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What are the rights of a patient when a Skilled Nursing Facility (SNF) refuses to discharge them to an acute care inpatient hospital, even though the facility admits it cannot provide the medically necessary care the patient requires? The patient is experiencing worsening symptoms, including orthostatic hypotension and circulatory issues, due to delays in presurgical orthopedic neurorehabilitation, which are critical within the neuroplasticity time window for recovery.


The facility claims it is providing care within its scope but acknowledges its inability to treat conditions such as dehydration and stercoral colitis. Additionally, they refuse to discharge the patient unless a home address is provided or the patient signs out Against Medical Advice (AMA), despite requiring 24/7 ADLs and bowel/bladder care. The patient has reported medical neglect and abuse, and the facility has stated it will only send the patient to the ER if his condition worsens.


How can the patient advocate for their health and safety, ensure access to appropriate care, and hold the facility accountable? They have no access to a treating provider since he requires inpatient acute care interdisciplinary team and this has been documented by outpatient specialists, yet because they are out of network and outpatient they cannot initiate a transfer for a patient already authorized at custodial care level which was never actually appropriate for him.

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I would talk with an Ombudsman. Contact your local senior center (here in Missouri it's called Care Connection) and they can connect you with one.

The question in my mind is...is the SNF waiting for you to make provisions at another facility for the patient? Is it an insurance (or lack thereof) issue? Someone has to finance the patient's transfer and care in the new facility or the patient can't move. Either insurance has to cover, or patient's money, or you pay out of pocket.

There IS an answer to the problem. We just have to find it. Hopefully, an Ombudsman can help sort things out.
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Your profile says that you are caring for your father who is 62, in a NH, and that you are “advocating for my father to come home”. Yours is a new post, so you probably wrote this recently. ‘Coming home’ is very different from “discharge to an acute care inpatient hospital” and also from “he requires inpatient acute care interdisciplinary team”. Your grip on medical language suggests that you should understand the difference - or are talking about different people. Please explain?
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For context, what is your relationship with the patient? Are you their PoA? Guardian? Relative? Does the patient have the cognitive ability to make decisions in their best interests? How old is the patient? Important to know because the "out of network" thing will come into play depending on what health insurance they have. If you work at this facility maybe suggest to the patient to talk to an ombudsman. If the patient never assigned a PoA and now is in need of an advocate, then perhaps social services needs to get involved. Call social services for their county.
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Is there an issue of the acute care hospital not accepting the patient b/c the patient's needs do not "justify" hospital admission? Are you or the patient withholding a home address for some reason? Is the facility only willing to discharge the patient to his/her home?
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They can not deny anybody treatment in a hospital setting. Have the loved one taken to the hospital, through the ER if necessary. Ask for case manager/social services to help you with follow-on care.
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First, I would contact whomever is paying for the patient's care and get a list of in network hospitals that accepts his insurance before attempting to move him. Can this patient walk or would he need a special ambulance service for transporting to the ER?

What kind of facility lacks the ability to treat dehydration? Most SNFs have an acute care unit with their own doctors and nurses. If a treatment is beyond their scope of practice, they will send a resident to a hospital.

I'm with others here. Contact your Ombudsman for that county where this facility is located. It sounds fishy.
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swmckeown76 May 5, 2025
If he's on a Medicare Advantage plan, there are networks. He may have few choices for hospitals. If he's on traditional Medicare + a Medicare supplement, there are no networks. You can choose any hospital you like, preferably an academic medical center.
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Seriously, the facility can not treat dehydration and chronic constipation?

The stercoral colitis is a diagnosis that needs immediate treatment, you should be calling the ambulance for transport to the ER.

What happened to your dad that he needs neurological rehab? A Stroke and injury?
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If your profile's mentioned patient is your father at age 62, I'm sorry to see his condition. He is not age 65 and ineligible for Medicare unless on disability.

Your scientific terms about his conditions look like a doctor's descriptions and are hard or impossible to comprehend. Can you please convert your scientific descriptions to general our readers can understand what they are to enable us to help you better? Thank you.

Patathome01
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JeanLouise May 5, 2025
Sounds like an attorney wrote this
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An SNF doesn't "discharge patients to hospital". It may send an acutely ill patient to the ER, but it is up to the Hospital and their doctors whether or not a patient is admitted, and a patient will be kept in hospital care only so long as he or she is ACUTELY ILL and requiring hospital level care, a very HIGH level of need.

How old is this patient?
What underlying illness has led to the patient being so bedridden as to have stercoral colitis?
Is this patient well and competent enough to advocate for himself?
If not, who is POA for this person?

As you can imagine, the colitis is going to be an ongoing problem with someone this ill and debilitated. It is not something normally addressed in an ER unless there is an obstruction and disimpaction is needed. That may be an ER procedure with immedicate return to LTC.

You mention a need of stablizing this patient for surgery. WHAT surgery?
The person you are describing sounds as though he is now suffering from both chronic and acute debility. But the acute isn't in need of hospitalization. Hospitals now only keep patients with acute needs. So an ER would address an electrolyte imbalance, a dehydration problem, and etc. But would not keep a patient stable enough for SNF.

This is truly an individual situation with one very ill patients with needs for surgery who cannot apparently be stablized enough to qualify for said surgery. This is a medical issue that can only be handled by the patient, the medical team and the care facility. And some issues simply cannot BE handled, dependent on illness, age, infirmity and etc.

Sorry, but we can only guess at all that's involved in this apparently very complex situation, and can only wish you the very best of luck. So sorry for all you're going through, but there can be no other ways to intervene here other than those you are already attempting.
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MiaMoor May 5, 2025
I should have read the first 3 paragraphs of your post, Alva, before writing mine!
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Sounds Like his needs exceed the facility. My DH had an amputation due to broken tibia and bone infection. Before he was accepted into the preferred rehab his antibiotic regimen had to meet their level of care standard. (IV 3X was too frequent) the hospital applied a PICC line which thankfully satisfied our local facility Surgical Transition Unit.
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