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Father in law is in skilled care nursing home from a fall at home. Rehab staff recommends LTC upon DC and family agrees as just before his fall we were noticing several instances with dementia like behavior. He was never one to spend anytime with family so awareness of this by family was limited. On the surface he can carry on pleasant conversation and can recall recent events but is lacking in very many other areas to be independent and care for himself or make decisions. Awaiting to get a diagnosis as the mini mental exams do not capture all his deficits. He is Medicaid pending awaiting approval. My husband is his POA as we realized quickly that things were a mess recently after his fall. The skilled facility he is at states that upon his DC day they cannot keep him if he doesn’t want to stay, which of course he will say because naturally wants to return home but has no insight to his inability to walk and care for himself. No one in family are able to take him in to their home and that has been made clear to social services. We and rest of family are extremely distressed when DC day comes what will happen and he wants to leave. He of course has been very difficult and argumentative as we have tried not to upset him but plan accordingly for his best interest. We are extremely stressed dealing with all his affairs. And concerned that facility will dump him on us to care for if he states he doesn’t want to stay. Can they do that? Especially since he has not been diagnosed with dementia officially. He hasn’t been able to be assessed by a neurologist. Soonest appointment is made for September.

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Where was his home before he was in LTC? Was he living with you or on his own? If he was living on his own they can't make you take him into your home. If he was living with you, you need to make it clear it is not safe for him anymore there, you do not have the resources and ability to be his caregiver. They cannot discharge him to an unsafe environment.
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MKM533 Apr 2020
Thank you for you response. He was living on his own prior to his fall. As we learned more. He wasn’t doing very well at all. Since his interactions with family were limited by he’s own choosing, it was easy to hide or compensate for a lot of his deficits. We are extremely stressed and appreciate your input. Thank you.
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I'm sorry, I understand the stress level. Keep trying (or your husband) to gently convince father that the Nursing home is really the best place for him now. He'll get 3 meals a day and people to look after him to make sure he's safe. If living with you comes up (don't bring It up) explain to him it is not possible because you can't be there all the time. As far as the working with the Nursing Home, DO NOT sign any release papers (your husband needs to know this). Doing so would not be in father's best interests. Let us know how it goes.
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Do not let him stay with you, no matter what. "Temporarily" taking him in will quickly turn into a permanent arrangement. Last resort is to let him return to his home and await the next crisis.
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Your husband needs to talk to current facility and ask for a social worker. Explain to social worker that a discharge home would be an unsafe discharge.
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If he wants to be discharged, it will be to his home. You then wait for him to be hospitalized again.

Point out to discharge staff that it would be an "unsafe discharge". They are obliged to get a plan in place. YOU are not the plan

You are under no obligation to provide care or housing.
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In my state you are entitled to have his mental status assessed by a professional psychiatrist, psychologist, or social worker with training and experience in geriatric behavioral issues. This can be done before the neuro exam and can serve the same purpose as far as behavior. It may or may not be covered by insurance he has currently.

Don’t discuss this with him, just do it. If you need to tell him that he needs “an assessment” before deciding the kind of help he needs, tell him that, without getting into specifics about his behaviors.

As stated by others, all family members must be on the same page that no one can take him home. At worst case, you will need to have an aide with him 24/7 in his previous housing until you can get a documented report indicating that he’s incapable of managing for himself.

If the assessment has been scheduled, be like water on stone- say you cannot plan appropriately for him until it is done, prepare a list of the questionable behaviors you have observed, determine objectively what would be needed to make his house safe for him.

You stress is totally understandable, but the fact is that HIS WELFARE depends on full time care, so therefore his future depends on being declared cognitively incompetent.

Final thought- you need to accept the fact that there will be no good, successful, comfortable solution for himself or for you. Dementia is a capricious, vicious, brutal enemy, forcing us all to make choices from the best of the terrible solutions.

Good Luck.
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mstrbill Apr 2020
Just want to input here regarding your stated "worse case scenario" of full time aid. Full time Aids are very expensive and family does not have to pay for that out of their own pockets. That is not their responsibility. If Medicaid covers that, then fine, but family does not have to put that in place out of their funds.
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This is what I did...
Find a facility I was comfortable with and explained that this is a rehab hospital and when you can do ABC and three of your doctors release you then you can go home. Mine accepted that after a bit of a fuss, but it worked.
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Alicew234 May 2020
We did this too. Once he's placed, the facility will have a duty to make sure any discharge is a safe discharge. The facility keeps reiterating that he needs to do XYZ before they can consider him for discharge. And he can't do any of those things.

He is really unhappy about it but we are hopeful that he will accept this new normal eventually. He also was not doing well at home but the extent of his decline wasn't apparent until he went into the hospital.
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Read your husbands POA. Is it "immediate" or "springing", which means he has to be incompetent for the POA. If immediate, I think your husband can make the decision to have Dad transfer to SN. If springing, then DH can ask for Dad to be evaluated and declared incompetent to make his own decisions. If found Dad cannot make informed decisions, then the POA kicks in. Our rehabs also have SN attached. If Dads is set up like this, you can transfer him over to the other section. Then you tell him a little white lie that he is needs to stay a little longer. If Dad has no money, then u apply for Medicaid. Thats a whole other thread. If you need more info about that, come back. Right now getting him to stay is the main thing.
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If it is an unsafe discharge then I have advised my families that the person needs to be able to organize and arrange his own discharge, including a ride home etc. with the understanding that the discharge is against medical advise. Many times this ends it since cognitively that person may not be able to pull it off. I also tell them to not agree to take them home without the doctor saying it’s safe. It takes more complex problem-solving to work out a way home that often is beyond current ability. If they do manage the discharge I tell families to keep an eye, the person will likely be hospitalized again.
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Don’t accept him into your home or you will regret it for the rest of your life . Hugs 🤗
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Lots of sound advice has been given to you here already. They could try to get him to sign out AMA (against medical advice). That would be for their own legal protection. Since he might not be deemed as competent to sign such a waiver, not sure how that would hold up in court if he figures out how to get back to his own home.
Does he have a car at the facility? Take it away and/or immobilize the car so it won't run. I'm not a mechanic, but I'm sure there are at least a few ways to render a car undriveable; disconnecting the battery or removing all the gas are a few examples. Of course, tell the facility that you cannot take him in, he cannot safely take care of himself alone at home, and that you and your family don't have the ability to take care of him and all his needs in your home.
I'm so sorry you're having to deal with this situation in these troubling times; it's a difficult scenario to begin with, but with the pandemic added into the mix, it sure is even More Stressful!!
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I would recommend that he is evaluated by a neuropsychologist or geriatric psychiatrist as soon as possible for a diagnosis. I would also contact the area agency on Aging and speak with the ombudsmen regarding your concerns. The facility can't just dump him; a safe discharge plan needs to be in place. With your husband as POA and a diagnosis of dementia, your husband should be able to be the decision maker. Another option is to contact an elder lawyer to see if they can provide any assistance.
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He needs to see a neurologist.
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When my brother was in the hospital and later rehab, they decided he was dying and did not worry about a safe discharge.
they wanted him “out of there”.
I wish I had known this group then.
They kept telling us what HAD to happen. It was like having drill sergeants on all sides and was VERY difficult to fight back during the high stress time.
Please get with family and try to discuss dad sanely ( away from the furor) and do what is right.
These people are NOT family.
Please let us know how you were able to deal with this terrible situation.
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MKM533 May 2020
I hope all that have responded to my question can see a big Thank You!!! My husband and I deeply appreciate your response and guidance. It has been so comforting as well. This is the current update. First, the quarantine has made things difficult and helpful at same time. It doesn’t help that he already is bored, wants to come home and we are unable to visit except on other side of window of room. There have been no activities for residents, no outside to courtyard on pretty sunny days and all meals are in rooms. This adds to the overall “ I want to leave” feeling . He has used all 100 days of Medicare and are awaiting Medicaid approval. We keep encouraging him through phone calls to stay until he is approved. Sometimes he is open to idea then totally forgets. It’s always a back and forth battle. What is frustrating is half of staff state he needs long term care and then others just off hand say he’s a lot better than some others here. I wish they would quit comparing and see him and his ability to do things either independently or with assistance on his own. The facility social worker gives the feeling all the time that if he doesn’t want to stay we can’t hold him against his will. They give him papers regarding his care and insurance that upsets and scares him. My husband gets them also as POA in the mail of course but at a much later date. So trying to figure out a panicked phone call from him and not knowing yet is also frustrating.
We just are keeping fingers crossed trying to keep him calm and willing to stay until Medicaid approved then we are looking into a facility that will take him long term and allows residents to smoke in monitored specific area as this seems to be, for the last 40 years, his favorite social activity. We keep holding the card of there is no safe DC plan in place but if he is adamant and walks out ( which he can’t. His main form of mobility is the WC). I feel like facility is so bent on protecting his rights to leave despite also seeing clearly that he is unable to care for himself. I wish they would work with us not against us. So confusing and stressful for us. Oh and regarding his car. He does not have it. He totaled it when he drove off the road when he became disoriented and didn’t know where he was. He was less than a mike from house but got confused when attempting to return home and was about 7 miles from home when it became stuck running off road. We were just beginning to add things up and see the problems when he fell and this journey began. Again thank you so much!
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What facility is this? Lol. If anything it would be financially advantageous for him to stay. Surprising they have not worked on you to make that happen
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gemswinner12 May 2020
I think it seems as if the facility does not want him to stay. If they aren’t being reimbursed or paid to keep him any longer, they will of course be attempting to get him out. Facility managers are very well paid for meeting placement goals.
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MKM533, JUST REMEMBER, although social worker may seem focused on "protecting his rights" of not wanting to stay there, she is probably more focused on protecting the facility's desires. And REMEMBER, you and your family cannot and will not provide a care environment in your home for him. If the facility chooses to drop him off at his home they are committing gross negligence.
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The smoking might become an issue if you're trying to find a medicaid facility that will accept a resident with this habit. It takes extra time/manpower to facilitate this habit, especially knowing that his condition will probably make it so that he needs more and more assistance in order to safely proceed. One of my friends was able to switch her Mom to a vape device from cigarettes. It's not at all more healthy, but less of a fire hazard, and less smell, easier for him to continue the nicotine habit without requiring someone else to help him go outside, find a lighter, ashtray, etc... It's not cheaper, either, but just a thought in case you find the smoking to be a big obstacle, especially if he ever needs oxygen (now or in the future). I remember one patient who was on oxygen, so I had to disconnect his tubing, wheel him outside, make sure he had smokes, lighter, ashtray, then drop everyone else to go retrieve him and put his oxygen back on ....three or four times a shift. Very time-consuming!
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If you can manage the effort, find an affordable live-in with a non-irritating personality and some brains in their head. If it’s not severe, his dementia symptoms can probably be reduced if whoever stays with him makes the adjustments to his diet and activity described in The End of Alzheimer’s by Dr. Dale Bredesen.
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