I apologize in advance. This is a long, drawn out story…
My mother (93) went to rehab after a hospitalization left her too weak to do her own transfers at home. It was a six week nightmare, relying on reports from nurses and therapists since they were in lockdown status. Sometimes it was very hard to get these communications, and my mother came out with substantial cognitive decline, and still not able to transfer and new onset incontinence. Ended up moving her into an ALF after having her with me for 9 years. She was only there for 3-4 weeks, developed CHF and ended up back in the hospital. Wanted her to go back to ALF with additional therapy (out of pocket if need be), but ALF refused until another rehab stay😔 Now she’s in a different rehab, at first I thought it might be better, but it’s actually worse. The hospital never notified me ahead of time of the discharge other than to tell me they secured a bed and their van was there, so I had no opportunity to sit and explain to my mom what the plan was. (Confused and no hearing aids, I imagine it was scary for her). I begged social svc to place in a rehab that wasn’t locked down, well that didn’t happen. She has her phone and aids now, but I’ve only gotten a hold of her twice (she says the phone is placed out of her reach, not sure the validity of that). The main # rarely answers, and forget about talking directly to a nurse. I want to move her, but our choices are limited with her insurance. And I don’t even know if it’s wise to put her through one more transition to endure, only to find out conditions aren’t any better. Has anyone successfully navigated through similar circumstances?
Feeling so frustrated and helpless…
Rehab places don't perform miracles, and I found them to be of minimal value. Your mom is likely at the point of needing a higher level of care than AL, which is totally normal. At her age, a trip to the hospital/rehab is going to result in a pretty significant decline, and she won't bounce back to where she was either. Keep in mind, any bouncing back that does occur will likely take twice as long as you think it will, too.
You're at a point where you need to decide whether another trip to a hospital is in Mom's best interests. I decided it wasn't worth it for my Mom and put her on hospice last January. I make the choice to have her treated in place for any issues, and she was with good results. Of course, if she'd had a true emergency like a broken hip, I'd have sent her to the hospital, but her last trip in December '20 resulted in more decline with her dementia plus a case of Covid caught in rehab, and she was never the same. That was when I decided to focus on quality of life rather than quantity.
Our local Ombudsperson was the one who clued me in to the bad reputation of one rehab facility a hospital discharge person recommended: "people who go in, sometimes don't come out." Did some research of my own and learned that was true; apparently the place is bad, and people die there more often.
First, I would contact the hospital administrator and advise of the failure of the discharge planner to pre-notify you of the impending transfer, as well as the selection which apparently did not include you. This discharge planner needs to be counseled on her poor planning and behavior.
That happened to me, once, in a frigid cold spell. I arrived to visit and was informed that Dad would be discharged that afternoon. I informed THEM of the obvious: since they hadn't called, and since I don't carry oxygen tanks with me as a matter of course when my father is in the hospital, I had NO oxygen for him, and they would have to find some tanks. And they did. I made them do all the work, even having the tanks delivered to his room.
I also raised the issue of poor planning and lack of courtesy in not notifying me, especially since was a multiple day stay and discharge had been unresolved the last time we spoke. (I was unaware at that time that treatment and service were declining, and this was one example.)
As to the existing facility, I would give it a chance not to be fair to it but b/c of the stress of moving that your mother would endure.
List all of the problems, contact the Administrator of the rehab place, stating you want to work out a solution for the current issues. Ask either for a meeting, depending on contact status b/c of the pandemic or how THEY plan to address the issues.
If no meeting is possible, advise that you have a series of issues that HAVE to be addressed, so you can e-mail them, the Admin can evaluate and then you'll have a phone conference to address them. Don't let them get away with not addressing these issues.
Don't give this rehab facility an out or excuse not to address the issues. Ask "what" can be done and what are their alternate solutions. Put the change onus on them. If they don't cooperate, or give you a brush-off, consider moving Mom.
But before taking action, contact her own doctor who would be overseeing her care and discuss the issue of transfer to get his/her backing. I did this once, got a letter in case the transfer was challenged, but it wasn't. Part of the concern was ensuring that Medicare would continue coverage. You might want to raise this issue with your mother's health care insurer.
Find out from your insurance carrier what other options you have as to rehab facilities, then start searching for alternate placements. That might also include the ALF; it doesn't seem as if their staff are being cooperative either.
You might want to contact the Alzheimer's Assn. and ask for a list of rehabs. They've been very prompt and helpful, with well prepared lists.
You don't develope CHF in 4 weeks. She had it before her ALF stay. And they may not take her back if she can't be transferred by one person. ALFs don't have the CNAs for 2 people assists.
I agree, Mom may need more care. So your options are place her in skilled nursing or bring her home with help. If you bring her home, I would have her evaluated for Hospice or ask she be evaluated while in Rehab. That way you get an aide 2 or 3x a week to bathe her. A Nurse will come in. You will get incontinence supplies. Prescriptions.
If you are not being able to contact her rehab, I would call the Ombudsman in your State. The Rehabs/NHs my Mom has been in have receptionists that pick up the call. Someone should be manning those phones especially if in lockdown.