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89 yo mom with dementia was admitted last Thursday with a heart issue. The back story is she is in memory care. Stage 6/7 dementia and had been consistently falling since moving to AL 1 yr ago. One month ago we moved her to a different facility because this one will accept Medicaid (which will be an issue within 12 months) and ALSO this facility said that she most likely would never have to move on to SNF as they do just about all care that an SNF would do. Only 2 things they can't do (can't remember what). There is a woman in her unit in a geri chair, many have bed alarms and hospice comes here. 2 weeks ago, she had a significant fall and they put her in a wheelchair. She was not talking much, put on pain meds, which in turn caused another big fall with a huge contusion on her head, as well as lesser falls. We were in the process of setting up hospice and bed alarms when she had heart trouble and went to the hospital. Supposed to be released today (Sunday) and hospice was meeting us at her arrival to get her set up.
But the hospital would not release her. The doctor wants her in in-patient hospice. But the doctor's concern is falling. She has no med change and they started thickening her liquids.
At the hospital they have a bed alarm and check on her. SNF would do same. But this memory care AL does this care also. The hospital literally ordered a specific hospice company to come out and wanted to find SNF here in OH. Completely usurping our hospice placement and our wishes. BTW her facility is just over state line in MI but the closest hospital is in OH. The doctor just wouldn't hear me tell her that her MC is still appropriate. She wants PT to evaluate to see if she can stand etc. for AL.
I am having MC go to the hospital to do an evaluation. My hospice nurse declined because she is licensed in MI. It's the weekend, so hard to get to people in charge. The hospice they ordered also goes to our MC but they also have inpatient in OH.
Soo. Tomorrow will bring more people's input, PT and MC evals. But can I disagree with the doctor and get her sent back to her MC/AL? She is feeding herself and needs help with everything but our MC will do this. I have a private senior advisor who facilitates placement and has decades of experience working in hospice and AL. She knows this facility and told me to refuse the doctor's order to change facilities. She is going to contact higher ups at MC for me. I am DPOA and brother is health POA and both our names are listed on both documents. My brother has high anxiety and is unable to deal. Part of the issue may be he didn't tell the doctor what we have set up.

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No, a Hospital can not force you to do anything. They are going to fall no matter where they are. Even in a NH in a wheelchair. My DD will tell you, she's an RN, that you turn u back for a second and they have stood up and fallen.

There was another post where the OP was having problem with a Hospital. We told the OP to agree to what they were suggesting then when they got their LO home, cancel it all.

Mom going to a MC is not an unsafe discharge. You can have her doctor order in home therapy to evaluate her and give her PT. I have learned when in the hospital to see my PCP ASAP. None of that "see ur primary in a couple of weeks". My husband and Mom were over medicated on B/P meds because they were in pain when they were admitted. Not when they came out. Moms was caught by a visiting nurse. I questioned my husbands discharge papers because...until an AFib episode, he was never needed B/P meds, His has always normal. This one his Dr caught and took him off because his pressure was too low and he was lucky he was walking.

Glad Mom got back to the MC.
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Here you are interchanging MC and ALF. These are very different. Much more care and staffing in the former. Does the doctor understand that she WILL have hospice and that she WILL be in MEMORY CARE. Because I agree that AL is not appropriate, but I think memory care may be.First of all, even the in facility Hospice will not have better ways of preventing falls now that restraints are not allowed.
You may be looking at changing doctors here. Doctors can and do often get a kickback from Hospice and Hospitals often have some deals afoot as well. When my brother was going home on Hospice from Hospital in Palm Springs they all bet hung onto his hospital gown to get them to use THEIR in house hospice and not the one recommended by his ALF. He only wanted to go home to die. Had to fight them for him!
And yes, you can always go home AMA as you are POA. You will want to look up the laws about signing out AMA in your State to make certain there are NO legal repercussions, but as of when I was a nurse a few decades ago, you don't even need in the State of California to sign the forms they SAY you need to sign. You don't have to do anything. It isn't a prison.
With safe transport and arranged care waiting, you can transport your Mom where you please. They will threaten you with "Medicare won't cover this stay" ( almost certainly a lie). They will threaten you with "You won't be admitted to a hospital again", (moot point as that's unlikely with Hospice anyway, but also not generally true.)
You will face the label "non-compliant" and a host of nastiness, but that's about it. Hospitals aren't prison. As long as you are not endangering a person, have a plan for care, a hospice and a Memory care capable of caring for her, you are safe. I would caution you to be CERTAIN of those two things, however.
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Karenina Jun 13, 2022
Previously she was in AL. Now she is in an AL facility in their highest care which is considered MC. Locked windows (she went out the window before). In Toledo all MC is private pay and any MC that accepts Medicaid is an SNF. We went over the border to this place. It is the best of both worlds. Accepts Medicaid, is MC will continue acute care so SNF will not be needed. The hospitalist would not listen to me. All the hospice companies in the area in Toledo are familiar with this place and agreed this is appropriate.
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Thank you for all the input. It helped. Mom is back at her own MC/AL and we are waiting on our hospice to come evaluate and get started. Hospital had sent ref to 3 hospice co because when they asked my bro his pref he said he didn't know. Argh. The hospitalist even this morning was telling the care navigator ( soc wrkr) that it was unsafe discharge. They told her it was up to the family.
Meanwhile all the hospices agreed with me that this facility was appropriate. I put in a complaint on the hospitalist. The only way to keep her from falling at this point is strapping her in which they won't do. And there is no way phys therapy in SNF is appropriate. Had I gotten to hospice a day before that heart attack this would all be moot as she would not have gone to hospital. Should be better going forward.
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I wouldn't see it as "going against" the doctor's order. The order is only a recommendation based on what information the doctor had at the time, but that wasn't all the information. So: it's an ongoing discussion. Approach it as that, and not as a battle.

A health POA who is unable to deal with decisions had better resign his POA. Would you be able to suggest that to your brother gently and also cope with the workload? If that would worry him too you can undertake to share information with him so that he's not left out of the loop.
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Karenina Jun 14, 2022
To be fair to him I should say we do everything together. They tend to call him first because he is first on health POA. I make him do the money which is technically my job because my mom was accusing me of stealing. As the end gets closer he is more upset. People think I don't have feelings but I do. I just keep them hidden because I am afraid I'll be overwhelmed. I probably have more feelings than average. Meanwhile we have had to process our feelings together every step of the way. It's been an intense year of family therapy without the therapist. My mom doesn't deserve our care but that is for another thread.
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You have the right to choose which hospice agency you want. If the facility feels that they can meet her needs and are willing to accept her back, then the doctor can go blow it out his piehole.
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Cover999 Jun 13, 2022
You do, but some facilities try to hold up discharge unless the patient uses the place they have picked.
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You can decline and/or change hospice according to your Mom's needs.

There are no requirements for a patient to be able to stand entering hospice.
Contact the hospital administrator and Ombudsman, tell them that. Tell them that the doctor has over-reached, and their hospice is fired.
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I do not believe that a hospitalist has the authority to demand hospice facility care and I know they don't get to decide what hospice provider you use.

She is overstepping her authority BIG TIME.
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Cover999 Jun 13, 2022
They can try to do this through orders or holding up discharge.
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It sounds like you already have in place, or can set up what Mom needs. Her AL/MC sounds completely suitable. That box is ticked.

I think the problem getting to the Person in Charge to explain this is your biggest hurdle.

Without this, there could be assumptions that Mom's AL is not suitable, is lower level care etc.

This happened to my relative too.

Partly because the person explaining was softly spoken & not bossy or questioning.

When I heard, my bossy ears pricked up & I was able to call & add my 2c.

So once a clear conversation was had with the right person, the *Person in Charge* who had authority, it was worked out. Hospital had concerns for safety & lack of mobility. Fair enough. But once it was clear the caregivers could manage this level, the box was ticked.

While your Brother is POA & is the contact person, & while the hospital staff many not call you or even wish to speak with you - they can LISTEN.

Their Social Worker can also ASK you questions to fill out a better social history for Mom (confirm w POS is required).

This is how I got the info to the right area & then spoke to a person with authority.

Karenina, you are an amazing advocate for your Mother.

I wish you continued strength through this hard time.
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