New update on my 98 yr old dad. Do homes have to follow these directions?

Dear BlueJasmine,

I hope at this point you are receiving the appropriate care for your father. To answer your question; absolutely, yes! The ALF must follow the latest MD orders and if some reason they cannot, they must contact the MD and explain why not.
ALF do handle many medical issues but they cannot accept residents with: running IV, woundcare vacs, feeding tubes and I will check on some other things.
ALF does except hospice care residents. If a resident goes to the hospital and the hospital staff attempt to send them back to alf with any of the above, they will be denied reentrance. The social worker of the hospital , the alf DON or admissions nurse will work together to see what options the resident has.
Someone dropped the ball at the alf. And I do not want to place blame but it appears to be that way. I work in an ALF. And tbh, we have some great staff BUT we are completely overwhelmed at times; inadequate staffing, higher acuity residents, families refusing to put mom or dad on hospice or palliative care when it is so clear that that is the best choice for their loved ones, so we the nurses have to keep going back and forth to the MD trying different things & the combo of these unfortunately means things are going to be missed.
We have some residents who have no business being in alf but get accepted because, well, for the payment it brings. We have lots of hoyers & they require 2 people to assist.
I can’t even begin to tell you how much we have to keep track of & if a nurse or aide is not organized, that is not going to help the residents at all.
We do really try our best and love our residents like family!

Sincerely,
L

Caroli1,

When a person is Hospitalized, yes there are a certain number of days that they have to be in (3 or 4) before "Rehabc can be suggested. Medicare only pays for Rehab. First 20 days 100%, 21 to 100 only 50%. The balance has to be paid out of pocket or the secondary may pay full or part of it. Medicare determines how long a person is in Rehab. It has to do with how they progress in therapy. If they plateau or do not progress Medicare has Rehab discharge the patient. Rehabs are not skilled nursing. If skilled nursing is needed, then the patient is transferred. Since Medicare does not pay for skilled nursing, it becomes out of pocket. If the person does not have the money, Medicaid is applied for. If approved, the persons SS and any pension are used to offset the cost of the patients care with Medicaid paying their share.

When I posted I was in a hurry because we were going out.

Need to say that ALs are just that for assisting. They are not skilled care facilities. They are primarily for people who can still do for themselves with a little help in certain areas. They are limited and eventually residents need to go to Memory Care or Skilled Nursing.

If Dad had transferred to Skilled Nursing, they would have requested Hospital paperwork and taken it from there. Skilled nursing is who you would expect to do the things that you thought the AL should have done.

I’d suggest that you try to get him evaluated for hospice. His MD can write the orders for this. It will provide maybe 2 -3 of caregivers coming in per week. It will not be intensive services but more palliative care.

He ‘s 98 and has pretty intense health care needs and medications. He is not going to get back to the Dad of 95 or 85. Try to be accepting of his being in his final stages. Hospice can be a total godsend for this period.

Your dad should not be in assisted living. AL is for seniors who can handle their own affairs and need little to no help. Since you are propping his independent lifestyle up by doing everything for him he needs a place that will do the same.

I am trying to figure out who dropped the ball here. So I am just brain storming here, not finding fault.

Who picked Dad up from the hospital and took him to the AL? (This was a new AL, correct?) First, the person picking him up should have gotten discharge papers then. Those discharge papers should have been given to the RN at the AL. My Moms RN handled anything needing to be done concerning meds. If there was a new medication, she called Moms PCP and got a prescription that was sent to the pharmacy the AL used. All of the meds could have been ordered by the RN unless this kind of thing is left up to family in Dads AL. Oxygen maybe the only thing that could not be ordered. That may have to be done by you or RN by calling his PCP and getting him to order it.

Did the doctors not talk to you? Is Dad competent so they talked to him? The AL is probably not entitled to know about Dads health issues. Thats up to him to disclose or you if he is not competent to do so. But they should have gotten the discharge papers and followed thru IF that is part of their responsibility. If considered yours, then you should have made his PCP aware that prescriptions were needed as per the discharge papers. If you received no discharge papers at the time Dad was released, thats on the hospital.

His primary could have requested those records. I finally learned after a couple of times of hospital stays for Mom and DH, get them to their PCPs ASAP after discharge not wait the one or two weeks the discharge papers suggest. You may find out Dads PCP does not agree with the Meds prescribed. He/she knows Dad not a doctor in the hospital that has no idea about his prior health.

I would discuss Hospice with the doctor. Your Dad has a lot wrong with him and Hospice will keep him comfortable.

Assisted Living doesn't provide medical care. They may have some physicians they more typically work with, but this is not a part of their service. MDs are a patient's own doctors. Followup with the patient's doctor is required. In the case of some ALF there are MDs who work closely with the facility, sending a nurse practitioner who is going to visit in the facility, checking blood pressure and so on. Otherwise there is no medical care in assisted living. You are on your own with seeing your own MD.
Are you the POA? It is up to you then to get the patient to the MD and to discuss with the MD what medications the patient should be on. These medications are then written orders to the Assisted Living for the medication nurse. The medications are provided through the facility or through you yourself. Assisted living isn't the same as SNF (skilled nursing facility, where there is a doctor on call. There is no medical personnel at your average ALF unless patient is in Memory care, and even there there is no ordering MD.
How long have you been POA? Who is the MPOA? Who has been discussing your Dad's condition with the medical personnel on his hospitalization? Your Father's doctor is the one to discuss his condition with, and find out what medications should be given to him. The same would pertain were he in ALF. His own doctor prescribes his medication. If he is not capable of taking them himself he is put on the care plan for a med nurse who will deliver medications as ordered by his own MD.
If your father isn't doing well he needs to see his own MD unless he is in a skilled Nursing home where he is being followed by THEIR MD, who should have all the records from his former doctor.
It's complicated for certain.
Your Father is 98 and he is diagnosed with severe illness of his major systems including his heart, which is failing. It is time for you to discuss palliative or hospice care with the doctors now. Medications can help to treat these illnesses, but there is no answer to aging body and failing major systems. I wish you the very best.

I don't know what the protocol is in the States. When a patient is discharged from hospital, he (I assume) is given a copy of his discharge summary. No doubt your father put it somewhere safe and it was never seen again. But who else is routinely copied in? Anyone? So when he then went through the admission process with the ALF, who was responsible for providing them with his medical history? - which, you'd have thought, would have included the most recent discharge summary (which routinely has a schedule of prescriptions attached).

One of the blessings - and they're not so many you shouldn't count what they do have - of a socialised universal healthcare system is an established, predictable communications pathway. Discharge letters are sent by the hospital consultant to the patient's GP with a copy being (metaphorically) stapled to the patient's ear for the attention of whoever is in charge where he's bound for, whether that's home, rehab, residential care or family care. So at least in theory they are available to whoever will next be leading his medical care.

Whether or not anyone reads them, let alone reads them with understanding, is a different question.

But, so, I'm wondering - were the notes sent to the ALF, to your father's GP, or seen by anyone supporting or responsible for his care? Why did you have to go and dig them up?

And to address the original question: the ALF couldn't comply with directions they didn't have, nor even monitor whether your father was able to himself. Did they have them? Could they have known about them?

AL will assist with ADL's but they are not responsible for the medical conditions of the residents.
If anything the AL could have said that with the current medical conditions he can not return to AL he needs a SNF (Skilled Nursing Facility).
The Social worker and or you would have had to locate a SNF that would accept him on discharge.

Assisted living is not able to deal with the medical issues. He needs a higher level of care. My dad was in AL up until covid and the outside caregivers we hired couldn't be there anymore so the extra eyes were off of him. After 9 mo. in skilled nursing, we got him leveled out and he is now in a small memory care run by an RN who is able to deal with the medical issues.

Very distressing to be the last one to know such important information. I know you've been posting and updating but I can't fully remember the details of your adventure: you just recently became his Medical PoA? Or you are now his guardian? If this was all recently then if he was in AL without a diagnosis of dementia, it is not surprising that this all went unattended. He should have been in LTC where they are equipped to deal with this level of medical care. They were probably going by his what he was telling them, which was nothing. Although it is important to put the pieces together, if I were in your shoes I'd spend my energies in getting him improved or properly situated. You can deal with the medical care issue later. In light of this problem, you may want to consider moving him to a different (better, more reputable) facility for LTC. Wishing you all the best and thank you for the updates!