Saint Mungo's Hospital - Inpatient Rehabilitation Department

Case Management Note

Inpatient Rehabilitation (Setting 2)

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Name: James Krum

DOB: 12/25/1960

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Care Conference 10/21/24: therapy team recommending patient discharge to skilled nursing facility for continued therapy based on current progress throughout his course of inpatient rehabilitation. Patient upset by the recommendation and insists on discharge home. Therapy team and Physiatrist provided education regarding concerns for discharge home, including need for 24/7 assistance given physical and cognitive impairments, wheelchair accessibility of home, and inability to negotiate stairs into home. Son available via phone for conference and reiterates he is unable to take time off of work to assist patient, but he will talk to patient’s siblings regarding their ability to help. Multi-disciplinary team to continue to offer education as to why discharge to a skilled nursing facility will be the safest option for the patient.

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Update 10/23/24: writer was informed by nursing that patient nearly fell when attempting a toilet transfer toward his left side with 1 CNA. He had been previously completing toilet transfers with 2 staff members or the Sara Stedy, but due to improvements with transfers in therapy, upgraded his mobility level on the nursing unit. Writer and Physiatrist had discussion with patient regarding the near fall and the implications if that were to happen at home if he has inadequate or non-skilled assistance. Patient with limited insight into situation and Physiatrist to seek input from speech language pathology and consult Neuropsychology to determine patient’s competency to make his own medical decisions.

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Update 10/24/24: Neuropsychology assessed patient and they determined he is competent and able to make his own medical decisions, so POA not activated. Received phone call from patient’s son. He expressed that his uncle (patient’s brother), may be able to move in with them for a limited period of time to provide assistance. Writer to discuss with members of multi-disciplinary team and patient at upcoming care conference. 

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Care Conference 10/25/24: patient continues to make progress within physical and occupational therapy, but he continues to be non-ambulatory outside of therapy and level of assistance with squat pivot transfers fluctuates anywhere from contact guard to moderate assistance depending on the side that he transfers to and his level of attention in the moment. Patient continues to refuse skilled nursing facility despite team’s recommendation and education. Will move forward with plan for patient to discharge home, and he is open to home visit with therapy team prior to discharge. Insurance authorized inpatient rehabilitation for 1 additional week with plan for discharge 11/1/24. 

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Update 10/28/24: confirmed with patient’s brother that he will be able to stay with patient at discharge and provide 24/7 assistance. Home visit completed by physical therapy. Patient unable to safely negotiate 2 stairs into home. Wheelchair from hospital does not fit through doorway into bathroom, but brother may be able to widen the doorframe. There is a guest bedroom on the main level, and he was able to successfully transfer bed to/from chair with therapist assistance several times. Therapist reported low pile carpeting or laminate flooring throughout home. Will work with therapy team to determine what equipment is recommended for discharge home.