She was in rehab for 14 days, but started to have skin breakdown, so now the insurance is trying to have her sent to a nursing home (at her expense, since insurance pays for rehab, but not skilled nursing home) the insurance covers 100 days of rehab, but 0 days nursing home. my sister is 64, she is making very slow progress. but the psych medications sedate her.
When I didn't have the money for a lawyer and was in the process of trying to find one, I faked it that I had one (or was waiting for a callback) and actually that scared the heck out of the offending party and they backed down.
I had good results calling the attorney general recently. You will get action. Don't settle for their claims that they are doing an in-house investigation. A real investigation is external.
However, it is a MAJOR problem that your sister started having skin breakdown after 2 weeks in a rehab facility. That is a state reportable incident & should be reported as such. All you have to do is tell the rehab facility that you are going to be contacting the state to report your sister's skin breakdown after 2 weeks (in order for skin breakdown to even occur, a person must be in the same position for extended periods of time---over the course of 2 weeks, if she is in rehab, she should be getting exercises that move her around to keep her from being in the same position for long periods of time.) and how insurance wants to move her to LTC at her own expense.
Was your sister in the hospital at the time she fell while on Depakote? Why is she on Depakote & how long has she been on it? If she can't function taking Depakote, it would probably be a good idea to change the medication to something she can tolerate.
So, calling an ambulance?
As for the rehab facility, skin breakdown can happen from numerous causes (e.g. dehydration, malnutrition, underlying disease like diabetes, failure to turn and position, sitting in wet linens or undergarments, etc.). However, skin breakdown is not considered acceptable complications in that setting. (Trust me I have handled medical malpractice litigation country- wide for 30 years). And, if she goes to a NH the care will likely be worse. What kind of rehab facility is this? A glorified nursing home? Does your sister have any other underlying medical conditions? Was/is your sister bed-bound? Has she been receiving physical therapy? WHat has the rehab facility done to rehabilitate her and improve her conditioning? Blood work? Adequate hydration (dehydration can lead to slow progress and lethargy, as well as skin breakdown)? What have they done to evaluate her medications so that she is not so lethargic? I would shoot back a letter to the rehab facility and the Rehab Social Worker (that is their job) and indicate that this is not a safe discharge and that rehabilitation services are now in question.
With that said, the insurance company will likely say that is not their problem. The coverage under the policy does not exempt for medical negligence. Does the insuranc policy provide coverage for 100 days per event, or per year? And are you still in the same calendar year? You need to see what the policy says. Meantime, the rehab Social Worker should be able to help somewhat.
It is hard to give specific help without knowing more about your sister's condition. But, if you bring her back to the ER be sure she is admitted with the complaints of skin breakdown at rehab, failure to thrive and medication induced lethargy requiring evaluation. Her blood work may help out with figuring this out. You want to be sure that this comes across as newly developed problems to avoid any disclaimer of coverage for pre-existing condition that fell under the first 100 days of coverage. You need to really let the ER doc and triage nurse know all the medical concerns. If you take her back to the ER (where she fell) for evaluation of the skin breakdown, psychotropic medications that are impeding her rehabilitation and her general status, then that is a new and separate "event"/condition and a new diagnosis, which insurance will have a hard time excluding for. Be sure to tell the ER doc that she initially fell there at their hospital, which necessitated the admission to rehab. ER docs are generally good people who really don't like to hear that the people they patch up end up in worse shape after they are transferred. ER docs can really be helpful sometimes in directing the course. Insurance will have to pay, likely she will be admitted for evaluation of the medications (and with the potential lawsuit exposure for the initial fall) and they will treat her, provide PT and then be responsible for a safe discharge. The Care Managers at the hospital will help with that. Even if your sister has to go to a NH for a short stay, the Care Managers will be able to set up financial assistance for that. They can't move a patient to a facility when the patient cannot pay, without providing assistance. Seems to me, your sister's treatment and condition need some real attention and that is not something Nursing Homes are geared to do well!
You tell 'em
If you know anyone who was harmed by malpractice, ask if they got their records. Go look at the records in malpractice and you'll see all kinds of inaccuracies, fudging, missing information that was simply pulled to protect the institution, and other very deliberate errors. Look at ProPublica's study on malpractice. The statistics are shocking to many.
Go watch the movie "Gaslight" and you'll see how workers treat patients in many settings. The United Nations has been alarmed at how elderly people with dementia are treated worldwide, and the USA and Canada are no exception.
While it's the law to act a certain way, there's no guarantee that the laws will be respected and followed. It's against the law to litter, against the law in some communities to not pick up after your dog, it's against the law even to jaywalk in some places. And in every way, "Do no harm" is both ethically and legally binding. Tell me that one is followed!