02/28/2013

We lost the reconsideration.  I tried to call Sadie to let her know but got transferred to Debbie when I tried to get back the operator could not answer I hung up. I have things to do.

I started calling the list of SNFs and learned that Palomar has their own and they ONLY take patients form the hospital. So I called Kathy at the Department for Health to let her know that they could make this go away if they would put mom up there until life Care has a decent bed. I really wish the hospital would step up and take responsibility and make this all better. If not, I will be taking it to the media, and then their reputation will be in question.

PALOMAR CONTINUING CARE CENTER D/P SNF
1817 AVE DEL DIABLO
ESCONDIDO, CA 92029
(760) 739-2000

REDWOOD TERRACE HEALTH CENTER
710 W 13TH AVE
ESCONDIDO, CA 92025
(760) 747-4306                                                             spoke to Lisa call back, they do not have a wait list

LAS VILLAS DEL NORTE HEALTH CENTER
1335 LAS VILLAS WAY
ESCONDIDO, CA 92026
(760) 741-1046                                                 left message 9:22

POWAY HEALTHCARE CENTER
15632 POMERADO ROAD
POWAY, CA 92064
(858) 485-5153                                                 left message with Linda Salee at 9:25 She said there is a 20 person waiting list

ENCINITAS NURSING AND REHABILITATION CENTER
900 SANTA FE DRIVE
ENCINITAS, CA 92024
(760) 753-6423                                                 left message for Katherine 9:30, missed her call at 10:32 no message left for me.  760-753-6423 X229 She called and said they had a bed and we went out there and after receiving my mom’s paperwork from the other facility all of a sudden there was  20 person waiting list WHAT??????

THE DOROTHY & JOSEPH GOLDBERG HEALTHCARE CENTER
211 SAXONY ROAD
ENCINITAS, CA 92024
(760) 632-0081                                                 left message Cheryl Portnoy 9:30 could be 2 years

CARLSBAD BY THE SEA
2855 CARLSBAD BLVD
CARLSBAD, CA 92008
(760) 720-4580                                                 left Maryanne C message at 9:35

LA JOLLA NURSING AND REHABILITATION CENTER
2552 TORREY PINES RD
LA JOLLA, CA 92037
(858) 453-5810                                                 left message on v/m at 9:37

FALLBROOK HOSPITAL DISTRICT SKILLED NURSING FACILI
325 POTTER AVENUE
FALLBROOK, CA 92028
(760) 728-2330                                                 spoke with Wanda don’t take straight from hospital left message for Anita or Terry?     

Lauren from LB just called (9:58) to inquire about mom I told mom is doing well now but I will need hospice after they move mom as I am certain it will push her in a bad direction b/c of the womans crying all day/night and or just b/c of any move to a new facility.....

Maryanne from LB Hospice called to say how can she help? Well, how much time do you have? 

So, Gregg could tell that I was overwhelmed so he took off work and came to my rescue and we went out to Encinitas took look at the new facility. Turns out it was a complete waste of time, they have no beds available. WHAT? I asked over and over again about a wait list and she said they had a bed available right now. It was a case of someone in a job for only 3 weeks and not knowing what the hell they were doing. So, it got our hopes up AND wasted 2-3 hours we did not have to spare.

I must say that the admin director at the current SNF has bent over backwards to help us. She did not have to do that. SADLY, Mom will be moving into my worst nightmare bed tomorrow. 

02/27/2013 Wednesday

I just closed up my mom’s apartment and had Salvation Army carry off most of her belongings.  I turned in her keys to the manager.

I rec’d a call from Sadie  (10:30 ish) at SNF and she wanted to move mom today. I said wait., what about the reconsideration verdict? Oh yeah, ….she called them and the doctor still has the records and will tell us by noon tomorrow.

So I called Kathy at the Dept. of Health. She has been sick and could not get out to Palomar yet. So I had to go over the entire situation with her again. She said she’d go out and get back to me. She says there will most likely be no way to prove the teeth had a major part in the loss of coverage since she’s had a stroke and pneumonia too. very encouraging. NOT

02/26/2013 Tuesday

I went at 9:00 to see mom she was doing fine except her right eye is inflamed again. I asked Ava for the blood work results. They are from 2/2 but Dr. L. did not do a liver panel like I asked, he did a CBC. So I asked Ava to please contact him and request a liver panel.

Sadie called me and told me that she has a call into Susan at Kindred (Village Square). She suggested I go look it over. I did, at 1:30 and Jasbeer was not her in room 317 like Sadie thought and I did not see her anywhere. The rooms are laid out nice and it was not smelly or noisy. There is a second floor lock down right now with some infection or condition.  It is a small facility. It will depend on if they have a bed and what roommate they have.

Mom’s purple blanket has not reappeared. That’s another item lost and or stolen.

Angel just called (4:14 PM) from SNF and wanted to know if I’d heard from Medicare. I told her yes and that she should talk to Sadie as we are doing a reconsideration with Maximus b/c your people did not include all the pertinent data ( our letter) so that Medicare could not make an informed decision.  The communication at that SNF business is very poor. 

02/25/2013 Monday

I am freaking out, there is no acceptable bed in the Skilled Nursing Facility and they have screwed us up to the point that no other facility wants her. The deal is it’s all about the money; no surprise, right? The Skilled Nursing Facilities get much more money for Medicare patients than they do Medi-cal patients. So they limit the number of beds they allow in their facility.  

YOU MUST ALWAYS REMEMBER; they are a business and in this to make money!!!!!  SO, they have figured  out what you do not know and that is how to screw you into taking the LEAST desirable bed in the place with the promise (so far they have not been able to deliver) that she would be moved. There is a 6 person waiting list and who controls the list? You’re getting it now, right?

02/24/2013 Sunday

Went to see mom and watch her have lunch. Not much of an appetite today.  She wants salt and it’s hard for her to ask for it. I told Haeifa on the way out.

Got a call from Medicare and they denied the appeal. I asked if they had the letter that the Skilled Nursing Facility said would absolutely be a part of the medical record and they said no it was not there.  They told me I could contact Maximus for reconsideration.

I called Maxius 866-950-6509 and left a message I will hear from them tomorrow. I need to ask for a FAX number so I can submit the letter on our behalf as I cannot trust anyone else to do what they say they will. 

READ THIS February 13, 2013 State of California Department of Health Services                                        

                                                                                                                        February 13, 2013

757 Metropolitan Dr. Suite 104

San Diego, CA 92108 (619) 278-3700

The letter below was hand delivered by me and mailed to Palomar Medical Center on February 7, 2013. I have had no response from Palomar and have been notified today, February 13, 2013 that on the 15^th of February my mother, Ione will be moved to custodial care status. This is a direct result of the fact that she is still not able to eat solid food because her new dentures are too painful to wear.  Please open a grievance for our case.

Palomar Medical Center                                                                                      February 6, 2013

2585 Citracado Parkway,
Escondido, CA 92029 (442) 281-1006

The purpose of this letter is to list the various actions that the Palomar Medical Center either took or failed to take that have resulted in the continuity of her residence and earned benefits being placed in jeopardy, and to ask for compensation.

In summary, she has recently been evaluated as failing to show progress and we see this circumstance as being a direct result of her inability to eat or speak normally due to the loss of her teeth at the negligent hands of Palomar hospital system and employees. The resulting weakness and embarrassment, in addition to her coping with the underlying difficulties actually attributable to her stroke, have confounded the chance for any objective evaluation at a very critical juncture.

We demand that Palomar compensate Ione in the event that she loses benefits or residence.

In specific:

The impact that the negligence and inhumanity that Palomar Medical Center imposed on my mother, Ione  (89 yr. old, 2 stroke survivor) has now further adversely impacted her ability to recover.  She has suffered greatly in probably more ways that I can describe. But, I have to do my best, as I am now her spokesperson; she had a stroke in November 2012 that left her with speech and cognitive difficulties. 

Palomar Medical Center threw away her dentures (that were soaking in the sink in an open, hospital supplied denture cup) on December 29^th, 2012. This has been stipulated by your own employees and you have agreed to replace them. This has since had further impact on her life. As a result of that loss, the Skilled Nursing Facility is reporting that she is not able to make progress. What that means is that she is in jeopardy of losing her benefits and her chance to recover to the best of her ability. 

Since she was not able to eat regular food for 30 days, she lost a lot of weight, about 20 pounds. With that weight loss, she lost strength and muscle.  With that loss of strength she was unable to participate in Physical and Occupational Therapies at the same level she was before the hospital stay.  I would have to say she was neither able to meaningfully participate in speech therapy as she was upset and depressed and inhibited from speaking clearly due to the absence of teeth. It impacted her self-esteem and confidence.  It took 30 days for her to receive her new dentures and now she is in day 5 and her mouth is full of sores (as the teeth are not completely fitted) and she continues to give up on eating due to this continued difficulty.

I contacted Deborah LaG. (442-281-2222) and advised her that I needed the Medical Center to expedite the replacement of the dentures and that someone at Palomar needed to apologize to my mother. I also requested a letter showing that some action was taken so that this does not occur again. I have heard from many other sources that this inhumane catastrophe happens all the time. I have not received any correspondence from anyone at Palomar Medical Center since.  And I did fill out and return the survey that was sent to us asking about our experience at the hospital in the mail.

It took until January 2^nd for Diane from Palomar to call me to tell me I needed to get someone to give Palomar a quote to replace the dentures. I said no, I am not going to do anything, you do it. I did not throw them away. I have enough to deal with outside of the denture disaster.

This has been a MAJOR inconvenience for the patient, and the entire family. We have had to suffer along with her, trying to find alternatives for her diet and constantly worrying if she was getting adequate nutrition to sustain life.  Which in most cases she was not receiving anything other than yogurt, and a few bites of oatmeal daily. We suspect that organ failure may have begun, but that hasn’t been confirmed medically. There were other issues that we suffered during the hospital stay at Palomar Medical Center; such as:

• The Emergency room physician, Dr. Leb., gave a cavalier diagnosis of COPD without performing an examination. The actual diagnosis found later was pneumonia.
• Dr. G., dismissed a request to consult with a respiratory specialist and suggesting hospice prior to understanding the cause of the respiratory problem. 
• It was finally, after the family insisted to Dr. H., that Dr. B. was brought on board and he discovered Ione, the patient, had pneumonia.
• Moving a STROKE patient (very disorienting) from the 7^th floor to the 8^th floor without notifying the family. Did I mention the document I have says it happened at midnight?
• At discharge, the nurse did not read the discharge order to continue IV antibiotics and she removed the IV. This required that a very fragile elderly patient had to in endure another IV insertion, which had to be delayed for an “expert” due the condition she was in at discharge.
• Repeatedly, after the move to the 8^th floor, the hospital caregivers in direct contact with the patient showed an unacceptably low level of concern for what was actually in front of them and were clearly more interested in processing the patient through as if her advanced age gave them license to ignore an adequate standard of care. 

The result is that she has been handicapped even further in an environment in which she has to demonstrate performance in order to survive. What is the hospital willing to do to compensate Ione for the dis-service they have caused in her life?

If she loses her Medicare benefits because of your negligence then the least you can do is provide compensation in same amount and a premium room with full comparable care, until her current skilled nursing facility has a long term room available. 

I will look to hear from someone within 5 business days. After that time I will need to take further action.

Sincerely,

NOTE: I have since received two letter from Palomar saying they are looking into this and they need 30 days. we don't have 30 days!!!!

02/23/2013 Saturday

Now that we are in appeal this was a relatively uneventful visit. We actually got to see mom and talk with her without being on high alert with something going on with the staff. They have managed to lose her blanket and several other things. That is something that just happens at SNFs.  You may as well plan on it. Even if you write their name on everything.

We found out from the director that sometimes you might get “customer service” reports from the various people handling your loved one. They want to make things pleasant and might give a “better than” report of progress as you pass them in the hallways. You have to be very careful what you hear from whom. Always ask the people in charge if you can figure out who they are, what you need to know.

We are in the process of closing down mom’s apartment. She was living on her own last November 2012 before the 1^st stroke and was a very independent woman. So, in the middle of all of the nightmare of balancing the government agencies (Medicare, Medi-cal, Ambulance Services, Hospitals and Doctors) and the games you have to LEARN and then play to survive, and the learning curve that you need to know in order to communicate with the Skilled Nursing Facilities and then the doctors on top of all that and THEN you might have an ounce of energy left to love your person who just had their lives turned completely upside down.  It’s exhausting and then you feel like but hey, wait, it’s not about me……

So, we sit here and we wait to hear our fate; will the little guy win the appeal and get to take advantage of her last few days in Rehab? and avoid being subjected to a three bed room (fr the rest of her life) next to another injured soul that cannot control herself and her attack on others senses?

This is my worst fear and nightmare, who would want to live this way?

Non Coverage Medicare Appeal position:

·       Mom was doing well in rehab before she got pneumonia, which took me 5 days of bringing it to the SNF attention to get any action. Sure, they did x-rays which came back “clear” but there was clearly something still wrong with her respiration. Then on 12/25 we came into see her after taking 2 days off and noticed she had another stroke, none of the staff even noticed. They called the on call doctor and he said call 911 and off we went to the hospital.  Additionally, there was a massive infection in her mouth, which no one was attending to. The hospital nurse had to pry gobs of green gunk off of the roof of her mouth.

·       She recovered from the pneumonia after continuing IV antibiotics in the SNF after the 7 day hospital stay where they threw away her dentures.

·       So from 12/29 to 1/29 (30 days) she had no teeth.  She had very little appetite before and was on an appetite stimulant (Meghase) off and on over that period.  She was not eating and no one was taking a very big interest in the fact.

·       I asked the SNF for a “ready set go” meeting 2 weeks after her return (1/2/2013) to the SNF.  At that meeting they revealed that she was not doing very well. REALLY, you waited 2 weeks to tell me and what are you doing about it? I am busy going through all of her belongings and trying to liquidate her apartment. I don’t have time to continue to police your staff. We had that talk before I brought her back her: I do not want to police the staff. They are the ones who did not notice the stroke and could not see the pneumonia and the massive infection in her mouth. I need the SNF to do their job; to monitor her health and bring it to the professional’s attention to manage it.

·       Then, yesterday (2/14) in an impromptu meeting at the SNF, Anne the assistant director of nursing remarked how much more alert and stronger mom was. What? Then why the no progress report?

·       The ombudsman says SNFs pull this all the time. How is it to their advantage to rob my mom of her rehab?

·       So the bottom line is that you don’t eat you get weak. If you are a two time stroke victim you cannot tell someone how you feel and what is going on, you need the pros to recognize and manage this. Since her intake has been so little and she has lost so much strength and muscle mass then she was not able to perform and get better. These are directly related to Palomar’s negligence in the act of throwing away her dentures. They robbed her of a month’s worth of rehab.

·       Mom’s condition currently is that she is now able to wear her teeth 60-90 minutes 3-4 times a day. The dentist put her on a puree diet on 2/13 to see if it will not strengthen her and give her some more stamina. I am preparing smoothies with high quality protein in them and delivering them every other day to the staff. The staff will need to pour some of it into a glass for her every day and provide a straw, as often as she will drink it.

·       She received her teeth on 1/29 and was allowed to wear them for as long as she wanted. That should not have been allowed. It is like new shoes you cannot wear them and walk in them for 24 hours straight. After day 2 she had major sores in her mouth and was not able to put the teeth back in. I called the dentist and he prescribed hydrogen peroxide treatments and adjusted the teeth to make sure they fit.

·       When she is physically able she will begin to improve again. She wants to be independent. I see it often when she struggles to sit up in bed. She wants to be able to get up on her own and she would be doing that by now if she hadn’t been sabotaged. 

02/22/2013 Friday

I got a call from Mary at HSAG 800-841-1602 she said they will request the medical records. I just called Sadie before that and she assured me that our letter to Dept. Of Health would be in the record. 

Our new Conf. # is $%#@**&^&^^^ she asked me if I wanted to add anything and I said no, but then when I thought about it I do.  I called and spoke to Mariah at HSAG at 2:15 PM and told her I think that maybe the rehab staff has given up on my mom and that I feel that it would be very hard for them to reverse themselves.

I called Poway Healthcare facility to see if I could get mom in there and they told me she was not attractive as a Medi-cal patient, so NO there is no room. 

I called Kathy Chelius at the Department of Health and updated her to the fact that if we do not win the appeal mom has to go into a 3 bed room with a crying singer and that No other acceptable facility will take her now that her Medicare is likely gone.  

This is all a direct consequence of Palomar throwing her teeth away. 

02/21/2013 Thursday

Got a call on voicemail at 5:17 from Anne stating that 2/25 will be mom’s last day non coverage. I was not asked to come in and sign anything but given a phone number (866-800-8749) to call before 10:00 Friday to appeal if I want. I called the number I had previously last night (same number) at 5:20 and reported my request to appeal.

Mom wore her teeth some on the morning, said they did not hurt.

Dr. L. authorized the change to remeron and blood draw. I will need to check her mood next week as it’s an anti –depressant. 

02/20/2013 Wednesday

At 8:11 am I left a message for Dr. L. on Sonia’s voice mail at his office. I asked that she find out how to get mom switched to Remeron off of meghase like Dr. L. and I spoke about on 1/25 and to have a liver panel drawn as her eyes are not white, they are not yellow, but mostly grayish.

I called Sadie and left a message saying what is going on? She called at 2:30 and said their form is still wrong and it might be another few days.  She was unaware until I called. Not very good on their part. We spoke about Haeifa and Gwen and salt for mom’s food. Sadie said she would also pass on the word to give her salt to add to the food. She thinks it’s just because I am there. We’ll see.

She said Dr. L. said he thought I wanted mom to stay on meghase…..he has not returned my call.

We received another letter from Palomar saying they were concerned that we had a bad experience. 

02/19/2013 Tuesday

I called the QIO on Monday, 2/18 at 6:20 PM and did not get a return call yet. Skilled Nursing Facility  (Sadie) said on Monday we would get another non –coverage notice but we did not. She said Thursday was the last day…..NOT if I do not get to appeal?

The Dept. of Health called; Kathy Chelius, 619-688-6054 at 9:00 AM to let me know she was assigned to our case and she would investigate and get back to me.

Gwen the Dietician called about 3:00 PM. from Life care to work on a menu plan for mom. She said it was going into effect immediately.  Gwen said mom is still on Meghase. I have to call Dr. L. again. He said he was going to switch her on 1/25 but evidently he did not. I noticed the whites of her eyes are not very white. Not yellow yet, but not mostly gray. I will ask him to run a liver panel.  Why am I doing this?

I prepared a fish Lean Cuisine for mom today at lunch and she ate about 50% of it. Sherry and another staff were at the table. Mom fed herself.  She would not give up her dentures so it was good that I arrived when I did. 

02/18/2013 Monday

We met with Sadie at 10:00 and went over many concerns. She is going to get back to us re: communication. She put me in touch with nutrition and cited reasons they do not want me bringing in food: too hard on me, liability for them…..I spoke with nutrition and she said they have to track her nutrition.  It’s on the mfg. boxes. She also said that they had to worry about spoilage. I told her the grocery receipt has a time and date stamp on it and I can bring it to their custody right from the store.  She asked for the list and is going to try and purchase the same.

Sadie called at 5:00 and told me Gwen would call tomorrow and she said she needed a few more days to work on the list of questions I had re: mom’s condition and the communication issue. 

02/17/2013 Sunday

We went in at 11:15 with all of her food. I put a weeks’ worth in the refrigerator and freezer and non –perishable items in her nightstand in the room.  We met with Gil and Dave. Gil had made a special note and posted it in her room and in the chart? He was really listening and trying to make things better and work. Dave too seemed to be listening and had empathy about her weight loss and wanted to help.

I fixed her lunch and we sat with her while she ate. It became clear that she wanted to be in the dining room with the others. So we are going to request that the kitchen prepare her food and she can eat in the dining room for meals and in her room for snacks. 

02/16/2013 Saturday

When we arrived at 11:00 moms teeth had not been in her mouth. Gil was unaware but then there was some confusion later, someone said she refused. I need to be called when that happens.

We came for lunch and she refused to eat the food. She does not like it. We came up with a plan for us to bring lunch and dinner and she will eat in the dining room for breakfast and or have a smoothie in the dining room that we provide.  I will provide a menu and the food each week for her meals.  The staff will have to heat it up and make sure it is small enough so she does not choke.

We received a letter from Palomar saying they were investigating and would get back to us in 30 days. From when we received the letter or when it was dated? Feb 7, 2013. 

2/15/2013 Friday

We met ombudsman at mom’s room at 3:30.
Before the meeting when we arrived we discovered that NO ONE was taking care of her dentures AGAIN. They did not pass on the instructions from the dentist (2/13) to the next shift. This is the third or fourth time we have personally had to fill the staff in about what the dentist ordered.  Anne overheard me ask the nurse when did she stat her shift and how could she not know? It was 4:00 and she had started at 2:00.

We were on our way out and we met with Gloria and told her too. Anne had stated she would put it the notes on 2/14 during the impromptu meeting we had about signing the termination papers.  Gloria agreed it should not occur and she would handle it, yet here we are on Saturday still telling the staff what the orders are.

2/15/2013 Friday

We met ombudsman at mom’s room at 3:30.
Before the meeting when we arrived we discovered that NO ONE was taking care of her dentures AGAIN. They did not pass on the instructions from the dentist (2/13) to the next shift. This is the third or fourth time we have personally had to fill the staff in about what the dentist ordered.  Anne overheard me ask the nurse when did she stat her shift and how could she not know? It was 4:00 and she had started at 2:00.

We were on our way out and we met with Gloria and told her too. Anne had stated she would put it the notes on 2/14 during the impromptu meeting we had about signing the termination papers.  Gloria agreed it should not occur and she would handle it, yet here we are on Saturday still telling the staff what the orders are.

02/14/2013- Thursday

When Gregg and I went in we had to re-educate the staff about the dentist’s orders from last night. They were unaware. Mom had not had her teeth in at all and this was around 11:00 AM.  I spotted Anne and got her attention and told her I wanted to sign the form she had given me on Wednesday but had some questions. We stepped into an office and I asked about financial liability during the appeal. She said by me signing it, it was not making ME personally responsible.  We had other questions so we decided to have an impromptu meeting in mom’s room since she was at the nurse’s station. So I informed them about my concerns moving her and asked that they make sure I was present during it. I asked how much room she would have so we walked down and they showed me the space. Very tiny and next to a woman that is a previous famous singer but now her singing l sounds like crying. It would get on my nerves after only a few minutes I have no idea how mom will handle it. 

Hopefully, we will win the appeal and we will not have to find out.
 

While in a meeting with Miki, Anne and trainee case manager today; Anne remarked mom is getting stronger and more alert……What? Why this no progress report then?
 

I spoke to Susan (ombudsman north county) and she is referring us to the ombudsman, He will call ASAP.

I spoke to the Dept. of Health and started a grievance against Palomar Hospital.
 

The appeal is in progress. We should know in 2-3 days or sooner. Susan said SNFs always do this. I can’t figure out why as it is not to their bottom line advantage.  We saw the room they want to move mom to today, it’s tiny, with 2 roommates, and the woman next to her sings but it sounds like crying. 

02/14/2013- Thursday

When Gregg and I went in we had to re-educate the staff about the dentist’s orders from last night. They were unaware. Mom had not had her teeth in at all and this was around 11:00 AM.  I spotted Anne and got her attention and told her I wanted to sign the form she had given me on Wednesday but had some questions. We stepped into an office and I asked about financial liability during the appeal. She said by me signing it, it was not making ME personally responsible.  We had other questions so we decided to have an impromptu meeting in mom’s room since she was at the nurse’s station. So I informed them about my concerns moving her and asked that they make sure I was present during it. I asked how much room she would have so we walked down and they showed me the space. Very tiny and next to a woman that is a previous famous singer but now her singing l sounds like crying. It would get on my nerves after only a few minutes I have no idea how mom will handle it.  Hopefully, we will win the appeal and we will not have to find out.

While in a meeting with Miki, Anne and trainee case manager today; Anne remarked mom is getting stronger and more alert……What? Why this no progress report then?

I spoke to Susan N. and she is referring us to David R. the ombudsman, He will call ASAP.

I spoke to the Dept. of Health and started a grievance against Palomar Hospital.

The appeal is in progress. We should know in 2-3 days or sooner. Susan said SNFs always do this. I can’t figure out why as it is not to their bottom line advantage.  We saw the room they want to move mom to today, it’s tiny, with 2 roommates, and the woman next to her sings but it sounds like crying.

02/13/2012- Wednesday

When I went in she was lying flat and had no water near her. She was having trouble breathing.  I brought the bed up to sit her up so her breathing we might ease.  She tried to tell me something was wrong with her diaper. I told her to push the button for someone to come and help. She had no idea what the button was about. I had to show her and have her do it. It took about 30 minutes for someone to come today.  I spoke to the DDS office at 3:00 and they said he would be out today and would call me so I could be there.

Anne the assistant nursing director stopped me as I was leaving and told me that mom was no longer receiving rehab and that on Friday she would go into custodial care. I said what does that mean? She said she knew I was having trouble finding a place for her and that they could give her a middle bed for now and move her to something else later. I told her I need to appeal/contest the decision because this was a result of Palomar throwing away her teeth.  She gave me a form to sign. I took it home and reviewed it. It says Medicare may not pay for the services after the Friday date. So, I called Susan N. 858-495-5731 for her to get me in touch with the Skilled Nursing Facility ombudsman David R. I do not know how to handle an appeal.   

Anne gave me the number for Medicare and I called them and they gave me the number of the QIO 866-800-8749. I am on hold with them now 4:08 PM – 4:30.  They will tell me about the appeal process. I had to leave a message, I was on hold for 20 minutes. 

I am very concerned about them moving mom twice. She is very fragile and will most likely get agitated and act out b/c of the new surroundings.  When should I start hospice?  I need to speak to Dr. P. at Lightbridge.

When I went back at 6:00 Pm to meet the dentist I found out that the food I brought in on 2/7 was still in the freezer. No one had bothered to prepare it for her.  it’s like none of the staff is aware and listening to anything I say. Are they not the professionals and they need to be actively involved in her care, health and well-being.  At the dentist’s suggestion we put her on a puree diet for 7 days to see if she takes to it better than the mechanical soft food.  He advised Joel that she should only wear the dentures for 1- ½ hours at a time and to use only a tiny bit of poli grip. As her mouth is extremely dry due to some meds side effects and it might rip the skin off if they have to pull hard.

NOTE: added 02/18/2013. A day or two after this I asked Joel to check with the doctor to see what if any meds were drying her out. I never heard back from him. And as we reviewed the meds list, I saw that a breathing treatment was ordered on some regular basis but had not been administered in at least a week. As I had moved the machine across the room and it had not been moved back near her.

02/11/2012 Monday

I went in at 3:00 and she had no socks on and no water near her and she was freezing. The dentist office said they would come back out on Wed or Friday and call me so I can be there.

02/10/2013- Sunday

I filled out the weekly menu but not hopeful Moms aid she cannot wear her teeth at all, they hurt too badly.

02/09/2012 – Saturday

Gregg went to see her alone.  She was unable to remember that Minerva was just there when Gregg arrived.

02/08/2013 – Friday

I arrived at 2:30 and there is no water near her. An aid runs in with a “health” shake but does not open it for her. She is completely unable to open things or to even pour a glass of water for herself.

I gave her Linda’s gifts and she barely even noticed them. She said the pictures are pretty. Nice. What is going on with her? Joel came in and we talked about the teeth. He says she does not want to wear them.  So, I talked with her about it while Joel was there and said you need to put them in for meals. Will you do that tonight? She agreed. I advised Joel I had brought in some food that she might eat. Also the smoothie needs to be refrigerated. It was left out all night on her side table with no straw in it, thankfully.

02/07/2013- Thursday

I hand delivered the letter to Palomar to the info desk at 9:30 AM, Wanda and Martha (volunteers) said they would take it up to admissions. I called Elvira S. 442-281-1006 and she suggested that.

02/06/2013- Wednesday

I was told by Minerva that she heard from a PT? OT that mom was moving. So no therapy? I stopped Ursula to ask and she said she thought that was the case. I told her no, mom is not moving.  Ursula said she would check with Oliver.

02/02/2013 – Saturday

Minerva called at 10:30 saying mom was not doing well. We were on our way there and saw that she just needed some sleep.

02/01/2013 – Friday

Checked on mom and she was doing well. She has had a couple of very good days cognitively. One good day was before her teeth arrived and then one after as well. Maybe that has been the influence? She knew they were coming? Self-esteem? Not sure. We inquired with Joel today as to when the Ritalin was re-started and we found out it was not. I thought that was the reason for the improvement since I spoke to Dr. L. last week and he said he would re-start it on the 25^th…..but now I found out he did not re-start it at all.  We did discover that she is on Meghase which I was told was stopped due to its negative side effects. Dr. L. was going to switch her to Remeron but did not. Why? He did neither thing that we spoke about on the 25^th.

Spoke to Susan N. today 858-495-5731 she said she could put me in touch with the ombudsman David R. if I need the help.  I decided I want mom to stay at Skilled Nursing Facility and get on Hospice however we can make that work. They need to find a bed for her. I won’t file a complaint about the “missed” stroke, pneumonia and oral infection.  So, they can give her another week or so to come back from being so malnourished and see if she can participate in the therapies. If they want her out they will have to give that to me in writing and I will appeal with Medicare.

01/31/2013

Mom has her teeth now but I didn’t know it until l she took them out and was holding them. I was meeting with Joyce from Silverado in her room.  I spoke to Sooki immediately to see if anyone there knew she had her teeth and Sooki said she knew and I told her about the horrible gunk she had in her mouth at the hospital from the neglect at the SNF. She assured me that she would clean them every day that she was at work. I told her mom likes to sleep in them so she would have to take them out in the morning for a short period and put them right back in. she agreed.

I signed a consent form for a nurse to evaluate mom. I did NOT sign up with Silverado for hospice yet. I am still evaluating the companies.

I was not happy about having to go back to the SNF for the nurse Nancy visit from Silverado at 3:00. She was very on the fence about IF mom qualified for hospice. I don’t get it.  A doctor ordered it and anyone can see that in her condition she is very fragile.

01/25/2013

Question for Dr. L.

Why did you take her off Ritalin on Jan 3rd? Meghase? I asked that you switch her to something else that might help but never heard anything. What else have you d/c without notifying me? How do you expect her to make progress without eating for strength?

What happened to the psychologist appointment you were going to set up before she had the second stroke? What is anyone doing to comfort her emotionally?

How are you treating her dementia? He is not, he said the meds for it compound other problems.

01/24/2013

The results of the meeting were that mom is not progressing and that is a medicare rule in order to stay in the 100 days. So they have deemed her a long term care patient but have no beds so she will have to be transferred to another facility as a Medicare patient. 

Then IF she can show progress there she can maintain the 3/15 date if not she will go on to medi-cal long term somewhere…. I could challenge the no progress rule and may do so. The fact that she has no teeth (for a month) thanks to the negligence of the hospital and cannot eat food enough to sustain her and thus she has no strength then she is not likely to participate in rehab very robustly. 

And on Jan 3rd, when she returned to the SNF, the doctor d/c her Ritalin, and meghase without my knowledge. So, how much can you expect a stroke victim to accomplish with out the meds they need? The second stroke happened on their watch when they d/c the aspirin b/c she was “bleeding” even after we found the bleeding source I had to tell them to start the aspirin stroke preventative again.

I did not appreciate having this “no progress” status sprung on us, it would have been nice to have been notified after the first week.  If you, Miki have been so on top of my mom’s condition then how is it that you first learned that her dentures were thrown away from me on 1/22?

01/23/2012 Wednesday

Questions for 01/24/2012

·       What are you all tracking? Food intake, elimination habits, what else? Time out of bed, participating in activities?

·       Progress to date, quantified by how much help to stand, walk, what other parameters do you measure? etc.

·       Attempt to forecast her progress at March 15^th. Medicare deadline for going home

·       Options to go home- covered by Medicare or Medi-cal

o   Caregivers in the home, 24 or 12 hours?

·       Other options?

·       Emotional support,

o   Other stroke victims, psychologists, I want to be present on some visits.

o   How do I tell her what is going on so she understands it?

·       What are her current meds and vitamins? Still on Ritalin? If not when did it stop and did behavior change?

·       What is palliative care doing and what would hospice do? And where? Here after March 15^th or at home?

01/07/2013

Went to the SNF and saw mom. Dr. L. called before I could enter her room and told me he was sick. I told him I wanted to go over the hospital orders with him. He could not b/c he didn’t have her chart and could not come in until Wednesday. I said to have the SNF fax him what he needed to go over with me. I asked for his backup and he said he didn’t have one and that they could not take care of mom since they did not know her the way he does. I said that’s ridiculous; get them on board now before you are too ill to perform.  He and I argued and he said something stupid about “trivial” matters and we hung up. He said he’s do the best he could whatever that means?????

I called Dr. B. (pulmonary)  office and so did Basil and they spoke to someone in B.’s office and he said 7-10 days was enough of the Antibiotics depending on her condition. B.s office said that’s a judgment call. Well, I have no faith in Dr. L.’s judgment at this time. I want a follow up with Dr. B. in 4 weeks.

Gloria A. said the PCP I am taking mom to will “suggest” but cannot practice at SNF.

10:00 AM Faxing Dr. L.’s office to get her vitamins started again:

·       Bone Maximizer III – take out of the capsule and give in yogurt. With each meal.  This is a Calcium supplement so you can STOP the other calcium supplement that is currently ordered.

·       B Complex – one a day

·       Comfort Zone – 2 with Breakfast, 2 with lunch

·       5HTP - 2 with Breakfast, 2 with lunch

At 5:17 PM Dr. L. called we went over the entire list of hospital orders and made a few changes. We forgot to talk about meghase.

01/05/2013 – 01/06/2013 Saturday & Sunday

After finally calling the on call dr. for the SNF was I finally able to get the swish and swallow and aspirin approved. We went to see mom 3 times, she was sleeping. They reported she was refusing meds.

We went and bought 4 cartons of yogurt. I have told them repeatedly she hates applesauce.  I asked about her vitamins but she is not on any of them and the Ritalin is scheduled to be stopped too. She needs both for her mood.

01/05/2013- FAX I sent to Dr. L.

Dr. L. I have been leaving messages for you to contact me re: Ione. She has been back in the SNF for over 4 days now and I have had no contact with you. I learned from Joel yesterday that you intend on d/c the antibiotics for pneumonia. What makes you think that is a good idea?  I need to speak to you ASAP about her entire medicine protocol.

I am not happy that she had to be hospitalized for a new stroke, pneumonia and oral yeast infection that no one at Skilled Nursing Facility detected.  We need an aggressive plan to make sure this does not reoccur and stopping her life saving antibiotic does not seem like the way to do it.

01/04/2013-01/05/2013 – Friday

I fired Dr. Carty and filed a formal complaint with Denise.Lynch@archhealth.org. She will give to her CMO 01/07/2013

01/04/2013- Dr. Carty 

I have been trying to reach you regarding my mother, Ione’s  care for a week now. You were going to get the hospital records and get back to me. It has become life threatening situation for my mother and I need your input. Her bleeding issue has been [preventing the nursing facility doctor from treating her with stroke prevention medication. I would like for her to be treated and monitored and if the bleeding increases then back off the treatment, but in this case to NOT treat has already resulted in another stroke since the first on 11/17/2012. What method do you recommend and what monitoring method should I suggest to the nursing home doctor to use to monitor her viscosity?

I need a reply from you today, January 4^th, ASAP.

01/01/2013/01/02/ – Tuesday/Wednesday

Discharge from Hospital - The hospital doctor needed to stipulate that mom does not participate in PT or OT until the pneumonia is cleared up and breathing is returned to normal.  She will return to Skilled Nursing Facility and continue on the 100 days of Medicare, expires March 15^th.

Breathing issue is still number one. She is on antibiotics (Vancomycin & Aztreonam ends 2/28/2013) since Dr. Frank B.r (760-489-1458) came on board and found the pneumonia as of 12/29. Why could the ER not find that? Or Dr. G. or Dr. H. (760-739-2371)?  What other breathing support does she need? Oxygen and change the Albuterol to Xopenex if possible; it will not make her shaky.

Coughing- this needs to be monitored with re: to choking and swallowing hazards.

Bleeding from the rectum or vagina. No one seems to know exactly where the bleeding is coming from or why. The stool and urine continue to have blood in them. Treating the bleeding is important b/c we cannot treat to prevent more strokes with blood thinner agents until the bleeding is stopped? Or go ahead and treat and then stop if we see it causes more bleeding.  There was a doctor’s visit set with her primary for 12/27 but she was in the hospital. Now, we will hope she can make the Dr. L. (OB/GYN) appointment on the 11^th of January.

UTI- this has been an on again off again diagnosis since the stroke (11/16/2012). Treating it with Levaquin (since 12/25, she was on CIPRO 12/20-12/25 from Palomar emergency) and get rid of it to see if the brain fog improves.

Probiotics – added a daily does on 12/16 at 5:45 PM ok per Dr. G. (Palomar) Had to stop this as they thought she was aspirating food, will continue ASAP.

Incontinent – is this a result of the stroke weakness or laziness? Either way; it will contribute to sores, disease and possible continued UTIs. I asked Skilled Nursing Facility to do something towards getting her off the diaper; they were supposed to ask her every two hours to go to the bathroom. I have no report on how that was progressing, other than the obvious that she is still in diapers.

Swallowing meds and vitamins – problems reported at SNF; we now find out that she could not swallow due to breathing problems and the gunk that was in her mouth; it was choking her.

Daily hygiene- dentures need to be cleaned, mom is not capable of doing it all herself. She arrived at the hospital with a major yeast infection in her mouth. Hospital treating with Niastatin swish and swallow.

Regular Meds- has she been restored to all daily meds? Thyroid – yes, Amalodapine- yes, Colase – yes, Ritalin? Meghase?  All have been restarted.

Yeast Infections - The nurses at Palomar found that mom has a severe yeast infection in the groin area. They are treating it with Niastatin powder, the same medicine they are using as a swish and swallow for the yeast in her mouth.

Is there an external test to see if she is reactive to penicillin?

Skilled Nursing Facility issues - Spoke to Ann at Skilled Nursing Facility 12/27/2012 and Gloria A., the head of Nursing today (01/02/2013) about these issues.  Gloria has been on vacation and not aware of any issues. I told her Ann was going to move mom to 109 but Gloria says it is not available now, so what is the new plan to prevent a reoccurrence of the poor attention mom was receiving?

Dental hygiene and no breathing treatment administered, she suffered another stroke that went un detected until we arrived on 12/25 at 10:00 AM

Gloria said she would investigate and get back to me.  I have little confidence that mom is getting adequate care at their facility. I spoke to Sadie 12/19 about my concerns and she told me that mom was getting her meds for sure. I have my doubts. These concerns must be addressed before she can be returned to the facility.

Skilled Nursing Facility 7:00 PM mom arrived at Skilled Nursing Facility  The orders came over for her to continue IV antibiotics but the nurse at Palomar did not read the orders and removed her IV. Joel at Skilled Nursing Facility called the IV team and got her a new IV and started her antibiotics at 9:00. He called just to let me know, that was very comforting.

·       In today’s meeting we want go over the plan to prevent the health risks that occurred that sent her to the hospital. Move her to station number one if not right now ASAP a bed is available.

·       We want to set up a meeting with the doctor to make a new health plan to prevent stroke even before we get the OBGYN appt.

·       Discuss the personal property that was stolen.

·       Get her nails trimmed and haircut and dandruff address on a weekly basis.

·       I don’t want to be the police. I want to come in a visit my mother daily but not have to monitor your staff.

·       In the event I cannot come daily or need to take a couple of days off, do you know of reputable agencies where I can hire people to check in and visit her?

Questions for Debbie:

Re: hospice and treating her pneumonia? And what impact does that have on the 100 days and after? And can we start and stop? And what does that do to Medicare benefits?