Help for mom. Any advice?

I think you your Mom was not safely sent home. I think she should have gone into placement.
Did no one in discharge planning suggest to you/her that this was not going to work at home?
I am sorry she wasn't placed after her rehab. While she likely no longer qualifies for further rehab and has reached the level that rehab can take her to, she is not safe at home alone and will deteriorate. She should have gone into placement whether temporarily or permanent.

I am sorry you took her into your home. I would have sent her back to the ER saying that she cannot manage at home, was unsafely discharged from rehab and is not safe at home. I would have not left your own home as the option, and once you have taken her in it will be almost impossible to undo that, and as you acknowledge, you don't have the wherewithall to care for her.

You may be looking at a return to ER. And Social Serivces being contacted for safe discharge planning. I am so sorry. This will be a lot of confusion, but a real set back if your Mom is without adequate care at this time.

Is the age mentioned Moms or yours?

I will assume you do not live close. Have you been in touch with the Rehab since Mom was admitted so they knew there was a child involved. Really 100 days is a long time to recover from a knee replacement and end up like Mom. I would wonder why.

Did Mom tell the discharge person that someone would be at her home to care for her when she got there? Did anyone talk to you about her discharge? They cannot release her unless there is someone to care for her. Sending her home by transport shows they knew there was no one to pick her up. IMO without making sure there was someone there to care for Mom and all safety measures put in place, your Mom was an "unsafe discharge". It does not matter if she wanted to leave, it was unsafe to allow it. Someone dropped the ball here. I would call the facility and find out how this could have happened. If you can't get a straight answer, then call ur State Ombudsman. The facility has to give you the number.

I would ask Moms PCP to order in home therapy. I would ask for a PT evaluation to find out why after 100 days Mom is not mobile.

I want to make you aware that Medicare only pays 20 days 100%. 21 to 100 only 50%. So unless Mom has a good supplemental, she has a balance due to the Rehab.

If your mom can't take of herself, the facility should not have released her without a care plan in place. My apologies, but something doesn't make sense here. It sounds like she should still be in a nursing home, and never should have been released. At this point you can contact a state elder care social worker to help you find a solution, or get her into the hospital again and have a hospital SW find placement for her.

Did your mother tell the rehab facility that you would be her in-home help? How else did they release her?

Please reconsider your plan to move her into your home! You already don't know how you will be able to help her if you move her in.

Call your county office of aged and disabilities for guidance / solutions. They will help you work towards Medicaid.
good advise below…

Are you her PoA? Does your Mom have a diagnosis of cognitive impairment?

When she went into the ER after her fall is when her medical advocate needed to be there. Surgery usually means anesthesia which can often create after-effects in seniors, like hospital delirium. This may be part of the problem: that she went in as an independent, competent person with no cognitiive problem but came out with one, so the hospital and then rehab discharged her. It is possible she developed a UTI while in rehab, which would possibly explain her inability to care for herself. This can be treated with antibiotics.

Someone now needs to be her daily advocate until she is stabilized or regains her mobility. They won't order more PT if she isn't progressing or doesn't cooperate. You can call in social services for her county to see if she qualifies for in-home help. This will also get her on their radar and she'll be assigned a caseworker that you can communicate with. This is a temporary solution. In the long-term if she doesn't regain her mobility and cannot do herr ADLs then she might be a candidate for LTC, which is covered by Medicaid, if she qualifies. You should consider consulting with a Medicaid Planner for her state to know what this pathway requires and how long it may take. I wish you all the best to get her the help she needs.

I’m so sorry that your mom was at home without any care.

Were you in touch with the rehabilitation facility while your mom was there?

When my mom was in rehabilitation there was a meeting to discuss her progress. She wasn’t quite ready to be released and the facility asked me about her staying a bit longer. My mom did stay a bit longer and she paid out of pocket for those extra days. I picked her up to bring her home.

Were you not informed about the day that she was scheduled to leave the rehab facility?

Your post is a little confusing to me. Would you please tell explain this situation further?

It doesn’t sound like your mom is capable of living at home by herself or even living with you.

She needs to be in a facility where she can receive proper care around the clock.

Medicare will not pay for a skilled nursing facility. Your mother will have to apply for Medicaid.

Wishing you and your mom all the best.

Is Simply a Medicaid plan? She still needs to be in a facility from the sounds of it. They probably sent mom home at her request. If she is not incapacitated then they need to do as she says. Once they told her the cost of a day in rehab, she probably told them to send her home.

Get her on Medicaid and get her in a facility that can provide the services she needs.