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Mom who is in her mid 90's fell and broke her hip. She is in a rehabilitation center after the surgery, but isn't eating, or really participating in her recovery process, yet she insists she wants to go home. She isn't able to walk independently nor use the toilet without 2 assistants. The nursing home is not telling the truth on her daily sheet what she is eating as family has been there during meals and when they have been shown the reports they do not coincide. I would like to see if she can be transferred to another nursing home rehabilitation center via Medicare even if we have to self pay for the transport. I am sure co-ordination of benefits for the two homes would need to be worked out as long as making sure that the place I would like to move her to is accepting new patrons. I know there are a few people who have made comments, but what I am interested in knowing is were the parent(s) able to be transferred or did an attorney have to make the move happen?

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If she is not cooperating with rehab, you may have trouble getting her another bed and moved under Medicare coverage. You will have to pay out of her funds to move. Has she used up the initial period of 21 days at which point she has to pay copay and get approved for additional days? I’d ask if the facility was trying to get her extra time about the meals. Failure to thrive and not compliant with rehab is a quick exit for Medicare coverage of stay.
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I've had to do this too.  One time we were able to work things out at the facility; the second time I had to transfer.

First time:  my mother had a therapist who didn't know how to work with older people, and was pushing her in therapy beyond her capability, criticizing her b/c she was afraid to stand on her broken leg.   My father, sister and I asked for a meeting with relevant staff.

First we discussed it with her orthopedist, who affirmed that she was totally non weight bearing at that point.   Second, we met with the staff. My sister, a nurse, had her medical notes and I had my legal and general notes.   With Dad, we presented our case that the therapist, who insisted that Mom stand, was inappropriate and hampering Mom's recovery.

NOTE:  if you meet with staff and can bring family or friend support, station yourself at opposite points at the meeting table.   Staff will do that so you can be observed from multiple angles.   Kind of makes you feel surrounded, and outnumbered.   My sister alerted me to that strategy (she was a psych nurse), so we did the same thing.

The therapist was transferred to another facility within the chain, and Mom was rewarded with a very congenial, understanding and supportive young therapist.   Life changed for the better, for all of us.

Other than the orthopedist's involvement, no outside support was necessary.


Second time was when I chose what I thought was an outstanding rehab facility.  I had 3 pages of questions and notes, toured the facility and was impressed.   A son of one of the residents confirmed that it was a good facility.

First day, we realized how wrong I was.   Dad's medical records got lost, the food was disgusting, and not even edible.   (I tasted the brownie; it was at least several days old.  The fish looked like plaster).   There was inadequate support and after dinner bathroom breaks were like trying to manage after a natural disaster. 

That evening, Dad said:  "GET ME OUT OF HERE!"   I contacted his orthopedist, got a letter from them confirming he still needed care at a satisfactory facility (for Medicare purposes in case payment was denied, which it wasn't), toured facilities the next day, found a very good facility, advised the staff and Dad was moved either the next or following day.     

When his PT/INR was checked, he was close to being highly anticoagulated as a result of the first facility having lost his records and not administering Coumadin.

So, get a letter from her doctor and interview and find a good facility, then just advise the current one you're making a transfer.  You don't need to provide reasons; just avoid all that and say that you've found another facility that's more suitable.

Good luck.   Post back if you have any problems or other concerns.
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I see from your past posts that your mother lives with one of your brothers (who works). Is the plan to get her back home after rehab is completed? And, if so, do you think that plan is realistic? Or will she placed into a long-term facility?
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thingsarecrazy8 Aug 2019
That is a two fold question. Mom thinks and everyone else in family feels it is a realistic plan. However, with a walker, wood steps to enter her residence and the inability to add a ramp due to the incline the ramp would require it is not realistic. She has been in rehab for 16 days as of today. Long term care is looking to be the only recourse at moment unless something happens to change that soon.
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We did the same as isthisrealyreal. Found a new facility with an available rehab bed, and their business office and admissions office contacted the first rehab facility and arranged transfer, paperwork, etc. It’s been several years now and I can’t remember if we had to pay out of pocket for transportation (probably did). My grandpa was very elderly at the time and was going downhill. He was often delirious in the hospital and would sometimes get disoriented and upset in each facility. However he was very agitated and having an especially hard time at the first facility. As soon as we got into the second place he was calmer and the doctor there got his meds straightened out. It wasn’t perfect but it was better than the first place. If the rehab staff are not responsive to you, or if you feel they are not managing mom’s pain and care well, then it’s worth trying a new place. It’s a difficult spot to be in. Good luck to you and your mom.
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I moved my dad.

I found the facility and called them and asked what I needed to do to move my dad. They walked me through everything.

I had to stand over the jerk facility to get them to send the paperwork, that was the hardest part. I was told multiple times it had been sent yet never received, when I literally stood over her shoulder it was miraculously received. Be prepared to have to be tough with the discharge facility. I actually got so pizzed that I thought they would call the police. I didn't care, they weren't taking care of my dad.

The receiving facility arraigned and paid for transport.

Good luck, some of these facilities are reprehensible.
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The short answer is, no, you don't need an attorney, you can move mom to any facility that you want as long as it's covered by her insurance and they have an opening.

But the long answer is, I think that if she is not participating at the current facility, she most likely will not participate at a new place. A broken hip in your 90s is often the beginning of a downward trend in health for our poor parents, no matter what facility she is in. There are much more important things to worry about than whether she ate 40% or 60% of a meal.
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thingsarecrazy8, your Mom could be having a spell of delirium. One has to remember, Mom is in a strange place for what will be a few weeks. She doesn't recognize anyone's face.... there are different noises all day and through the night.... and the food isn't what she is use to. She wants to escape.

Don't forget, Mom had major surgery so her brain is still in that fog. For the number of hours that your Mom was in surgery, for every hour it equal one month of brain-fog. That even happens to young people.

Even if you move Mom to another rehab center, the same thing will happen.

At such an advanced age, doing rehab will be extremely exhausting for your Mom, and with pain she may not want to do the routines. So, don't be surprised if Mom now becomes very limited with what she can now do.
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thingsarecrazy8 Aug 2019
Mom went to orthopedic surgeon today for stitches removal. He was very displeased with her as he said she was not even a leader to slide her leg on the bed just a little and even when he asked her to bend her ankle she either couldn't or wouldn't. While she was being loaded into the medi-van transport, the surgeon stated that records show she not taking any pain medication other than Tylenol and this has been for 9 days now. He was trying to determine what was going to happen next. Not sure if it is stubbornness, comprehension that she has been repaired and can give things a try, if she is giving up, or if the facility is failing to break down her therapy to shorter times more frequently. The doctor stated I have done several surgeries in her age group, and although their recovery is slower as it will be due to age, by this time, most are standing, up with support, and able to slide their leg on the bed it maybe limited range but nonetheless they are doing it.
It was asked should I move her to alternative facility or what? Of course, I knew he would not be able to give a direct answer, but he said if I chose to do it, it may help if she doesn't see it as a nursing home.
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The amount she is eating will not matter to how long she is staying in rehab. The thing that will matter is how much she is progressing, how much she is able to participate or how soon she reaches the level they think that realistically she can reach. You could well end up with worse care, and esp if seen as a wheel that squeaks with too little reason. Your mother is, as you said, in her mid 90s. This is the age at which a broken hip can be truly a bad thing. In fact, at this age there is any number of things that can be too much to survive.
I myself would not over-worry the eating thing. Weights are taken regularily. THAT is what doctors look at, not at the percentages recorded on the chart. They honestly do not have time to do that at all.
Wishing your Mom well.
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thingsarecrazy8 Aug 2019
The surgeon today stated she is not making progress. However, I have asked to see her daily reports, the information provided is not accurate. I have been there for several meals and I stay the day, I have even taken photos of the food she receives and take a photo of what is left when they take the tray. Monday's breakfast she had scrambled eggs, toast, 1 sausage link, juice. She opened her utensils, but drank and ate nothing. Chart was marked she finished her scrambled eggs. Lunch she received tomato soup, grilled cheese. She took 1 spoonfuls of soup and 1 bite of sandwich. The report says she ate 1/2 her grilled cheese, and finished all of the soup. Dinner was meatloaf, mashed potatoes and green beans with watermelon. She ate 2 cubes of watermelon, took a small taste of her meatloaf and a small portion of mashed potatoes. Report stated she ate most of her meatloaf, all her green beans and none of her potatoes. Why would they lie, how can they lie? This is a persons life that is at stake.
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