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My Mom, who has dementia, fell 3 weeks ago. She lives alone and the neighbor found her. She was in the hospital for 3 weeks and we fought like crazy to get her into a care facility. Long story short, the social workers and case worker said that it was faster to send her home and do an emergency assessment on her and that they should be able to get mom into a care facility in a week or two. Mom came home and on Tuesday the assessment was done and they said that mom is 100% fine to live on her own with help. We were flat out lied to and are wondering if anyone else has encountered this kind of flat out lie and what can we do about it?! Thanks in advance!

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I would follow up with her doctor, and he/she could make a recommendation as to what level of care your mom needs, and assessing her level of competency. If her doctor recommends a care facility, be sure to get a written statement from their office to that effect also, and have them give you a referral letter for insurance purposes. The letter will also be useful in the event that you would need to seek guardianship over your mother should it be determined that she is incapacitated.
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I’m so sorry this has happened to your mom and your family.
No. I have no experience with this but I’ll bump this up and hopefully someone will be able to help you.
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What kind of in-home help were they recommending?
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Dear Wendufer,

I'm so sorry to hear what has happened to your mom. I know its hard to see her in this condition and worrying for her safety. I would see if you could escalate this further with the social worker and tell them you do not agree with the assessment. And request another person do the assessment. I hope you can get the help your mom needs. I know its tough. Thinking of you.
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Keep pushing! They will try to wear you down. I went through this with a relative who was in and out of the hospital. They too kept saying things like "She will do fine if she has family helping her." She didn't want to go to a rehab facility even though she had a BROKEN BACK, so she kept lying to the care planner and telling them she had PLENTY of help at home with family coming and going. I had to sit down with the care planner and tell her this was ABSOLUTELY UNTRUE. Had to do this every time she was hospitalized. We went through this over and over for a year. She is finally in an AL facility.
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Were you or someone else from the family there for the assessment?

Did mom tell them that she can do everything for herself and that she has loads of family helping her out?

What help do you think mom needs? Does she agree?
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What was the diagnosis post fall? Was anything broken? Three weeks is a long hospitalization for a fall so I'm thinking that there might have been some other issues.

However, if rehab wasn't recommended, there had to be a reason. Did you speak with any of the doctors, leave messages for them at their offices?

The social worker/discharge planner should have been the one to provide rationale for no followup rehab care, but you're wise to return to your mother's regular treating physicians, preferably an orthopedic doctor, and get the full story. Did one of her regular doctors treat her in the hospital?

WHO specifically did the "assessment"? Was it someone from the hospital? This doesn't make sense to me, so I would think there was an agency involved to do an assessment. Was this the situation? A home care nurse could do an assessment, ask for a physical or occupational assessment visit as well, and either of them could determine that there was no need for followup. However, I'm finding that a little bit implausible given that she had 3 week stay in the hospital, although she could also have healed quite well.

There are definitely some answers to be discovered in this situation.

You can also call the hospital and ask for someone who follows up post discharge; I don't recall right now the various terms, but they're more or less troubleshooters whose responsibility is in fact getting the "scoop" on why specific decisions were made.

If a home care agency did the assessment, contact that agency directly.
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Thanks for all of the replies, in September of 2017 I got Social workers and Older Adult mental health case worker involved because my Mom is at home on her own and we could see that she has Dementia, CT ,cog tests etc done,and huge personal changes in her

3 days before the 3 week hospital stay she ended up in the hospital for high blood pressure 270/77 yikes ,she took 2 days of meds at once ,by not remembering!

Then she fell at home which we thought would be a good thing in a bad way because we had meetings in hospital with Moms social worker ,hospital social worker, etc and they assured us that mom would not be going home,

In hospital mom assaulted 2 nurses (bad) and took off all her clothes and climbed into bed with 3 other patients, we were shocked mad sad it was one thing after another!

They kept her for 3 weeks because they were trying to stabilize her meds , tried a anti psychotic med ,and increased others

On Tuesday the social workers and Older Adult mental health case worker came to the house talked Mom ,said that home support would be provided ,go to mom's 3 times a day ,give meds ,assist with bathing ,do light meals ,and they said that mom would be fine on her own ,since then mom has wandered off ,started smoking ,and is very confused and upset by the new faces coming into her house ,she has also been able to figure out the combo to the lock box for her meds ,our family can see a disaster in the making and there seems to be nothing we can do about it

Unfortunately there is no one within the hospital that provides discharge support ,all of that has been discontinued due to cut backs etc
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This is our medical system in the 21st century. It’s disgusting.
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Yes my brother and myself were there for the assessment and we both voiced our fears ,disappointment etc

It's like Mom has to hit rock bottom before help will be provided, the problem is that we need a funded bed because mom doesn't have the saving or the pension to pay for a $5000.00 bed in a long term care facility
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Maybe they are having a hard time finding a care facility that wants to take your mom. Many care facilities protect their selves first and foremost.
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I'm sorry to hear about your trouble. It's luck of the draw. I've had a hospital team insist that my grandma be sent to a rehab hospital instead of going home when I thought it was no big deal at all, simple fall. I've had a hospital team deny recommending that she go to a rehab hospital when I thought it was a big deal, cracked ribs.

In this case, I think the last poster was right. With the behavior you are outlining, they might not be able to find a facility willing to take her.
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Wendufer, thanks for sharing the back story. This is much different from a fall; I can understand the frustration you feel at not being able to get help. Unfortunately, I think that the assessments might not have been for the proper diagnosis and appropriate help needed. It seems as though the advice of being able to be cared for at home was either premature, or inaccurate, or both.

It also sounds as if some type of medication is appropriate to control her challenging and inappropriate behavior, IT this is more or less standard and wasn't just a one time thing at the hospital, and I do think also that it was unwise and unrealistic to suggest that she could be cared for at home.

Are there any treating physicians who are more familiar with the behavior, someone who has a longer term familiarity with your mother and could assist you in finding, perhaps, a memory care placement? Do you have a psychiatrist who could help with stabilizing meds? I have the feeling the hospital staff was more or less experimenting to try to find an appropriate med, but really didn't have the resources.

I don't know whether that hospital had a secure ward, but I think that's where she should have been, for her own safety.

And I think someone should be raising the issue of Medicaid for funding.
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Patient Advocate at the hospital? Sounds like she needs an inpatient psych eval
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Try calling the local County Human Services Agency also? I had a social worker come from the county and her in home assessment was very thorough and complete. She looked at the whole picture and not just a bit of info here and there.
The Hospital Social Workers didn't seem to be interested much in what happened after sending her to rehab, it seemed they were happy to get 'rid' of my MIL.
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I would have her see another Dr.
my mom was recently discharged she has FFL dementia and cannot care for herself. MasonicRe sent her home to my 81 yr old father and we haven’t seen any home care in 3 weeks because the dr went on vacation so my poor mother suffers because of connecticare.... we won’t be going to the dr till tomorrow (finally!!) drs need their vacations!!) trust me I am beyond exhausted tired depressed but I am using humor to cope. Please excuse me.
I digress, please get another drs opinion so your mother can get the help she needs...
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not only is it the medical system., it is the trend and reality that no one can seem to simply do their jobs. You have to be the advocate. It truly is a job in itself
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You answered your own question, Wendufer. The problem is money. Perhaps there was no facility who would accept your mother, especially if assaulting nurses is on her record. You may have to take control of the search and rely less on the hospital social workers.
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Does your Mom own her home? Could the house be sold to provide for long term care?
Sounds from her behavior that she should be placed in a safe facility and needs meds to keep her calm. Some states and counties have offices that provide assistance in finding placement for those in need. They can give you lists of approved facilities and homes.
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I could be wrong but i thought the facility you were sending her to might do the assessment. Was she being assessed for a Nursing Home or an Assisted Living . She might fit into the later better
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First I would like to say I'm sorry you are going through this and it's your mother's health that hangs in the balance until a workable solution is found.
I'm going through somewhat a similar situation with my partner who has vascular dementia and diabetes. One thing I must say is that you must challenge anything that seems unusual or improper. . For example, my partner's doctor told me, today in fact, that based on her notes that he didn't qualify for intermittent home health. Fortunately I had been in contact with Medicare and reviewed the requirements for this service. To make a very long story short, I asked her how she came up with this conclusion given the fact that she had never performed a face to face assessment that Medicare requires.
My situation is different in that we live together. Otherwise we would be looking for a facility. Does anyone have the Medical Durable Power of Attorney to make decisions on your mother's behalf?
Generally speaking it is the agency that does the assessment. The doctor just places the order based on the recommendations.
It's unfortunate that our medical system is such a maze. My only suggestion is that someone is there with her for any and all appointments and to do the leg work in finding the appropriate facility. You are not obligated to accept their recommendations
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Finding your way around a complex system, for the first and only time, is a huge job and huge waste of effort if you can find someone else who knows the system well. Finding a placement for violent dementia patients who are physically strong is one of the hardest calls, as they can be dangerous to each other and to the staff, as well as a risk to themselves.

My daughters have just used a ‘placement’ advisor for my ex, their father, admittedly a much easier proposition, and I have seen it suggested on this site. Is it an option for you, financially? And have you read the posts about ‘showtimers’? If your mother can put on an act during assessment, there are suggestions about recording (even videoing) behaviour at other times, in order to give the assessors a better grasp on the situation.

You have a very difficult problem with your mother’s health and behviour issues, and you have my heartfelt sympathy.
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"Showtimers' in mom's case they say that she "presents well", but there are a few subjects that she will lose control over her thoughts feelings etc

The social worker was in place before mom went in the hospital, the in hospital social worker assured us this is the fastest way to get her into a care facility, send her home and do a emergency assessment and move on from there

Mom needs too much care now ,help taking meds ,bathing ,dressing etc to get into assisted living, now she would go to a nursing home
Mom's pension isn't enough to pay for NH care, if the social workers say she needs it ,they can put her on a list and the first bed available would be given to mom at no cost !
Big differences dollar wise and this just doesn't seem fair
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