Hospital say ready for discharge, family disagree

[Pl242]

Posting for any advice or insight which would be gratefully received.

MIL currently in hospital after a fall resulting in fractured shoulder. Also has dementia, limited mobility (now further curtailed by shoulder injury as can now longer use walker/zimmer), is incontinent and also generally very frail.

After just over a week in hospital they advised she was ready for discharge. They stated she would be fine with a care package of carers coming in four times a day to change her and move her from bed to chair then chair to bed. She would need to be confined to her bedroom at home. They said this would work as she was not attempting to move from chair/bed in hospital.

FIL, her primary carer, expressed that he was not able to cope with her coming home at this point. Prior to fall she was coming to end of 6 week care package following a minor stroke in March. He and other family members disputed the hospital assertion that she wasn’t trying to move from chair/bed in hospital. She has been. Is constantly removing sling as forgets she has a fractured shoulder. Dementia symptoms currently much worse in hospital due to delirium and drowsiness from painkillers. We all think it’s just totally unrealistic for them both to be confined in an upstairs bedroom as we don’t think she can be left alone so in effect FIL would be placed into an almost 24/7 caring role save 4 x 40 mins carer visits per day.

The hospital staff said our only option was to request a social services assessment, which we have. MIL remains in hospital whilst we wait on this. Since this there have been a few other incidents in hospital which have confirmed our view that her being discharged is unrealistic - passing out when physios try to get her to walk, pulled out a cannula overnight leading to blood loss and passing out. Doctors also saying she’s not making much progress, there are other things that have cropped up which they are investigating eg infection. Yet in same breath saying they think she should go home and would be discharged if a social
services assessment hadn’t been requested by the family. None of this makes sense to us.

Grateful for any insight on what we might expect next, tips on how best to manage decisions. FIL torn between wanting to try and bring her home vs going into a care home, but worried that if he says yes to the care at home package he’ll essentially be left alone to cope with a very difficult scenario.

Sorry this is long. Thanks for reading.

Social care will assess if she is safe alone. I've never heard of the spouse being expected to 'watch over" someone unless they say they want to. Also we don't tend to leave everything to family unless they say they want to look after. Also you can't just place an individual in a care home as they have rights

MIL agreed to go to a LA funded rehab care home for a few weeks, after she broke her hip. She was deemed to have capacity; but was of the generation, who did what professionals (ie a social worker) told her to do!

DS fell down the stairs and broke his shoulder badly in January. He is in his thirties, and was fit and healthy. The first two weeks, he was in so much pain, he could hardly move. It took him 45 minutes to have a shower and get dressed. He couldn’t get himself any food one handed. He went to sleep at bedtime, but woke up again around 2 am and couldn’t get back to sleep again, due to the pain. He said paracetamol didn’t touch the pain. He finished (private) physio last week, but it’s been 4 months and he can now lift 4kgs. He’s got to carry on with weight lifting. They told him it would take a year to fully recover.

If OP’s MIL is in the state DS was (and he’s no wimp), I can’t see her FIL being able to cope with 4 care visits a day. What if MIL was waking up at 2 am in pain and painkillers didn’t work?

I’d seek a 6 week reablement placement in a rehab care home, if I were her.

FIL needs to keep saying he cannot cope - on repeat. Does MIL have mental capacity? Has an assessment been done? Who is the social worker assigned gof discharge? Has a care and support assessment been done? I’m guessing yes.

MIL has a right to return home if she has capacity to say that is what she wants.

Thanks for all the helpful responses. A full
social care assessment of her needs has still not taken place, but the hospital discharge team persuaded social services to place her in a nursing home on a “health “ basis (ie free) for a few weeks until the shoulder (hopefully) heals and there is potential for her to use walker again and become a bit more independent. Early days at the home but so far going ok and much better than being in hospital or home as really don’t think FIL could cope.

We have also had some success with getting FIL to engage more fully with the realities of her being at home, even if with carer visits. He has finally admitted that he doesn’t think he can cope with her in this condition and has started to face practicalities and research home options and sort out finances/paperwork etc. This is a massive step forward.

obviously we will have to see how she goes and what makes sense when shoulder heals/we have to pay. I can’t see her coming home in the forseeable, mostly as I just can’t see her regaining significant mobility re walking/toileting etc and her dementia is obviously not improving. But you never know and like many we hope for the best and prepare for the worst.

I have had a similar situation with my mum on two occasions in the past. Unfortunately you have to stand your ground and insist that she is not safe to come home and adequate care cannot be provided for her. If you ask/insist they should be able to find her a rehab placement or temporary placement until you can get a more permanent solution sorted. Unfortunately, the won’t tell you any of this unless you ask. Also, you don’t have to accept a particular care home offered by SS if you don’t feel it is suitable for the person’s needs. You can look at some in the local area and then ask SS if they will cover that particular one. Worth a try and I wish you all the best.

Are you sure it's free? If it's commissioned by social services and a care home, it is more likely to require a financial assessment at some point.

It may be free, but people often misunderstand and are surprised when when post hospital social care is chatgeable from day 1. Was it Discharge to Asses?

I’m sorry Op but it sounds like you should be looking at a care home now not a return to home with care’s 4 times a day, that’s not going to work.

You can't possibly know that! As said before, family can't just decide on a care home. Even if the person has a dementia diagnosis, their capacity has to be assessed by a social worker ( not a doctor/nurse) and even then , home is always looked at first. It is assumed there is no family support unless they actively say they want to support despite what people think.

If it's Discharge to Assess, social care won't have been involved and there wouldn't have been any 'persuading'. Social care will get involved at 2/4/6 weeks and charges will start from then.

The charges are often backdated to day 1, particularly for respite/residential care.

Unless it's Discharge to Assess(D2A) in which case charges will start at review stage only.If it's social care organised, all services are charged from day 1

I would ring a few local nhs dementia care homes and ask a senior person there what would happen to a resident if they were in this situation - would they go back to the care home or is there like a half-way option

Could you buy a care package with a live in carer?

That sounds like a discharge to assess type arrangement whilst they figure out what she can and cannot do which will inform a care and needs support assessment to be carried out by social care.

Well our optimism now back on the floor again. She’s fallen in the care home and now being taken to a&e to assess any damage etc.

They had moved from keeping her bed bound to moving her to and from a chair and trying to get her walking with a walker again.

Yet it appears that she has tried to walk from chair to toilet when in her room unaccompanied (she has nappies on but forgets, her wanting to go to the toilet constantly is one of her behaviours, often asking to go incessantly and most often not actually needing it) and has fallen.

they don’t think she’s broken anything (new, obviously her shoulder still healing anyway) but won’t know until x rays etc and no one was in room with her during fall (like last one at home).

I don’t know why I’m posting really. Mostly just to vent, as trying to support my DH and his family in supporting her, so can’t express frustration/upset elsewhere.

But I just don’t know how we keep her safe without keeping her pretty much bed bound (which has so many other negatives) or providing care that involves someone being with her 24/7 which just doesn’t seem to be a realistic care scenario in any environment whether that be in hospital, home or in a care home.

I just feel so wretched for her and the rest of the family.

Has she not got a sensor mat for when she gets out of bed when she's on her own.? These are used to alert carers if they are trying to walk unaided

I don’t know. Been in a new home for only a few days. But it was a chair she moved out of, not a bed. I believe the bed has rails. I believe she has perhaps not been put in the right type of chair maybe? But as things stand back into hospital so lord knows where/what happens next.

Sensor mats are on the floor so can be put in front of chairs too

Well clearly either there weren’t any or there were and no one in the care home heard them or came quickly enough. So yeah 🤷‍♀️

The thing being, nobody in any setting can 100% 'stop' elderly people falling. They can lessen the problem, they can put risk assessments in place and it's 'easier' to achieve this in a care home setting (24/7 at home care is extremely difficult) Wait and see what the new baseline is, they'll want her to be in hospital only for as long as it takes to check her over. It also sounds like she may have a urine infection if she's feeling the urge to go constantly. After this assessment, the family should have a clearer picture

Goodness, things have got even more stressful now! The good news is that following a&e assessment they said she’d not broken anything further etc and were happy to discharge her back to the home.

However the home refused to have her back. The a&e doctor argued with them on the phone apparently then said it’s sorted the ambulance will take you back. But she, my FIL, and the paramedics were met with three people physically barring entrance late last night flat out refusing to accept her back.

apparently a 90 minute stand off. No seniors either side would pick up the phone. Ended with paramedics taking her back to a&e for the night and exhausted FIL going home.

this morning we have a confused picture. Managed to speak to a&e earlier who said it’s all being sorted and she will return to care come this morning. But FIL spoke to care home who said they are not taking her back and have told the hospital this. FIL is heading to a&e to find my mil and try to speak to people there.

we asked FIL to send us any paperwork re her discharge to this home. It looks like it’s a 3 week icb funded placement to this home but funding covers physios and gps etc. I think what’s happened is that home/the physios etc running this scheme say mil does not meet the criteria. Ie she’s not fit enough to do the rehab. They have mentioned she needs 1:1 care. Hence refusing to have her back.

The home would have her if we privately paid for her as a resident but we feel if we do this we’re effectively going to be out of system and people will gladly wash their hands of her saying we’ve taken decisions into our own hands etc.

We still don’t think the social care assessment requested over 3 weeks ago has happened. Instead the hospital discharge team found this placement and got funding for it but it hasn’t worked and following an admission after a fall the home is effectively sending her back to the hospital.

we are advising FIL to get to
hospital, find MIL, find relevant doctors who are making decisions, explain context/history. Stand firm on her not being able to come home, that the placement put in place by hospital discharge has not worked and looks to have underestimated her caring needs. Ask when proper assessment of needs is taking plane to identify a caring solution that meets her needs and what will happen/where will she be until this is sorted out. Ie will she return to the geriatric ward vs lying in an a&e corridor which is where I suspect she currently is.

is this the best approach? Would welcome any views/insights. Thanks.

You need to speak to the discharge coordinator and hospital social worker urgently. We had this happen where I worked and the home is within their rights to refuse her, most homes won't accept discharges in the middle of the night anyway because of the low staffing levels. It sounds like they have clinically discharged her without actually doing a proper care discharge. And for goodness sake DO NOT let FIL say he's taking her home or that you'll pay. If they can meet her needs if you're paying then they can meet her needs under the 'discharge to assess' (usually 4 weeks, sometimes extended to 6 weeks)

Also ask for the comprehensive geriatric assessment.. often shortened to 'CGA'

Thank you @Lightuptheroom. Much appreciated. As things stand they are readmitting her to hospital again, following care home refusal to take her back. Awaiting ward/bed from a&e and then the whole assessment/discharge process will start again. I suppose the only silver lining of this awful 24 hours or so is that they cannot possibly argue that she can be safely cared for at home when a care home have refused her, saying her caring needs are to great for them to meet.

OP, just quoting you so you'll see my reply.

My Dad was in a similar situation, although my Mum was already gone. We had him cared for at home with 4 carer visits a day (mostly funded out of his attendance allowance plus his own funds) until the falls he had got so regular, together with his dementia, that he went into a care home.

The first home had to be found by us - he was in hospital untl we did and there was zero help with it - and he was eventually refused re-entry to thart home as (despite being "demential specialists") they said they couldn't cope with him.

This DID stimulate the hospital social worker to find him a really good care home and he spent his last few months there (again, funded by attendance allowance and his own funds). My brother successfully argued with social care for additional funding for 24 hour supervision. This did not stop him having falls, however - but he was well cared for and eventually died peacefully in hospital after an infection led to sepsis.