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Dad was discharged from a rehab facility to my sister's care based on information he had a higher level of function then he currently has. In August my mother passed and the next day my father fell and was admitted into the hospital with a septic infection that was previously undiagnosed.


Oct 10/28, he was discharged. In our care meetings we were clear on our situation with my sister working and that Dad would be home alone for several hours during the day and we needed him to be at a certain level of function as she didn't have help. We were not expecting someone that needed around the clock care and two people to transfer. The facility knew our work situation and lied that he could be left on his own for any length of time. We were expecting a grumpy man with incontinence that needed help with meals and cleaning up after himself not around the clock care.


We've reached out to visiting nurse service and they seemed shocked at his discharge and that we were given nothing not even medications at release.


We're waiting on a sociol worker meeting to discuss recourse or next steps but I wanted to post to see if anyone had advice or experience with navigating this. My dad's been out since Thursday and my sister is going to have to take medical leave from work until we have a solution but she cannot afford to do that. I knew we could appeal a discharge decision but we were not told his level of need and I'm not cheese on our recourse now that he was discharged. They stated he needed little assistance to stand and could walk 70ft with a walker and assist in his bathing and toileting. None of which it true. His mental decline is such that he can't take his own blood sugar or give himself insulin. He is diapered and cannot assist in changes and needs two people to transfer and cannot walk but a few steps with assistance.


Any direction is greatly appreciated.

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My first thought was that his Medicare paid period had reached its end, and the facility may not have felt the family had the funds or would pay directly to keep him there.

I may have missed it, but was he getting rehab after a hospital stay, or independently scripted for by one of his doctors?   If the latter, I would immediately contact the doctor and see if he'll script for either an extended rehab, or immediate home care.

I would also inform the Ombudsperson and file a complaint, but only after you get your father settled and either home care or an extended rehab stay is arranged.

There's another possibility:  long term hospital care.  My father had that, was in a separate extended care hospital after a multitude of life threatening complications that still required treatment.   Select Specialty Hospital is the facility with which I'm familiar. 

A doctor would have to script for it, but your father would get 24/7 care in a hospital which focuses more on care but with a little bit of rehab as tolerated.

BTW, I'm not challenging or rejecting suggestions by JoAnn or Mstrbill, but I think if you have to pay out of pocket for any type of facility, your father could benefit more from a long term care hospital, where he will get medical treatment in a hospital setting.  I was very impressed with Select Specialty Hospital.

And document everything the rehab did, sent, or conversations that were add, to share with an Ombudsperson.
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I'm sorry you are going through this. Your situation is yet another example hopefully others can learn from. Do Not let the hospital or NH put you and your loved one in a situation that is unsafe or unmanageable. At this point you are going to need to try to place him in a NH on your own or get him back to the hospital (find any somewhat reasonable reason to call the ambulance, and with his diabetes it shouldn't be that difficult, and have him sent to the ER.) Then you absolutely refuse any discharge other than a SNF.
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If Dad was in Rehab Medicare was paying. If it was found that he was not progressing or had hit a plateau, Medicare would have told the facility to discharge. I feel, though, that the Facility should have been forthcoming on the level of his care. For them to discharge knowing that there was no one to care for him or nothing set up for his care, was an "unsafe discharge". Call your State Ombudsman.

Is this SW from the facility? If so, you may not get any help there. They are big on family doing the caring especially if Medicaid is involved. They get more money from private pay. I would stand firm with this SW. To the point you will report the facility to the State. They released without making sure that you had the care needed for Dad in place and they minimized what that care would be.

Sounds to me that Dad needs more care than you or sister can give him. If he has any money, I suggest placing him in a nice Long term care facility. Even if he only has enough money for 2 or 3 months. My Mom had 20k. I started the Medicaid application in April placing Mom May 1st. She paid May and June. I confirmed with the caseworker that I had provided Medicaid with everything needed and Medicaid started July 1st.
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