Mom is 94 was in a Independent Care Facility using a wheelchair and transferring on her own. She is very alert issues are physical. She fell in the bathroom. Then was in the hospital for 3 days and they wanted to discharge her back to her apartment. I requested a mobility evaluation and on the 5th day they transferred her to a Rehab Facility.
Back to the hospital twice thereafter. First for pain in the left ankle that when X rayed showed a fracture of the Fibula. Splinted and has since healed without problems. A week after that hospital admission and back at Rehab she became confused. Blood work showed Hyponatremia.
During that period she was on pain meds and sleeping most of the time. She developed a heel pressure sore on the right foot. IMO – Poor patient management. Rehab claims the pressure sore on the heel is from hospital…hospital claims it was from Rehab. I blame both.
Her pressure sore is healing nicely with day to day wound care but this wound is keeping us from placing her in an assisted care facility. It is not staged but is I’m sure more than a stage 2. All her other issues are acceptable to assisted care.
Here are the problems:
Her 100 days runs out on the 14th Jan. with Medicare. She has AARP insurance as secondary.
Assisted cares facilities will not take her with the wound as it is and it may take 3 months or more to heal.
She has no money, home, or anything of value left. SS and a very small pension. She does qualify for Medicaid .
We as the family have put together a fund to help her but at $350/ day for care because of the wound we would go through that in a 4 or 5 months and then have nothing for her.
Can we put here on Medicaid to keep here were she is and get the care she needs for her wound. Or…how to stop them from transferring or discharging her?
Would it do any good to contact a ombudsman advocate?

I have an Elder law attorney appointment on the 10th of Jan.

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I'm so glad that you have an appointment with an attorney. It sounds as if your mom should be going on Medicaid regardless of her living arrangement. The problem, of course, is that each state is different. You've gotten some good advice on the forum here, so I hope that some of the suggestions will spur some ideas to get your through. Meanwhile, work on Medicaid and hope that she will be kept in rehab for as long as she needs. Good luck,
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Is her Rehab facility also a nursing home? Will she need nursing home care when she is released? States have rules about what is allowed in AL vs. NH. I'd explore that. Also, while I'm not familiar with CA's benefits to seniors and the disabled who need AL, I'd check on that. It seems that she would certainly qualify for AL if she's wheelchair bound. Maybe, others around here from CA will chime in.

Does the attorney you are seeing know about Medicare and CA rules on state sponsored long term care and AL? That would help.

What I would be very wary of is raising money for your mom. It's likely that her assets will be counted and I wouldn't want her having a lot of money that could artificially inflate her assets and cause her to not qualify for federal or state benefits.

I don't know anything about the AARP insurance you say is secondary. Is that health or long term? Maybe, someone who is familiar with it can help. I'd get the policy and read it carefully. Perhaps, attorney will be able to answer questions too.
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Is 42 CFR 409.32 b & c an argument to get extended coverage for her?

What about “Medical Appropriateness Exception” 20.2.2 i.e. “Letter of predictability”

The goal here is to get her wound healed to the point that she can be transferred to an assisted care and have it covered by Medicare and her AARP insurance after the 100 day limit…

“What I would be very wary of is raising money for your mom” Yes thanks I am very, very wary…

The attorney is Calif wise and there is AL. Also she is a Surviving Vets Spouse WW2. I started that process last week.

The big issue seems to be getting her in to the NH by changing her rehabilitation admittance to a wound care.
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This could happen to anyone. Please let us know what you found out from the attorney. How is your mom today?
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My aunt had the same situation. She had aarp supplement ins. And went on Medicade and stayed in NH. I had moved her to Ohio from Michigan before her money ran out. I followed all of the rules and it was easy. The NH helped steer me to the right people.
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The financial department at the rehab should help u with this. If she was not able to pay the part Medicare paid Medicaid should have been discussed then.
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The pressure sore on her heel is a MAJOR BIG DEAL. I doubt that a stage 2+ pressure sore developed in the hospital in a few days---it seems that all of the issues developed when she was in the rehab facility. It must be quite an extensive wound, as she has been in the rehab facility for 3+ months, and it is going to take another 3+ months to heal. The rehab facility doesn't want to accept accountability for the pressure sore because then they would be cited by the state, as the development of a pressure sore is a BIG DEAL in rehab facilities, especially if it is more than a stage 2. I believe that you could force the rehab facility to cover the cost of her care if you can prove the pressure sore developed at the rehab facility. A stage 2+ pressure sore likely did not develop in 5 days at the hospital---I suspect that they had her sitting up in a chair, getting some sort of physical therapy, etc., where constant pressure was not placed on the heel. Also, the hyponatremia developed in the rehab facility, not in the hospital. You'd have to get her medical records from the hospital to find out how often she was being positioned, how often she was out of bed, and the nurses' skin assessments of her heels. Then you could challenge the rehab facility's claim that it developed in the hospital.

The rehab facility cannot discharge her with a pressure sore if she lives alone and needs treatment for that sore. They'll try to, but they can't. This is where it is SO IMPORTANT for family to be aware of what the rules & laws are.

DO NOT LET THE REHAB FACILITY KNOW THAT YOUR FAMILY HAS PUT TOGETHER A FUND TO PAY FOR HER CARE. It is not your obligation to pay for her care----if she has less than $2,000 in assets, she qualifies for Medicaid. But the rehab facility will gladly take your cash without telling you that because they are greedy, money hungry pigs. Talk to the social worker at the rehab facility to start paperwork for Medicaid. Give the money from the fund back to your family members.

Another issue that raised flags in my head was the fractured fibula that she was sent back to the hospital for----were X-rays done at the hospital when she fell? I would question the rehab facility to find out if she fell there. If X-rays were done at the hospital initially that showed a non-fractured fibula, and then a fractured fibula several days later, that is a BIG DEAL. Something happened at the rehab facility that they did not tell you about, which is illegal. You are right about poor patient management---it is rampant in rehab and LTC facilities. I bet your mother was left in bed because she was taking pain killers & not moved or positioned from side to side, the pain killers being the "excuse" that she wasn't moved.

If I were you, I would try to find out where the pressure sore started & where it really developed. You don't say how long she was in the rehab facility before she went back to the hospital the first time for the fractured fibula. The ankle was splinted in the hospital, and she was sent back to the rehab facility. The splint should have been removed at least once a day for an RN to assess her skin condition. The rehab facility MUST accept accountability & responsibility for the pressure sore & its treatment. They won't want to, because then the costs is coming out of their own pocket. They'll deny until you can prove it by getting the medical records from the hospital.

My mother fell on the ice and fractured her elbow & shoulder, and had a total shoulder replacement. She was put in a very fancy orthopedic splint & her arm was immobilized for 6 weeks. When she was in the hospital, the nurses assessed her skin condition every shift---they removed the splint & looked at her elbow, where the most pressure was. She was in the hospital for one week & then sent to a rehab facility for what was supposed to be 100 days. I signed her out after 2 weeks because her stay was nothing short of a nightmare---she contracted a stomach virus that went around the facility like wildfire (proving that somebody didn't wash their hands after touching the initial patient that had the stomach virus) and she vomiting & had diarrhea all over the bed, floor, bathroom. They would bring her meal trays, with things that she needed 2 arms/hands to eat---open roast beef sandwich that needed to be cut with a fork & knife, juice cups that had foil tops which required one hand to hold & the other hand to pull the top off with. The food was so horrible that it was inedible--my mother is not a fussy eater, but she couldn't eat the food because it tasted so bad. (And they fought me tooth and nail on signing her out because they were receiving a higher rate from Medicare for the rehab stay, and she also had excellent secondary insurance. She sat in bed for 23 hours of the day, and went to physical therapy for one hour, so that was the only time she was out of bed. I was told that I couldn't take her for a walk around the unit or even take her for a ride in a wheelchair.) When she first arrived at the rehab facility, I gave her a shower/bath because she had a nice bathroom set up with a shower head & she hadn't had a shower in a week at the hospital. (I have been a nurse for 25 years, so I am pretty qualified to give my mother a shower) In the hospital, I was washing her in the bathroom but wasn't able to wash her hair or shower her. The nursing supervisor came & chewed me out for giving her a shower & told me I couldn't do it ever again because "if the state found out I did that, they'd be in a lot of trouble." I saw her elbow when I gave her the shower, and it looked fine. When I brought her home 2 weeks later, I took the splint off & there was a stage 2 pressure sore on her elbow!!!! So, obviously nobody was doing any skin assessments to see what her elbow looked like for 2 weeks at the rehab facility!!! She was out of the rehab facility at that point, but I took pictures of the pressure sore and included them with a letter about how I was chewed out about giving my mother a shower & how they could get in trouble with the state, but they obviously didn't care about the state when it came to skin assessments & development of pressure sore on a person that was there for 2 weeks. I was livid. The care at rehab/LTC facilities is notoriously bad. The thing is, I was there with her from 10am to 8pm every day!!! I thought the skin assessments were being done prior to 10am or after 8pm. Silly me to assume that. I could have made a giant stink about it, but I just wanted my mother to be home & out of that dump. And the sad thing is that the rehab facility she went to was one of the better rated ones around me. I'd hate to see what the care was like at a facility that had worse reputations than the one she was at.
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