clear to to supervising social workers and hospital administration. Your Mom is in need of SNF until the bedsore is healed. It could lead to sepsis and death. Could easily and quickly lead to that.
Meanwhile medicaid can try to get on board. I will tell you however that in an insulin dependent senior with diabetes who is bedbound, there is no good prognosis in offing in this country. I am sorry to tell you and I know you are already realizing that.
I am afraid that this falls under the "not everything can be fixed category", but I surely would make a lot noise about it, because I, as a nurse all my career, feel that this is almost like a death sentence. I am just so sorry. I wish I had a clue what to tell you to try. I hope someone does.
Skilled nursing, by the way, is covered by Medicare. Wish I was up on the guiding factors and restrictions, but I am not. Your Mom at this point need specialty care of wound nurses.
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JuliaDade May 2022
I basically did tell the hospital social worker that it would be a death sentence to discharge her back to the group home, but they seemed OK with me saying that. She's improved in the 5 days she's been at the hospital, but apparently not drastically enough to merit a discharge to rehab-instead they want to discharge her to her death with Hospice. They are saying she doesn't need insulin anymore because she's not eating very much--um, she's not eating much because she feels like crap from having A BLOOD INFECTION, and that she already can't walk so what's the point of physical therapy. Last I checked, a lot of people live their lives perfectly fine without being able to walk. I just want her to be able to sit in her wheelchair again and scoot around the house like she did before this whole fiasco.
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I am so sorry your Mum is in the situation.

Metformin is very hard on some people. My former MIL could not leave the house for the first few hours of the day due to having to be close to the toilet. After a couple years of encouraging her to advocate for herself with her doctor to no avail, she moved to my town and was a patient of my doctor.

I had a conversation with our shared doctor, prefacing by saying I know you cannot talk about her, but this is what is happening with the Metformin. He tried another medication and no more tummy trouble.

Eventually she became insulin dependent and for her there was no going back to tablets.
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Call Adult Protective Service and request a Social Worker:
https://dhcfp.nv.gov/Pgms/LTSS/LTSSHome/


FYI: https://www.nolo.com/legal-encyclopedia/when-medicaid-nevada-will-pay-long-term-care-nursing-home.html
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Ask the social worker at the hospital to help expedite the Medicaid, and discuss your concerns about the facility she was in. It sounds like your idea of skilled nursing is the better option for her. Try to get the hospital social worker to help you. All the best!
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In addition to being hard on some people's stomachs, metformin is a very low-level diabetes drug and is not at all a replacement for insulin. i agree you should do whatever you can to get her into skilled nursing, and report this facility for its neglect. in the meantime, is it possible to hire a private nurse to see your mom a couple times a week in the group home? it's a shame you'd have to do that to make up for a facility not doing its job but it would at least give you peace of mind until you can get SNF sorted.
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Who told you that "Medicaid Pending" doesn't exist?

Ask the discharge planners at the hospital if your mother is both Medically at need for skilled nursing. Find out if she is financially at need for LTC Medicaid. You may need to gather medical documentation that she is in need of an SNF.

A well-qualified eldercare attorney is probably what you need.
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my2cents May 2022
Exactly. Most people who get sent from hospital to NH have a Pending Medicaid application. I doubt very few people have all the paperwork gathered up for a worker to process a NH Medicaid application on the same day they review the application. Probably more like 99.9% of the applications require a 'pending' letter to be sent requesting more information.
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I don't have all the answers, but I can give you information about Metformin. I, too, had terrible gastric problems with regular Metformin. I now take a time release Metformin which is not causing any problems. As to the rest, I would call Adult Protective Services in your county and consult with a social worker about the other issues. They should be able to send you in the right direction at least.
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My heart goes out to you. I commend you for continuing to advocate as hard as you can for her. I have also had to push and push to advocate for my husband anytime he has ended up in an ER or worse admitted. He has Parkinson's which can be very debilitating, however he is still very mobile with only mild dementia. When a doctor walks in who knows nothing about him except what they saw on the chart, they often want to write him off when they see his condition at that moment. I often have to insist that he was walking and talking before he came in and no I will not put him on Hospice! I realize there will be a time that will be appropriate but until then I will advocate as hard as I can to get the care he needs. Like your mom, he has often rebounded despite the opinions of many providers. Yes, some natural decline is happening but as long as you know what her "normal" functioning could be with proper care, then keep standing firm.

On the Medicaid issue, here is what I might do. I'd go in person to the Medicaid office without her and ask for them to tell you exactly what else you need to do. If it is simply her doctor's recommendation then ask for the appropriate form. If it is an ER doctor's recommendation, ask for the appropriate form and the first time you see ANYTHING that justifies a trip take her to the ER. If the group home needs to make the recommendation then ask for the appropriate form and take it back to them. Medicaid may say they should already have the forms then insist you want it just in case. Sometimes it seems you have to hold everyone's hand and walk them through the system to be sure it is processed properly. Once you get the proper form(s) hand carry it to the appropriate person and tell them you want a copy of it once it is completed. You may not be able to walk the original back to Medicaid, so you need a copy just in case it is "lost" in the transfer. As polite as you can be, keep assuring everyone that you are simply trying to do your part to speed up the process so your mother can get the care she needs. Even if it is true, no one wants to feel accused of not doing their job.
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Myownlife May 2022
NO. You do NOT allow them to send this person back to the same group home for the THIRD time ! I would refuse to have her again prescribed metformin. And if that is an issue the dr. won't listen to you and resolve, I would first consult a an attorney for a medical practice lawsuit and show the dr. you mean business. If the hospital, dr., and/or social worker/case management will not assist her with preventing another stay in this group home, then she should have an attorney intervene.
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Insist she not go to group home but be placed in msg facility. Threaten neglect. BTW even in send she will still be alone & probably fall a lot. U will have to hire a sitter as I had to
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Skilled nursing home Medicaid is based on medical necessity. Talk to the Social worker at the hospital AND have another discussion with her doctor. The group home seems unable to handle 24 hour care for her - bed sore and meds they use there for diabetes, UTI which may or may not be a huge part of her mental confusion. If that group home allowed her to get in this shape, things won't get better when she returns. If they can't give insulin there (and that med happens to work well for her), she should be moved to a facility that can give her meds that don't create all the stomach issues...especially when there is one that is known to help her. Makes no sense to put her through stomach issues on top of other problems.
Talk to a few NH in your area to see if anyone has a Medicaid bed available - explain the problems and see if they will accept her so you have the name of a facility when you talk to Soc Wkr and doctor.

You should be able to start the NH Medicaid application with the help of the hospital social worker, in a local Medicaid office, or online. Get all of your paperwork lined up (income, bank accts, etc) so that Medicaid office has what they need to process. You can even take all the paper work you gathered to the local office and ask them if there is anything else you need. If a worker can touch the application one time and process, you avoid lengthy delays.
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my2cents May 2022
Another thought on this: She is already on a Medicaid paid group home case, right? More than likely group home and SNH have the same income limits so she should be able to transfer to the SNH program without much in the way of additional verifications or delay in processing.

Is it her primary dr or the hospital dr who wants to return her to the group home care? All you need is verification of medical necessity from either of these drs to do the medical necessity to move her to SNH now.

I definitely think it is in her best interest for you to pursue the move to NH. The group home should have tested for UTI and done something about the wound without you having to step in. UTI definitely is known to create mental confusion and there's a good chance one treatment won't clear it up - will have to be tested again after initial treatment. Bed sores are preventable - turning, wedging, etc to keep pressure off the skin should be part of her daily care. It wasn't happening at the group home. Actually, you might get more information by talking to the group home and asking specifically, does she need more one on one care than they can provide? The dr at the group home may be the one who provides you with medical necessity verification.
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I had my Daddy in a nursing facility. Not good. He finally had a toe amputated due to the lack of supervision. This was due to the pandemic and the lock-out or I would have caught it. Anyway, after the amputation and the rehab I found a group home that had 8 patient capacity and the people were awesome. They called me when there was a problem or a change/addition in the medication. Also, because this was a group home each room had access to the patio, in which I could sit on keeping the 6 feet apart and yet visit face to face. I know some accept assistance but you would have to check with your social worker. That was the best situation for me. Praying for you and yours.
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Medicaid pending is a tricky,complicated risky process for a facility. You need to call around and ask facilities if they consider mediciad pending patients. If a facility considers pending patients they are going to want a copy of the mediciad application and supporting documentation. The facility will want to review everything to see if there are any possibilities the patient could be denied or delayed. Apply online, it is much quicker but print the application out when completed. The hospital can submit for an e-arc pas (temporary permission from the state the helps certify the patient meets the ltc clinical requirements). The facility will likely also have the patients responsible party prior to admission sign a contract stating that they are choosing to admit mediciad pending and they are financially liable for any non covered services. You will also need to pay that month's available income upfront.
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Julia, whomever is telling you there is no Medicaid pending facilities in Washoe County is lying through their lazy teeth.

I would tell the social worker at the hospital that you will file charges for elder abuse and neglect if your mom is sent back to the group home. There is documented proof that your mom IS NOT receiving appropriate care.

Google washoe county senior services and find out what you can do to get the group home, hospice and hospital reported to every agency, licsensing board, DHHS and anything else that will stop this kind of treatment for her and others in the future.

Here's the thing, your mom could be dying but, doctors take an oath to do no harm and sending her back to that group home has proven to cause harm.

Advocate, advocate, advocate!!
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If she is still in the hospital, work with case management and/or social services to get her into a skilled nursing facility. Help them with filing paperwork with Medicaid. It might take awhile, but she should be placed appopriately.
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JuliaDade: Perhaps you'd do yourself a favor by retaining an elder law attorney.
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I am somewhat surprised that she doesn't qualify for wound care (she won't get that in a group home) in a Medicare approved facility but not having seen the wound it might be of the stage requiring care.
As a former Dir of Admissions for short and long term care facility, I can tell you that getting an admissions to a facility with Medicaid pending has become tricky in many states. In NJ every county used to maintain their own SNF and because they were a government entity, they always accept Medicaid pending cases. Unfortunately, that was partially their undoing because they didn't follow up with families who were not finishing the Medicaid applications (or were trying to hide assets). Anyway, all the NJ nursing homes have been sold to private entities who, while they must maintain a small percentage of Medicaid beds as long as they accept Medicare (ie federal funds), can legally refuse admission to any patient who does not have a guaranteed payment source. This may be the case in Nevada which seems.............. a difficult state to navigate in terms of healthcare. I was on their site yesterday to answer a forum question and got dizzy trying to navigate it! It might be worthwhile to have a consultation with an eldercare attorney who specializes in Medicaid in Nevada (some of them will do a 15 min consultation without charge). Just make sure it is a certified eldercare attorney. I would bypass the many claims of eldercare attorneys you will find in NV if you Google the term and go directly to the National Academy of Eldercare Attorneys at https://www.naela.org and do my search there unless you have a personal recommendation from someone.

Wishing you good fortune in this endeavor. Please keep us updated. I'm really interested in find out how it works in Nevada.
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I know the nursing home my dad was in wouldn’t except a pending application for Medicaid we had to private pay until Medicaid was approved. When you are approved you are reimbursed for however many months you payed for. If you’re dad was in the service she could apply for aid and attendance which would pay the nursing home I believe around $1,200 a month unfortunately it takes around 6 months to get it approved but it is retroactive. My sister did find an elderly law attorney that knew how to get the Medicaid and aid in assistance approved in 2 weeks. So it might be worth you checking into a an elderly law attorney.
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