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After a stay at a hospital, many people need to be admitted to a skilled nursing facility for additional help in recovering from an injury or illness.  A move to a skilled nursing home is a sign that a patient’s health condition is stable or improving and that it is no longer necessary to see a doctor on a daily basis. 

Physician and Nursing Care
Once you arrive at the nursing home, a physician will usually see you within 72 hours.  At a minimum, you will be visited by a physician once a month for the first three months, although doctor visits may be more frequent, depending on your condition. If your health is stable, you will still be visited by a doctor at least once a month, or you may be evaluated by a physician assistant or nurse practitioner.  These medical professionals are in direct contact with your doctor 24 hours a day to provide updates on your condition.  Licensed nursing staff will be onsite and available at all times.

Developing Your Plan of Care
Shortly after your admission, you will be asked to participate in a care conference.  This will allow you to have input in developing your personal plan of care. Your family or responsible party is encouraged to participate.

During the care conference, an interdisciplinary team of professionals will review your medication, dietary, social services and therapy needs. 

This is also your opportunity to discuss your wishes and your choices for medical intervention, and be fully informed of your plan of care.  You may discuss your choices for sustaining life treatment, such as a Do Not Resuscitate (DNR) order, transfers to the hospital for aggressive care, and other specifics such as whether or not you have an advance directives in place to document your care wishes and decision-makers should you become unable to express those yourself. Additional care planning conferences will take place quarterly or more frequently if needed.

Responding to Changes in Condition
Recovery from serious illness often means a combination of days where there is progress mixed with days of decline. Both patient and family members need to have a clear understanding of what will happen if a patient experiences a worsening of their condition. Certain conditions, like a low-grade fever or digestive issue can be managed at the facility, with a follow-up by a physician as needed within 24 hours.  Patients with abrupt, unexpected declines or life-threatening issues will be transported to the hospital emergency room.

Families will be notified of any change in a patient's condition.  Since each individual is unique, it is also very helpful for the family to notify staff of any changes in mood, appetite and interests in order to prevent a decline in health. Ideally, nursing homes want to prevent patient returns to the hospital, because the stress can actually result in a more rapid decline in frail patients. 

Nursing Home Routines
Each nursing home has its own distinct routine but typically, showers are offered two days a week.  If you would like to shower more frequently, feel free to discuss it with the nursing home staff. Meals are also offered at set times, but the staff will try to accommodate your unique routine as much as they can. You have a choice on whether you want to take a meal in the dining room or have a tray delivered to your room.

Depending on your condition, medication and treatments will be delivered to you by the nurse as ordered by the doctor at various times during the day.

There will be an activity calendar posted and there may be a personal copy for you to review to decide if you want to participate in any of the facility activities.  Activity professionals will ask you about your interests and hobbies and offer you reasonable opportunities to engage in those if your health allows.

Generally, you will share a room and a bathroom with one or more people. If there are concerns with a roommate please feel free to discuss them with the administrator.

Hospital Transfers and Discharges
If there is a change in your medical condition and you are transferred to a hospital, the nursing home is required to hold your bed for at least seven days, allowing you to return back to your room.  If your hospital stay is longer than seven days, and the seven-day bed hold has lapsed, you will be admitted back to the first available bed in the facility.

Discharge Planning
Discharge planning may begin as soon as you are admitted. The nursing home staff may visit your residence to see what if any assistive devices you may need including a shower chair, or grab bars in the bathroom. Some residents are prescribed home health visits for a period of time following their release from the nursing home. Your length of stay in the skilled nursing setting depends on your skilled health need, plan of care, and other variables that the staff will discuss with you. You will be given a 30-day written notice before you are discharged and notified of your right to appeal. Appropriate reasons for discharge include:

  • The facility cannot provide adequate care

  • The resident has improved and no longer needs skilled nursing care

  • The resident is a danger to themselves or others

  • The resident has failed to pay for their care.

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