Tag Archive | SNF

Thirty-Six Hours in a SNF

Wednesday morning I learned they would be discharging my mom from the hospital to a skilled nursing facility (SNF) later that day for “a few days” of rehab. I had already made the decision to cancel my trip to San Antonio, so I asked the discharge planner to look for facilities near my office location rather than have her sent to the same horrible place she went the last two times just because it’s close to home (and the owner of the board & care would visit her there). The discharge planner sent me three possibilities to research. I ruled one of them out based on their ratings and reviews, but both of the other two looked like they would (at least) be better than the last place. The decision was made for me when only one of those two had a bed for a female available. I felt pretty good about it. The facility is on my way home from work, only a couple minutes off the freeway, and while reviews are mixed, it gets solid ratings from Medicare and other agencies.

The transport that was ordered for 5:00 p.m. didn’t arrive at the hospital until 6:30, so Mom was able to eat a little bit of dinner first. She was in pretty good spirits and definitely seemed to be improving. I hoped that it really would be just for a few days. Maybe she’d be back at the board and care by Monday, even. As I was standing around while the medical transport guys were getting ready to load her on the gurney, one of my favorite CNAs came in to say goodbye to Mom. She reminded me of a friend of mine in Portland (if that friend had candy red hair) and she’d been really great with Mom. The stress must have been written all over my face because she took one look at me, said, “Oh honey” and put her arms around me.  And maybe it was because she reminds me of my friend that I didn’t hesitate to let her hug me. It felt so good to be seen, to be held.

We got to the “4 star” facility around 7:15 p.m. It looks pretty much like the other nursing home (they must all be built on the same basic floor plan), but it’s a bit older or hasn’t been upgraded as recently. Instead of individual TVs for each bed, there are two TVs mounted on the far wall for the room of three. Mom didn’t get a TV (or a remote for the one she can see from her bed), but at least she got the bed by the window. The medical transport guys got her into bed and comfortably propped up on pillows, someone brought an oxygen machine and they got her switched to that from their portable tank, and then they left… and we waited. And waited. No one came in to assess her or have me fill out any paperwork. After an hour, I went to the nearest nursing station to ask. The harried charge nurse gave me the paperwork and tried to tell me that both the flu and pneumonia vaccines are needed every year and Mom should get them while she’s there. Wrong. The pneumonia vaccine is good for five years. Mom got it last fall and, even if she hadn’t, a nurse friend confirmed to me via text that it’s medically inadvisable to give the vaccine while she’s recovering from pneumonia. Good grief.

It took TWO HOURS for the nurses to even come into her room to assess her, and I’m convinced it would have been longer if I hadn’t made it quite clear to the charge nurse that I wasn’t going anywhere until that got done. And, of course, when they did the body check, she was soiled. To put it more bluntly, she’d been lying in her own shit for who knows how long until they finally got around to her. I was NOT happy. And even less happy when I learned that they wouldn’t have any of her medications except the antibiotics until morning because their pharmacy doesn’t deliver after a certain hour.  There wasn’t anything I could do about it, and she was finally clean and ready to get some sleep, so at 10:00 p.m. I finally went home, feeling like this was going to be a disaster.

I had told my boss that I’d be in late, after I stopped by the SNF to do the admissions paperwork and check on Mom, but I slept so poorly and was so worried about the situation that I knew I just needed to call off for the day. I got over there about 9:00 a.m. and it was a much more cheerful place in the morning. The day shift charge nurse was much more responsive, they now had all her meds, and the dietician came around to talk about her dietary needs and preferences. The one thing I was still concerned about was that they didn’t seem to have the orders for IV fluids, which I’d been told was the main reason they couldn’t discharge her home to her board and care. I was told that the nurse practitioner would be in later that morning and would take care of it.

The nurse practitioner is awesome, and talking with her restored some of my confidence in the placement. She listened to my concerns and we seemed to be on the same page about what is and is not acceptable in terms of care. She confirmed the IV order with the hospital PA and got that started within an hour of examining Mom. The x-ray and blood draw for labs she ordered also happened that same day. Two physical therapists came to do a preliminary assessment on Mom, and they got her up in a wheelchair and wheeling herself around (which she’s never done before because the chair we have is a transfer chair). She seemed to enjoy doing that and it’s good exercise for her arms, so I resolved to find a way to get her a regular wheelchair when she gets home.

After spending most of the day with her, I left around 7:00 p.m. to get some dinner and rest. “Go,” said Mom with a smile. “Take care of yourself. You need to have a life too.”

The hospital had scheduled a follow-up with the nephrologist for Friday, but the NP and I both agreed that she wasn’t quite ready to be taken out to an office visit, so I got it moved to Monday afternoon. A case manager from Mom’s medical group called me to arrange the wheelchair van to take her to the appointment, which was something else the nurse practitioner had told me she would make happen. (Clearly this woman gets shit done. I respect that.)

I went back to work on Friday without worrying about Mom, though I was frustrated to realize that I couldn’t call her. There are no phones in the rooms and they don’t even bring a cordless phone in for patients who are on bedrest. The only way for a patient to get a phone call is to have their own cell phone — which, frankly, I would worry about getting lost or stolen, even if Mom had one — or go to the nursing station to take a call there. Ridiculous, if you ask me.

But when I got to Mom’s room around 4:30 p.m., she was a lot less perky than the day before. In fact, she was so weary that she could hardly keep her eyes open. “I may fall asleep on you,” she told me. “The only time I feel comfortable enough to sleep is when you’re here.” I held her hand until she fell asleep and let her nap until they brought the dinner tray. Despite what I thought were clear directions to the dietician, they persist in bringing her food that is impossible for her to chew with dentures. (I mean, come on, tortillas can be hard to bite through even when you’ve got your own teeth!) Thankfully, I had stopped at the grocery store and picked up a few items to supplement the bad facility food. Mom ate half a banana with some peanut butter and a few bites of applesauce, and that was dinner. She dozed off again as soon as she’d finished eating, even while sitting up at almost a 90 degree angle. I hung around until 7:30, but she never did wake up again for more than a few moments at a time, so I finally kissed her goodnight and went home for some self care.

Day three at the SNF was not a good day. I had let myself sleep in a little, then stopped at the pharmacy to fill a prescription and picked up some lunch to bring with me, arriving just before 11:00 a.m. Mom was asleep in her pajamas, and she barely woke up enough to acknowledge my presence. Despite the IV fluids, her mouth was so dry that she could hardly talk — but she was so weak, she didn’t even want to let me raise the head of the bed to give her water. “Just leave me alone,” she kept saying. “Let me sleep.” When they brought the lunch tray, I took a glance at the entrée and knew that (again) there was no way Mom could eat it.  “Try to get her to eat,” the CNA told me. “She didn’t want any breakfast.” But it was no good. I couldn’t even tempt her with chocolate pudding. I finally got her to take enough water to wet her mouth before she fell into a restless sleep again. I was really worried about her, wondering what had happened to set her back so far when she’d seemed to be on the mend.

She slept all afternoon and by dinner time was starting to seem a little more like herself, though still extremely fatigued. She even showed an interest in the meal, which was some kind of turkey sandwich with sweet potato fries, but after chewing and chewing at the same piece of turkey until her jaw was tired, she spit it back into her napkin and gave up. I managed to get her to eat one sweet potato fry, one bite of strawberry, three bites of applesauce, and three bites of chocolate pudding. I decided to stay with her until they came to clean her up and get the bed ready for overnight, and I’m so glad I did.

Only one CNA came to clean her (usually there are two), and she wasn’t very gentle or compassionate. She would have just flipped Mom onto her side if I hadn’t stepped up, taken Mom’s hand, and helped her roll over more gently. I ended up assisting through the whole process, even handing the CNA the IV bag so that she could pass it through the pajama sleeve and then back through the sleeve of the hospital gown the changed her into. I don’t mind helping AT ALL, but I shouldn’t have to. If I hadn’t been there, it’s not that I think Mom would have been mistreated, exactly… but it would have been a lot more unpleasant for her. Even with me there, verbally reminding the CNA that abraded sores on her backside are extremely painful, she scrubbed at Mom’s behind with a washcloth until Mom yelled and I grabbed the wet wipes the hospital had sent home with me and pushed one into her hand to use instead.

And that was how our first 36 hours at the SNF ended. Mom was tired and irritable, but clean and comfortably tucked into bed when I left around 9:30 p.m.

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Grateful

Filled with gratitude tonight. I am grateful for my aunt and uncle, who drove all the way from Ohio so my aunt could see her sister… and grateful that the timing of their visit meant I could go do an 8-hour workshop on Sunday and not be distracted by worrying about Mom. Aunt Alice took this picture of us.

Mom Sep 3 2017

I am grateful for my niece, Sarah, who has visited her grandma several times (both at the hospital and the SNF), so that I can have a break. I am thankful for the friends from church who visited her in the hospital while I was away in Oregon, and for all the family who have called or sent cards or flowers. I appreciate my friend Joy who visited today and brought a new kind of nutrition shakes for Mom to try, since it’s still a struggle to get enough calories in her. Also Joy’s visit meant I could take a couple hours off and go to my restorative yoga class, which I really needed!

I am so, so grateful that Mom is finally feeling like herself again — that she’s not only physically stronger today, but has less anxiety and improved cognition. Today was a good day. She was up in the wheelchair for much of the day; she got a shampoo, cut and style by the beautician who comes to the facility every Wednesday; and when I came back around 2:00 pm she was able to tell me everything they’d served her for lunch, and also talked about Sarah’s visit the night before. So much of the time Mom doesn’t remember that someone visited ONE HOUR before, so that she was able to recall Sarah reading to her last night from her book of daily meditations on scripture feels like a small miracle to me.

It also feels like a miracle that even though some staff member screwed up and forgot to put her back on oxygen when returning her to her room (she was without oxygen from at least 4:15 pm until a little after 7:00, when I arrived to question it), she didn’t have trouble breathing and remained cheerful and talkative… and when I asked them to check her oxygen level, it was still at 94.  I’m so glad for this sign of her returning health that I’m not even angry about what could have been a dangerous error. (Well, anger might come later. A complaint will definitely be made.)

Right now, I’m just grateful.

Every time I go away

The nurses all agree that Mom needs to spend more time out of bed. Sometimes she’s amenable to this and other times she just wants to rest and gets annoyed when the CNAs try to get her up. Yesterday I spent a couple hours with her in the morning and then went back around 2:00 pm. She had insisted on going back to bed after lunch, the CNA said, but we got her up again by tempting her with the root beer floats they were serving in the dining room.

She enjoyed the float, and I sat with her for a while, playing Words With Friends on my phone while she did her word search puzzles. Half a dozen other residents in wheelchairs were watching the movie on TV. When I needed to leave (around 3:30) to get ready for a friend’s 40th birthday party, I felt a little uneasy about leaving her there… but I knew if I took her back to her room she’d just lie down again, so I told myself she’d be fine for the hour or so before they would have brought her in there for dinner anyway.

This morning I got to the nursing center around 11:00 and she’d already been taken to the dining room for lunch. She was flipping through an old issue of People magazine when I pulled up a chair and sat next to her. She told me she “must have had a dream”: “You and I were eating in here together and then you had to leave to go somewhere, and suddenly it seemed like I was in the middle of something, that I wasn’t ME at all…” She floundered a bit to explain, concluding that it felt like she was a character in a story, and like she was watching the story unfold. I told her I often have dreams like that, and we moved on to other topics. But then she brought it up again, asking me to please make sure to take her back to her room before I leave because “I get sleepy and sometimes there’s no one around to take me back.”  A little later, when I started to get up to do something, she grabbed my arm and said “Don’t leave me!”

I don’t know if she dozed off in her wheelchair after I left her yesterday or what, but from now on I’m listening to that gut instinct that tells me something is not OK. This evening, for example. I’d spent almost 3 hours with her earlier in the day and my niece Sarah was going to visit her after she got off work, so that I could go to a planning meeting for an event I’m helping to organize. When the meeting got postponed, I thought about taking the evening off. After all, Sarah was going to be there by 7:00. But something told me I needed to at least drop by quickly to check on her.

I arrived at 6:15 pm and found her in a nearly empty dining room, working her puzzles. When I asked how she was feeling, she replied “Not good. I ate a bowl of soup and threw it right back up.” She hadn’t been able to eat anything else after that, and she said her stomach still felt queasy. I took her back to her room, stopping on the way to ask at the nurse’s station if we could get her something for nausea. “I’m so glad you came back!” Mom kept saying. Of course I came back, I said, kissing her forehead. “Well, sometimes you have meetings,” she said querulously.

Oh, and then there was the 90-minute wait for a CNA to come and change her wet diaper. I could rant about that, but I’m just tired. I feel like I have to be there almost all day every day to ensure she gets adequate care. It seems like a new problem occurs every time I go away.

 

 

It can turn on a dime

“Your mother is stable now, but at her age, it can turn on a dime.” That’s what the doctor from the ER told me when he called, two weeks ago now. Today I got a taste of what he meant.

I arrived at the SNF around 8:30 this morning, expecting to do the discharge paperwork and take her home. She was lying in bed in a hospital gown, but she sat up readily when I told her we needed to get her dressed so I could take her home. She mostly dressed herself (I only helped with fastening the bra in back), but when she was finished dressing she needed to lie down again — said she was feeling lightheaded. A moment or two later, she was taking big gulping breaths of air and saying “I can’t breathe!” I pushed the call button, reached over and turned the oxygen level up a bit, and sat stroking her hair and encouraging her to breathe slowly and deeply until the nurse came. Her oxygen sat was only 89, even with the increased oxygen she was inhaling. Her BP was high, but her heart rate was normal. The nurse brought her morning meds (which include blood pressure meds), along with an antibiotic and Mucinex, and went to notify the doctor on call. Discharge was put on hold.

Mom kept saying she didn’t feel right — “my insides feel quivery” was how she put it —  and when we were trying to explain that to the nurse, one of her roommates spoke up and mentioned that she had noticed my mom shaking in her sleep during the night. I asked if she could explain what she’d observed, e.g. was she shivering like she was cold? And she said no, it wasn’t like that. It was brief but strong tremors. I knew then that Mom definitely wasn’t going home today.

The doctor ordered breathing treatments with a nebulizer every 4 hours and a chest x-ray, and she’ll stay until he can read the x-ray results and reevaluate her, which will most likely be Tuesday (since Monday is a holiday). Mom was disappointed that she wasn’t going home, but felt poorly enough that she KNEW she wasn’t ready to be discharged.

We were so close. Sigh.

But whatever this is — if she’s still got fluid in her lungs or she’s picked up some new infection in the SNF, or whatever — I’m sure glad it showed itself before I took her home. Better that she stay where she is a couple more days than that we end up taking her back to the ER and going through all this rigamarole all over again.

No Dignity

So, it turned out that winning the appeal only bought her two extra days at the SNF. She’ll be discharged on Saturday. I was all set to appeal again, but what I found when I stopped by after work yesterday changed my mind.

It was dinner time, but she was lying in bed in a borrowed t-shirt, no pants and a soiled diaper. There was feces on the bed sheet. I went running for a nurse, who sent a CNA to take care of it. He (the CNA) also went to the laundry to find her pajamas, returning with the set that I bought her for Christmas. The pants were soiled and I said “Oh, these are still dirty.” He told me no, they’d been washed – it’s a stain. They were in perfect condition when my niece brought them over there a few days ago. Sigh. Though they quickly got her cleaned up when I asked, I wondered how long she would have been left there in a soiled undergarment if I hadn’t come to visit.

Tonight I got there about 5:45, a bit later than usual because I had a chiropractor appointment for the pain I’ve been having in my left shoulder and down my arm. She was lying in bed with the dinner tray untouched on her table. When I asked if she wanted to sit up to eat, she tried to move and winced with pain – telling me her private area was so sore that it hurts to move. Again, I ran to the nursing station. It was the same male CNA as last night who came, and he told me she’s been having diarrhea since yesterday and she says it burns, and it’s clearly aggravating the rash on her backside and between her legs. I asked if they were doing anything to treat the diarrhea, but he didn’t know. Her adult diaper was, again, soiled. The CNA got her cleaned up and put some ointment on the rash — and watching her wince with pain and grab the bed rails while he applied the ointment made me feel as if I was standing by and watching her be tortured.

I asked the nurse on duty for her section if they could give her something for the diarrhea that the CNA reported has been happening since yesterday. She said she would have to talk to the doctor tomorrow, but in the meantime she would hold the stool softeners. Yep, you read that right — she’s been having liquid bowel movements for over 24 hours and they were STILL giving her stool softeners! Y’all should admire my restraint that I simply agreed that this sounded like a good idea and didn’t lose my temper.

Thankfully Mom did feel enough better with the ointment that she was able to sit up and eat a little bit of her dinner, and the CNA was nice enough to take her plate away and rewarm it — since by then it had been sitting out for over an hour. When I left she was cheerfully finishing the last few bites of her banana pudding (the only part of the meal she finished) and looking at the book of word search puzzles I brought for her.  But I will be so, SO glad to get her home on Saturday to a place where she gets the personal attention and care she needs…. and, more importantly, a place where they truly CARE and manage that care in a way that still affords her some dignity.

 

 

We Persist

It’s been a challenging few days. Friday evening I arrived at the nursing center as the nurse was dispensing Mom’s evening meds, and I asked her to run through the med list with me — mostly to make sure Mom is getting her dementia meds. I was shocked when one of the medications she listed off was sertraline (brand name Zoloft), because Mom hasn’t taken that for over three years. I went to talk to the nursing supervisor to find out who had ordered that medication and learned it was started at the hospital. They were giving her TWO antidepressants at the hospital, he told me — Zoloft and Trazadone — but they discontinued the second when she was discharged to the SNF.

I knew something wasn’t right. She’d sounded unusually lethargic and depressed when I called on my lunch hour that day, and was saying things like “I just want to give up” — utterly out of character for my mom, who is nearly always cheerful. When I got home, I checked the discharge paperwork from the hospital and saw that they’d diagnosed her with Major Depressive Disorder (MDD). Umm, WTF?! She may have been sad, lonely or confused while in the hospital, but she most certainly does not have major depressive disorder.

I couldn’t do anything about that over the weekend because the nurses needed a doctor’s order to change medication. Yesterday I worked from home so that I could go over there first thing and talk to the physician’s assistant on staff. She wasn’t in yet, so I explained the situation to the social worker, who promised to relay my concerns to the PA and have her call me. I went home to get some work done and dropped by for another brief visit with my mom at lunch.

When I got a call from the nursing center in the afternoon, I assumed it was the PA calling in response to my request to discontinue Zoloft… and I was stunned when it turned out to be a case manager calling to tell me that the Medicare HMO was only going to cover three more nights and they would need to discharge her on Thursday. Wait, what? Will she get Home Health services? No Home Health, the case worker told me. The determination of the insurance was that Mom wasn’t making progress with her therapy, so they weren’t going to authorize ANY further physical or occupational therapy.

I felt like I’d been kicked in the stomach. Before she went into the hospital, she was ambulatory — getting around her home with a walker, though she’d started to need a wheelchair for excursions — and could transfer with minimal assistance.  Now she practically has to be lifted from the wheelchair back into bed, and they wan to send her home like that? How the hell is she EVER going to walk again without physical therapy?

The case manager and the social worker at the nursing center encouraged me to file an appeal of the denial of coverage. They gave me the phone number of the appropriate agency, and the social worker talked to me at length to document Mom’s baseline functionality. I was given to understand that winning the appeal was unlikely and that we might need to appeal several times just to get home health visits covered. I worried that we wouldn’t even get an answer on the first one before they kicked her out. But I filed the appeal, and I started gathering the information I will need to file a grievance against the hospital for misdiagnosing my mom and prescribing an unnecessary and potentially harmful medication.

Just before 5:00 pm today, I got a phone call from the woman who handled my appeal. I was braced for “We tried, and you can always appeal again.” When she told me something different, I was so surprised I had to ask her to repeat it. “She won!” she said, sounding a little bit astonished herself. “She won the appeal. Do you know how unusual this outcome is?”

I don’t know for sure, but I think this gives her at least another week of coverage for inpatient rehab at the nursing center, until the next weekly plan of care meeting happens next Tuesday. And I’ve been assured that when she is discharged, she will get home health PT. Meanwhile, the SNF physician agreed to step her down off the Zoloft, starting with a half dose today. I’m hopeful that she’ll soon be feeling more like herself.

And now I just need to get through my last two days on the job and an exit interview on Friday morning, and I can be there to keep a closer eye on her progress. I’m tired. Mom is tired. Nevertheless, we persist.