Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Martha Kern


We found Bob on the floor of his apartment, unable to get up or call for help.

His home was infested with mice, so the floor was a most unpleasant place to be.

We called 911, of course, so Bob would be brought back to the hospital… from which he had been discharged twice in the preceding 30 days.

A hospital and four community-based service providers had been key players in Bob’s drama, but Bob wound up helpless on a floor sprinkled with rodent droppings nonetheless.

What Went Wrong?
Bob was a quiet, cooperative man who had worked hard all his life.  A widower with no children, Bob was estranged from his only sibling and entirely alone in the world.

As Bob’s age advanced, so did his medical problems and physical limitations.  He lived in a three-flat in Chicago that he owned and which was otherwise unoccupied.  He got along well enough until this year, when two falls and an accumulation of diagnoses had gotten the best of him.

When we met Bob, his medical adventures were already well underway.  In the preceding month, Bob had endured the following calamitous lapses in follow through:

  • After having been admitted and treated for congestive heart failure, cellulitis, aortic stenosis, psoriasis, and a self-care deficit (living alone), Bob was discharged back to his home with an order for home health services;
  • The home health company completed an assessment and determined a need for continuing services. However, because Bob did not have a regular primary care doctor who could order ongoing home health services, the home health provider did not offer services and did not return.
  • Bob was also referred for hospice services. The hospice company sent a representative to assess Bob’s status, discovered that his apartment was also home to several mice, and declined to offer services on the basis of an unfit environment.

Somewhere along the way, Bob had the great good fortune of receiving attention from a community case worker.  The case worker recognized Bob’s self-care deficit and the failure of the other service providers to take action to remedy the situation and improve Bob’s chances to succeed at home.

The case worker, however, could not offer help because Bob’s financial resources, though not significant, were above the threshold for publically-funded care.

Instead of just abandoning Bob, the case worker called us and asked that we intervene.

Closing the Gaps in Care
After attending to an empty refrigerator and other basic care needs, we located a home-visiting physician to examine Bob and write an order for the ongoing home health services Bob had needed since discharging from the hospital.  Also procured for Bob was an emergency pendant so he could summon help more readily.  Bob refused placement and/or a caregiver at this point, insisting he could manage with just the minimal services already arranged.

Bob used the emergency pendant immediately.  He fell during the night and was once again transported to the hospital where he was admitted and treated for a wide array of medical issues.  Despite his obvious inability to care for himself or succeed at home, he was discharged back to that very environment, alone.

Bob became more receptive to a caregiver at this point, but he limited the service to just four hours per day.  About a week after his second discharge, we found him alone, on the floor, unable to even use the button on his emergency pendant. He returned to the hospital yet again, this time found to have C-Diff (an infection often contracted in hospitals) and a urinary tract infection, in addition to pneumonia, a hip fracture, and aspiration of fluids and foods.

Doctor’s Orders
It was at this point that the doctor recommended petitioning for guardianship.  He was more than willing to complete the physician’s report necessary for this process, given Bob’s growing confusion and inability to make sound decisions concerning his own care.  When Bob discharged from the hospital this third time, he went to a skilled nursing environment where his medical needs could be properly managed.  Lifecare Guardianship was named temporary guardian of person and estate.

Bob is, at last, receiving appropriate care in a suitable environment.  It’s far less likely that he will be re-admitted to the hospital now that he is properly supported outside the hospital.  Community support is essential to success at home and, in Bob’s case, there were myriad failures and snafus in the chain of care that led to three hospitalizations and his lonely night on the floor.

Hospital readmissions are usually considered in the context of percentages and the fines hospitals pay when they fail.  We don’t always think about the people caught up in the post-acute disconnections, the denied and discontinued services, the failure to solve the fundamental problems fueling the situation.

Living alone is a key risk factor for hospital readmission, and also for finding oneself on the floor with no means of calling for help.  When there is no family, professional eyes, ears and knowledge are necessary to manage these risks and support the frail disabled in the community.

© Lifecare Innovations