Who is responsible for following up on directives after release from hospital?

TrumpetSwan

It seems I have a new concern each time I visit my mother in MC.

Today's question of the day is "Who is responsible to ensure the medical staff and my mom's MC facility follows the orders given for care after someone is released from a hospital?"

My sister is POA for everything with mom. (I used to have POA jointly with her. Long story.) Anyway, that means most times nobody tells me anything. About five months ago, I noticed a couple plastic bags in the corner of my mother's room. I thought they were trash and picked them up to throw them out, but realized they were stamped with the local hospital logo and contained some of my mother's clothes and one had a breathing apparatus inside like what is used for asthma. My mom has asthma. Inside one was an index card with my sister's name on it and her cell phone number. I realized these were bags of my mother's belongings she was given upon release from a couple of hospital stays.

I asked the DoN later that day about the protocol after mom is released from the hospital and specifically I asked, "Who connects the dots to make sure the instructions given upon release are actually executed by the local team?" She looked at me blankly and a bit defensively and was very short in answers. She just told me the release papers from the hospital are given to the doctor on staff and they follow through. I told her about the bags I found, and also questioned if there had been a gap somewhere along the line. Specifically, I referenced my sister as she would have been the contact point at the hospital for my mother. The DoN said she would follow up with her.

Today, my mom was holding her upper arm saying it hurt. I rolled up her sleeve, and saw a dime sized wound in the inside of her upper bicep. It was dry and scabbed. However, it looked a bit red still one side. I also noticed what looked like a couple of stitches around it. I called an aide and she took a photo to give to the DoN. She said nobody was aware of this wound. I said it looked like mom had some procedure done and it needed stitches removed, but nobody removed them and it became infected and the stitches healed into the skin. She called the DoN while I was sitting there and the DoN replied that she would stop over in one hour. I had an appointment and could not stay. I just asked to be kept up to date on the plan to address this.

I wanted to raise this issue to the Executive Director. On my way out, she was passing in the hallway, so and I told her about the wound. She said the doctor visits on site in two days, and they would make sure he saw it and would advise on the appropriate next steps.

I think my mom was hospitalized, had a procedure, and the follow up care was not done. If so, my sister would have known about it. I think she would be the one to "connect the dots". I also cannot believe the MC staff did not see anything wrong with her arm during bathing.

Something appears to have been missed. I just do not know who would be responsible. Appreciate any thoughts.

SDianeL

The DON is correct. The hospital sends discharge papers to the MC facility. The question is whether the hospital included the stitches removal in the orders or not. If your sister is POA I would start there. She can call the DON. I would also tell your sister to question why it takes 2 days for the doctor to check a possible infected arm and take out the stitches.

towhee

It is the job of the doctor and facility staff to follow discharge instructions. They connect the dots. It is the job of the POA to backstop facility staff because mistakes can happen. It is the job of regular visitors/other family to backstop the POA, usually by contacting the POA, or if necessary, expressing concern to the facility staff. It takes a village. Not every POA visits frequently.

I understand that you want to improve your mothers care, but sometimes insistence on assigning blame is counterproductive. I understand that your relationship with your sister is bad, but I am seeing a pattern where you seem to be putting facility staff in the middle between you and your sister. That is not their job. If you create enough ill feeling among the staff or your sister, your sister could as POA bar you from visiting, or the facility could decide they no longer wish to care for your mother.

Please, come here and vent, we are a safe space. But be careful at the facility.

TrumpetSwan

Thank you SDiane and Towhee. Towee - You have a good point about being counterproductive with staff. That was nagging at me too, and you may have just given me a reality check.

I am going to step back from this for a bit. I get too worked up to see what I think are "lapses" easily solved but keep going unaddressed. However, the chilly reception from staff tells me that my input is unwelcome.

I will have to have peace of mind that I did what I thought was right in the moment. The rest from there, I am going to let go.

Thank you.

harshedbuzz

@TrumpetSwan

I feel like the others are probably correct that your involvement risks alienating your sister and the folks caring for your mom. Unless you feel you sister’s judgement is so egregious as to constitute neglect, allowing you to obtain guardianship, you are kind of stuck caring much without any ability to change things.

IME with my parents, generally the hospital discharge will include a plan for visiting nurses or a stay at a SNF after an inpatient hospitalization the patient or POA charged with scheduling follow-ups. Given mom’s dementia, she might not be an appropriate candidate for some services like PT or OT.

About the breathing device; do you know what it is? My mom has COPD and reactive asthma. She’s got a lot of “devices”— some critical to her well being and some very much not. I would be concerned if mom is supposed to be using O2 (Portable Oxygen Concentrator) or nebulizer, but not so much about an incentive spirometer. Hospitals seem to hand those out lie breath mints and few people use them once discharged.

The arm wound/stitches make me wonder if she had a PICC line at some point based on the location you describe. Mom’s had these for IV abx at home but they’ve never needed. Hers weren’t sutured, though.

I’m so sorry.

HB

TrumpetSwan

Harshed, you say: "I feel like the others are probably correct that your involvement risks alienating your sister and the folks caring for your mom. Unless you feel you sister’s judgement is so egregious as to constitute neglect, allowing you to obtain guardianship, you are kind of stuck caring much without any ability to change things."

I agree. I am stepping away from this.

Yes, I do think my sister's judgement has been neglectful. Some, even exploitative. I just do not post about everything. Two family friends called me in recent months expressing concern after they visited my mother. One said she wanted to call APS, and she only knows a few of the things. Knowing others are concerned weighs on my mind.

I am not going to seek guardianship or call APS since it will kick off a bad tug of war. I just have to make peace that I did what I could and let this be.

harshedbuzz

I am so truly sorry. This must be so painful for you.

jfkoc

If in fact the document is a POA and not a Durable power of Attorney and you mother is in memory care then the POA is, in all likely hood, now null and void.

Now from a practical standpoint, I would rather be friends with the staff than my sister. They are the ones taking care of your mother. Sometimes some home baked cookies works wonders.

JPJardinel

What you're describing, discharge bags sitting unopened for months and an undocumented wound with stitches that healed into the skin, is a real coordination failure, not you being overly cautious. The DoN's blank, defensive reaction is honestly a tell in itself.

On "who's responsible": inside the facility, once your mom is back in their care, the facility itself is supposed to receive and act on the hospital's discharge orders, that's their job regardless of who the POA is. Your sister being POA affects who gets called and who makes medical decisions, but it doesn't erase your standing to notice a problem, ask questions, or push for answers as her daughter. You don't need to be POA to advocate for what you're seeing with your own eyes.

The piece that's actually missing from most of this back-and-forth is that you don't have to rely only on the facility's own internal chain, DoN, then Executive Director, then the visiting doctor in two days. The Long-Term Care Ombudsman Program exists specifically for situations like this: a free, federally mandated advocate for nursing home and memory care residents who is independent of both the facility and any family dispute over POA. They can look into exactly this kind of missed follow-up and push the facility in a way you can't from inside their own reporting structure.

Keep documenting what you're finding, the photo, the dates, who you spoke to and when, since that record is what makes an ombudsman complaint (or anything further) effective rather than a he-said-she-said.

I hope these resources are useful:
https://hopebridge.care/care-transitions-after-hospital-discharge-whos-in-charge/

https://en.wikipedia.org/wiki/Long-term_care

https://www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html

SusanB-dil

Hi JPJardinel - Thank you for the good, and thoughtful input. But this post was from over a year ago…

Never know, though, it could help someone else dealing with that issue.

ARIL

The mother of the original poster died earlier this year. We need to be careful not to dredge up old posts that may cause pain to forum users whose circumstances have changed significantly.

Victoriaredux

Good points , and another reason that the website purge of prior number of posts by an individual matter.

Maru

https://alzconnected.org/discussion/73244/who-is-responsible-for-following-up-on-directives-after-release-from-hospital

It has been my sad experience that the patient and the patient's family have to make sure that doctor's orders are followed. An entity may have the legal responsibility to do something but that doesn't mean it gets done.