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Mom (88) fell and broke the head off the femur bone. She already had a broken fibula on the opposite leg for which she was wearing one of those big, awkward walking boots. She had a new ball and rod put in her hip during surgery last week. She suffered really bad delirium the second night after surgery but seems to be better now.


Her hemoglobin has dropped to 7.1 and they decided to give her one unit of blood which brought it up to 8. I think that is still way too low. She has been in the hospital for a week now and the case manager is starting to make noise about wanting to dismiss her even though Mom's hemo level is severely low. I keep asking her hospitalist to figure out WHY her hemoglobin keeps dropping. You would think I was asking him to come up with a cure for cancer!


Mom has to go to rehab after she leaves the hospital, especially since both limbs are now affected. She is weak and having difficulty getting out of bed. Each time she gets up to go to the bedside commode or to walk for PT, I have to put on her boot, get the walker, get the belt they put around her waist to help hold her, and set up the bedside commode. I do this all after I have pushed the button to call for a nurse or tech to come help her since it takes so damn long for them to get to the room.


My brother and I went to visit SNFs last Sunday and were underwhelmed with what we saw. One place even had a community shower with one stall! Yikes! We talked to some friends who had been in acute in-patient rehab at a place near the hospital where Mom is now. They require 3 hours a day of rehab or 15 hours a week. They are in the top 1% in the nation in success in returning people to the community. They truly have impressive stats. We have talked to admissions there and they reviewed Mom's hospital file and said she qualified for care there. Mom's insurance company denied her request to go to that rehab facility and said she should go to a SNF where she will maybe get 1 hour a day of rehab. Since she was independent and walking with a cane and dressing and bathing herself before all this, we want her to get back to that level or as close as possible.


I have filed an expedited appeal with the insurance company and it has been accepted as of today to be put before the decision-making committee. We will know within 72 hours. But the hospital may not let her stay that long (although she needs blood). Our Plan B for a SNF has not been approved yet as they have some "questions" about Mom's hospital file. Apparently, during the delirium episode, the doctor ordered Haldol which she never got. Now the SNF wants to know if she is violent or is "sundowning". She never took the dang pill! They may deny her admission for something that is absolutely irrelevant. She can not come home. I can not lift her or transfer her. I wish I had planned for this starting years ago instead of days.


Why is this rehab situation so difficult?

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Today is Independence Day for Mom at rehab and her chance to show her therapists what she has learned and how far she has come in 2 weeks. Best of all, it means she is going home tomorrow!! Yippee!
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GardenArtist, that is good to know. Before all this happened (broken left fibula and fractured right hip) Mom was going through peanut M&M’s by the bagsful! She has not eaten them for almost a month now (hospital & rehab) so maybe it won’t be an issue. I will look up other potential iron binders and try to keep them out of her diet. Thanks for the info.
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Texas, I learned the hard way that chocolate binds iron. There are other foods that also bind iron and prevent its absorption. Keep a list of the diet she's been given, then research to see if any of them bind iron.

I can always tell when I've had too much chocolate and when my iron level is low. It's the primary reason why I'm phasing chocolate out of my life.
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Barb, you are absolutely right! The doc keeps asking her if she is dizzy, lightheaded or nauseated. She says “No” to all. She is leaving rehab on Saturday to go home. She benefitted from her stay here and the hard work continues for her at home. I am so proud of her for soldiering on!
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Text, from what I'm reading on Mayo Clinic and other reputable websites, its not just the hemoglobin number that determines when to transfuse.  7-8 Is the range where they look at the other factors. Since your mom doesn't appear to be experiencing fatigue ( it sounds like she's doing amazingly in rehab!) I'm thinking the doctors are factoring that into their decision making.
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I asked the rehab facility doc today if they planned to check Mom’s hemoglobin level again and he said to wait until she sees her PCP after she leaves rehab. I think 8 is critically low and it wasn’t too long ago that 8 was the trigger for transfusion. Now it has been changed to 7 to need blood. Crazy! I have no idea how she is managing to do 3 hours of rehab every day. Plus, you can’t sleep for any length of time with vitals being checked throughout the night.
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Other than transfusions, Grandma ate beef daily. If the level wasn't over 10 immediately after the transfusion, she probably needed more a few days later. Most people can tolerate a slow transfusion. When my grandma's congressed heart failure progressed, they would check her into the hospital for 24-30 hours to use a very slow transfusion rate. At 8.0 her brain and organs are likely starving for oxygen and she's at increased risk for falls and/or a heart attack. Might need a geriatric physician to appreciate that 8.0 has a bigger impact on an older person with a weaker heart and organs than a younger person who can quickly regenerate red blood cells.
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TNtechie - thanks for the heads up about the hemoglobin. The docs are giving her iron pills daily and I have not heard any plans to do more blood work. Did they do anything for your grandmother other than transfusions? Last check showed Mom's level to have dropped again from 8.1 to 8.0. It was 8.5 immediately after getting one unit but that was about 10 days ago.

Pepsee - I am lucky to have a brother who pitches in. Happy Mother’s Day to you, too!
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Wow, so glad your mom is doing so well. She sure is a fighter! What a great family you are, your brother and you support your mom so much it's so beautiful to see!
PS, happy Mother's Day to you and your wonderful mom.
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My grandmother had a slowly declining hemoglobin count with no apparent blood loss and required periodic transfusions to maintain a level above 10. She had a femur break and cause a fall too. Doctors finally determine that she wasn't making enough blood cells anymore (femur is a major red blood cell producer and osteoporosis had damaged hers). If your mother's count hasn't started back up, you may want to ask her doctors if she could be having this problem too. As long as the count is coming back up the doctors may not want to give her another transfusion because that interrupts the process where she makes her own blood cells.
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Thanks so much for the update and so happy mom is progressing!
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Day 9 of acute rehab and Mom is a rehab "star"! She is standing and walking using a walker and using the tools to dress herself. She gets a shower every other day and is even feeling like applying some makeup and having her hair done. Good signs! The required 3 hours of rehab a day really adds up to be more like 1.5 hours. There is a LOT of wasted time, especially in Group rehab where several patients sit in a circle and do sitting-down exercises. A lot of the time, the therapist wanders off, leaving the group to sit there doing nothing! Mom uses those occasions to lift her legs and arms and continue to move. Nothing starts on time and usually ends a little early. So, I was worried about nothing as far as Mom being able to handle the 3 hours.

Her hemoglobin is still low so it is incredible that she does as much as she does. She only takes Tylenol for pain and never complains about anything. She is my hero! She has about a week more scheduled there with a release date to home of 5/19. I go to all her rehab sessions as I want to learn and observe how I can best help her when she gets home. I also spend every other night there and my brother is there on the other nights. I am really glad she did not go to a SNF.
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The hospital had her up and walking the day after surgery and each day since. She is going farther each day and working on getting up and down from bed and chair. She is doing well even with the boot on the broken fibula leg. There is a standing order for stool softener but it has not been needed so far.

The appeal was granted today so acute rehab it is. Her temp was 101 this morning with temporal thermometer. A retake with oral therm read 97..5. White count is fine. Hospitalist only saw 101 reading and is calling infectious disease doc! Would it not be easier to take her temp again? The tech came to take temp right in middle of Mom’s lunch and Mom had been drinking Ensure. She took it anyway. Yikes. Talk about an unreliable reading!
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With the oral iron pill ordered please make sure she is given stool softeners and fiber as well as she is at risk to develop constipation.
I agree with you as far as the acute rehab. I don’t think it’s imperative she go there.
What’s her level of activity now? Is she up and walking? I can’t stress enough the importance of getting up and walking soon post op.
Keep us posted!
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Mom is still in the hospital on the orthopedic floor where we wait for the decision from the appeal to her insurance company which will come tomorrow. While I think the denial is financially motivated, the insurance company also said she did not need daily physician visits that you get at acute rehab.

Please know that I have the utmost respect for those willing to be in the healthcare field. My exchanges with doctors and nurses caring for my Mom are always respectful and not without forethought. I asked the “hospitalist” in charge of her case (an Internal Medicine doc) why she can not have another unit of blood. The answer was that they did not want to create fluid overload. I still think 8 is too low. She was at 11.7 before coming to the hospital. She is definitely symptomatic with fatigue, paleness, dizziness. They have been giving her an iron tablet each day and multi-vitamin with iron. Stool test was negative. Internist keeps telling me low number is a result of surgery.

The rehab facility is an “acute” rehab hospital (not nursing home) and, after a lot of soul-searching, I am questioning her ability to handle that level of rehab even though the rehab place thinks she can. The 3 hours per day required by the rehab facility are not consecutive and includes both PT and OT.

My comment about not coming home meant not straight home from the hospital. I am hoping that, with the proper rehab, she will be able to return home, with a caregiver (most likely me.) My brother has been great in helping care for Mom. She was at his house when she fell and he got her to the ER.

Doctors won’t hazard a guess as to what caused either fall. But ER doc says he thinks the bone broke causing the fall that put her in the hospital.

Contrary to what I originally thought, I won’ t be devastated if the expedited appeal for acute rehab is denied. Maybe she could rehab at an SNF first and when stronger go to acute rehab. Medicare most likely would not approve that tactic.
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jeannegibbs May 4, 2018
Thanks for keeping us updated.
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A hemoglobin of 8 is pretty low. A symptom of low red blood cell count is fatigue. I don’t know how they can expect a person with a Hgb so low to be successful at rehab. I hope her doctors give her at least another unit of blood prior to discharging her anywhere.

One reason her Hgb may be low could be blood loss during surgery. If her Hgb doesn’t improve you may consider asking that she be checked for iron deficiency. Assess her stools for blood or dark really smelly stool (melania). Staff can do a test for fecal blood easily using a little card (hemocult test). 

Also if you can look back on what her Hgb has been running and compare the results to assess what her normal range is. Some folks do remarkably well with a lower than average Hgb. But I would still be concerned about the low Hgb she has today.

I would weigh those facilities closely, as 3 hours of rehab everyday is a lot for an 88y/o with her low red blood cell count.

Hopefully she will progress well and come home after her 21 days of rehab. It is good planning on your part to visit SNF in your area to find the right fit for your mother.

If you can, please ask your mom’s docs to transfuse her again. Ideally the minimum Hgb for her should be 10 or close to it. While still on the low side her body should have the capacity to produce RBC on her own. She will need adequate iron stores as iron is the “building block” for new red blood cell production.

It will be hard for your mom to find the stamina for 3 hrs per day therapy if her Hgb is low.

If I were you, I would try not to move her twice as Barb had to when her loved one needed to transfer from acute to “regular” SNF rehab.

In addition to the formal therapy sessions take her for walks around the SNF to help her build endurance. (Assisted, supervised walks of course).

Please keep an eye out to assure she is well hydrated as dehydration is common in her age group and can really make your mom feel worse.

Hang in there! Poor mom, both legs effected! Also be prepared for a new norm as these surgeries take a toll on our elderly population & she may permanently slow down.

I give you kudos for caring for her. It’s super important for anyone navigating healthcare to have an advocate. How lucky you two are to have each other!

Good luck!
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I'm going to assume that your mom is on an orthopedic floor of the hospital.

Ask for a hematology consult IMMEDIATELY to figure out the blood loss. Jump up and down. Call the patient advocate.

Years ago, mom was on a neuro floor becasue they thought she'd had a stroke--but she hadn't. they discovered that her sodium was out of whack and that's what had casused her symptoms.

It took me a full day to realize that these brilliant neurologists were in over their heads when it came to salt. One came in and said "no water". The next came in with 5 pint bottles of water and said "drink these all". The first guy came back and yelled "who gave you all this water?". It was like a circus.

I found the internal medicine chief resident and asked him to get my mom tranferred off the neuro unit before they killed mom. He was reluctant, so I said "Are you going to let these bozos tell YOU how to manage electrolyes?".

They rolled mom out of there 10 minutes later.

If you can't get hematology, at least get Internal Medicine in to see her. And dont fall for "oh we'll do testing once she gets home". Likely, it's the blood loss that CAUSED both falls, don't you think?
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Mom has been in rehab both before and after dementia, and it is very difficult to do even 15 minutes of PT let alone 3 hours

Medicare is strict and will stop paying if a patient refuses or can't participate 3x

Recently, with sepsis and on an iv, mom was asleep during her designated therapy time, so the SNF cancelled it without even telling me

Much of your mom's recovery will depend on her ability and willingness to participate but wherever she goes, she will need your support and encouragement and yes your help in planning where she goes next, as discharge from rehab could come quickly once Medicare stops paying
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So to clarify for you, you want mom to go to "acute rehab", which is a different level of therapy than regular rehab. In our case with mom, after a stroke, she was approved for acute rehab initially, but discharged from there after about 10 days to a regular rehab. So you are most likely looking at two different placements in short order.

In retrospect, we should have looked for a place that did less great knee and hip replacement rehab , ie, younger folks, and more stroke rehab that had a long term care possibilty built in.
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Haldol is used to attempt to calm extreme agitation. Whether she got it or not, seeing it on the chart would make them question why it was ordered. If she is violent or uncooperative for periods each day, she may not be a good candidate for physical therapy. After all, you can't retain your impressive stats if you accept patients who are not likely to return to the community. Delirium in the hospital is certainly not unusual or a reason to assume she won't do well in PT, but you can see why they screen so carefully. They have a reputation to maintain.

Is the insurance company objecting because this place is more expensive? Or out of network? Or what?

When you say "she can't come home" do you mean without successful PT, or are you thinking that she will need a long-term care facility even after she completes therapy?
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texasrdr22, I didn't realize that you had already posted information about your Mom's surgery on the post "Mom broke her hip. How do we find a good SNF for her recovery?" I'll add a note on that post also.
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I am so sorry to hear about what has happened to your Mom. As people get older, their bones become more fragile and the possibility of falling and breaking a leg bone (or breaking a leg bone and then falling) becomes even greater. I agree that hemoglobin of 8 is too low--normal is 10-12 and that it is important to determine the cause of the blood loss. You need to calmly discuss your Mom's care with the case manager and the hospitalist again. I realize that you are upset and angry, however, acting and speaking angrily to the case manager &/or the hospitalist is not in the best interest of your Mom.

"Why is this rehab situation so difficult?" Because it is YOUR MOM who is the person who is having health problems and because it is YOUR MOM who needs to go a SNF for therapy.

I am glad that you visited various SNFs in your community. In regards to the "community shower", most SNFs have one "Bath House" that all residents use and not individual showers in each resident room. There is usually a "Bath Aide" who gives a shower or whirlpool bath to one resident at a time. Each resident usually gets one shower or whirlpool bath per week and is assisted with "sponge baths" in their private bathrooms on the other days.

You mention that "They require 3 hours a day of rehab or 15 hours a week."--who is "they"?--the friends who had been in acute in-patient rehab or the facility? The "3 hours a day" may mean 1 1/2 hours of physical therapy and 1 1/2 hours of occupational therapy per day. The SNF's "1 hour a day of rehab" may mean 1 hour of physical therapy per day or it could mean 1/2 hour of physical therapy and 1/2 hour of occupational therapy per day. You need to clarify exactly how many minutes of physical therapy and how many minutes of occupational therapy per day and per week are being prescribed for your Mom once she will admitted to a SNF.

Unfortunately all SNF facilities need to evaluate each potential resident carefully so the questions that they have been asking about your Mom's hospital file are not unusual. The SNF is just being thorough and is trying to get an accurate "picture" of what type of care your Mom needs. Please do not take their questions personal, the SNF asks these types of questions of every potential person they might admit to their facility.

While I understand that you want your Mom to get back to being independent, dressing and bathing herself and walking with a cane...the possibility of this actually happening decreases as a person's age increases. The reality is that many elderly people who fall do NOT ever return to their previous level of independence. The reality is that for many elderly people, the fall is the start of continual decline in health with them ending up in a LTC facility for the rest of their lives. :(

As for wishing that you had planned for your Mom's fall and for her decline in health and for her need for care in a LTC facility "years ago"...none of us are ever ready when it happens even if we "planned for this...years ago". It still comes as a shock.

I am so sorry that your Mom and your family are having to go through this health crisis. Unfortunately, many elderly people experience similar health problems. Fortunately, this forum is for people who are facing similar health problems, who are wanting to vent about their situation, or who have questions about their situation. I hope that we can help you as you cope with your Mom's health problems.
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