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Hello all,


I have written here before about my 86 yo FIL. He was in an ALF for about 6 months, then caught Covid at that facility. He went to the hospital, where he recovered with no real issues (!!!). He has been diagnosed with dementia and has been bipolar for a long time. He now seems as though his meds for the latter are doing okay.


The problem is that he had some issues when at the ALF. These included angry outbursts, and possibly some threats to the staff (we are not 100% sure what exactly).


After he left the hospital, he was sent to a rehab facility. His original ALF will not accept him back, and the family is really struggling to find any place that will accept him. It certainly appears as though he is being blackballed in some way.


They are working with the ombudsman (this is NC) who has tried to help, but so far it has been a couple of weeks, and he has no where to go. I should add that he is a Medicaid patient.


I read a few other threads here that sounded similar, but I was wondering what else the family can do. Is it really possible that these places can all simply refuse him, even if he had some anger issues? I do not believe he has actually harmed anyone, nor do I think he would. He is angry, but this seems to be common for people in his position.


Any thought or advice about what his family might be able to do would be welcomed.

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This is becoming a huge problem everywhere. I have spoken to his insurance rep as well as local ombudsman as well. These facilities - regardless of what they advertise - are not capable nor do they have staff trained to professionally deal with folks with mental health issues. I know because my brother has been diagnosed with bipolar and he was brain-damaged in the local hospital 2 years ago when they had him on a ventilator for nearly 10 days. It destroyed his short-term memory. So when he asks for something and the staff don't respond, he gets angry (so would I). Now the staff record in the records that he 'refuses service' or has 'anger issues'. When in reality, they are likely more at fault. One day he asked a fellow patient to try his wheel chair. The other patient got up and then tripped and broke his arm. The facility blamed my brother but he had no idea that was inappropriate or that it was dangerous. Often the staff, mostly female, react emotionally, like little babies, instead of professional nurses or CNAs as they should. It's really frustrating!

Not sure about NC, but in California, when a person is taken to the hospital, the law requires the LTC facility to take him back. At first they refused to take my brother back from the hospital so I called the local Department of Health. The next day, the facility administration received 5 phone calls and he was taken back that same day. But now the staff at the facility seem to be giving him a hard time. Since I am not allowed in, it's hard to be sure. But the staff are also being rude and giving me a bad time as well.

The process of going from a hospital to rehab and back to a LTC facility may be a little different but California has a law that a person CANNOT be released from a rehab, hospital, or LTC facility unless they have a safe place to go and one that the patient and the family approve of. Do not let them release your loved one until a safe place is found. Good luck!
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The head nurse in a facility must evaluate him. Prior to her coming ...talk to Dr. and he will give enough Ativan to take the edge off and the nurse will approve. His anger will never leave his mind. With the med. he can be treatable in the facility.
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Why can't the family tell whomever (hospital, rehab) that they cannot take care of him at home and that they will need to find a place for him.  Also, why hasn't these places tried some meds for calming him down.  Surely they have dealt with this stuff before, but then again, depending on how large the facility they may just not have the means to do so.  I wish your "friend" luck.
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Imho, he requires a higher level of care than an Assisted Living can provide. Prayers sent.
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Assisted-living facilities are intended for seniors in relatively good health who just need some "assistance" with their daily activities - not persons with Dementia and Bipolar disease. Clearly, your FIL is no longer a candidate for that type of facility; it sound like he would do better in a memory-care facility. Also, very few AL facilities accepted Medicaid - but most nursing homes do.

I am a former Psychiatric nurse. One never knows what a person in the manic state of Bipolar Disorder might do - especially combined with Dementia - what we used to refer to as a "Gero-Psych" client. Is he not controlled on his meds? All facilities need to protect the health and well-being of their residents. If any resident might present a danger to the others then, yes, they can refuse to admit him.
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Whatever you do, DO NOT, REPEAT, DO N O T ALLOW HIM TO BE RELEASED AND COME HOME WITH YOU. I believe the medical people have to find a place to put someone like this - I do not know where but I think it is on their shoulders to solve this. Again, do NOT allow him to come home but keep researching with professionals what happens in cases like this.
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Diagnosed with dementia he would be better in Memory Care rather than Assisted Living.
Medications to reduce anxiety as well as a smaller environment for him might be what he needs to better cope.
He may not have harmed anyone previously but you never know what someone with dementia might do.
An assessment by a neuropsychologist indicating that he is taking antianxiety medication might help a facility accept him.
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His Dr. can get him a mild anxiety drug that takes the "edge off".
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As a former Director of Admissions in LTC and a current Cert. Assisted Living Administrator I can attest to the fact that an AL that accepts Medicaid is a rarity in any state. Also, Assisted Livings were originally started to offer fairly healthy senior with an "assist" in the activities of daily living. They are designed to be visually appealing and provide activities; they are not designed to provide skilled nursing services and are not staffed (either numerically or educationally) to provide more. In NJ ALs are not even required to have a licensed nurse on site 24/7, although some do - they only need to have access to a nurse. If staff or feels threatened by FIL's tirades or if other residents are upset or frightened by his talk or actions yes they will suggest (strongly) that you move him as " we can no longer meet his medical and physical needs and requirements"/ When you think about it and put yourself in the other family's shoes, you can certainly understand the situation from their viewpoint. And no other AL is going to be able to meet those needs either. Some ALs maintain a full time social worker so get them on board right to find him a suitable placement that can meet his current needs. At this point is sounds like he is definitely a candidate for a secure MC unit in a long term care (LTC) facility. They may have more staff and they are sometimes trained in anger issues.
Just so you know, even LTCs (aka Nursing Homes) have a right to refuse a resident if they can not meet that resident's needs/ requirements. And a new facility that does accept him may not be close to you or what you would normally chose for him but at this point you don't have a lot of options (might be the reason you have not heard a lot from the Ombudsman at this point). FIL definitely sounds like he needs an eval by a geriatric psychologist and a careful (possibly ongoing) adjustment of meds. This might lead to a stay in a psychiatric unit so they can carefully monitor the meds.

I wish you and your family peace and good luck in this difficult journey.
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In Orange County, CA. I had a VERY Difficult time finding any place that accepted Medicaid for my sister. Demand for eldercare is so great, it is almost RARE that a facility accepts Medicaid, when they can get a great deal more money otherwise. Reality!
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My step-dad has a mixed dementia, possible vascular, with psychosis. He has been in memory care for the past year, barely.
He is angry, aggressive physically and verbally. I’ve had meetings at the facility three or four times over the last 12 months where they were on the brink of discharging him, and were recommending he go to locked skilled nursing. We were not able to find a locked skilled nursing for him in our area and all involved agree that isn’t the best solution as he is physically healthy and agile. It’s just that he is a harm to himself and others when he goes into a rage. He also refuses to take his meds regularly. The place he is at is licensed as an AFC home and they can not force him to take meds or give him something in a pinch when he starts winding up for a blow-up.
He spent 10 weeks in two different psychiatric hospitals over the last six months. The main objective is to get his meds right so he will calm down. He is now getting a monthly injection of invega sustena that helps some but not the best. ECT electroshock treatment has been recommended also.
His dementia has not affected his memory much yet. What has been destroyed is his reasoning, executive functions, impulse control, and knowing the difference between what is real or imaginary.
There isn’t an “answer” for us but we are thinking outside the box and it has helped for the moment. A maintenance worker at the facility has “hired” my step-dad to help him out. This gives him some purpose and feeling of accomplishment. Also-we are very fortunate that my mom worked for the county prosecutors office until her death last year. She was well liked by all and local police stop in to visit step-dad regularly with coffee or sandwich and have a chat with him.
I, too, would recommend not accepting a discharge from rehab unless another facility is lined up to take him. There is no good place with long term care for our elderly dementia patients with consistent anger issues.
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Leave him at the Hospital or Rehab and tell them that he has no place to go and that you are not able to safely let him reside at your home.
They will have to find a place for him but if you take him home, they don't have to worry about it.
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Violence or threats of violence is a huge concern for residential facilities. That threat puts staff and other residents at risk. Make sure that your FIL is evaluated not only for Bi-polar disorder and dementia but also for anxiety. If he has anti-anxiety medication to keep him calm as well as medication for the bi-polar disorder, you may be more successful in finding him placement. Think about finding him placement for his mental health problems primarily that can also deal with dementia. He probably will need to go to a memory care unit and not an ALF.
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Go visit nursing homes yourself that have a dementia unit. They are more equipped to care for people with dementia. Talk to the admissoons person and the director of nursing if you can. Psychotropic meds are a fact of life with Alzheimers. They will understand. Tell them you're trying to find a good fit for your fil and see what they say.
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The short answer is that yes they can and will refuse to admit someone who has anger issues, is physically combative, and/or is mentally ill. The places that will accept him are likely to be places that you probably wouldn’t want him to go. Unfortunately that may be your only choice.
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If he has been violent and attacked staff, the facility has a right to refuse him. Aggression is a liability issue and families can sue big time if the facility takes him back and he attacks another nursing home resident. In many cases they end up in a hospital psychiatric floor and remain there for a long, long time as a difficult placement.
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I would strongly suggest an appointment be made for him with a geriatric behavioral specialist. Assisted living facilities have to keep their staff and other residents safe. With dementia, and especially is he is bi-polar, his mood swings can vary and easily go from one extreme to the next. I've seen this happen a lot in assisted living. It's not the resident's fault-their dementia/bipolar diseases sometimes trigger aggressive behaviors that are not the norm. The behavior specialist can look at his medications, prescribe new ones or make adjustments in the ones he currently takes to ensure his mental well-being and control these behaviors. They are not "drugged up" but their demeanor is much more calm. They are happier, you have peace, and everyone is safe and life is enjoyable for him and the family.
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I am a disabled Veteran who has had very good care from the VA and I have a friend whose husband is in a LTC facility paid for by the VA and he gets excellent care. The VA has had a bad reputation over the years but many medical centers and facilities are quite good. Worth investigating that option for sure.
I had a toxic father with a lifetime of personality disorders that got worse as he aged. From the time I got both parents into a beautiful ALF, I worried that he would get himself evicted. When people first met him, he was always on his best behavior, then after a while his true self would emerge. When on his second stint in rehab after a hospitalization, they diagnosed him with MDD and anger issues, but not dementia. The staff was amazingly patient with him, though he was stubborn, verbally abusive, and non-compliant. Towards the end, they even brought in Hospice rather than transfer him to a nursing home.
Make sure rehab or whoever are held responsible for placement. With mental illness issues, he may even be held in inpatient geriatric psychiatric hold for evaluation. Look into Baker Act laws in your state. Anything is better than an "unsafe discharge." Do not let them talk you into taking him home. That is not an option and not safe for anyone. Best of luck.
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Heartaches7849 Jan 2021
My husband has dementia and Parkinson’s , I ask the VA about a nursing home or facility in case I would need one. I’m trying so hard to keep him at home with me . But he’s weak and heavy for me to hold up. They told me they don’t pay for cate centers . I’m in Texas . Florida has so much more help for our veterans than Tx .
He’s slid down my legs a few times now then had to lay on pillows until help came to pick him up. My shoulders and back are ruined . I’ve had a lot of neck and back surgery I fell with him one day at the VA and it messed up
all of my neck surgery so I’m never out of pain. I really thought the VA had facilities. I need to go to another state to gather papers I need for court regarding his house he’s let his dead beat sister live in free. It needs to be sold and she’s fighting me doing it. I thought the VA could take him a week or so.
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We are coming to the realization that his combination of bipolar and dementia is something that these facilities do not want to deal with. I would have guessed that there were enough people in that position, including his age, mental status, health issues, and Medicaid status, that *some place* would take him.

The next option the family will be examining is the NC VA, as he is a veteran. The issue there is that the family has reservations about the hospital there (not exactly sure why... prior experience?).

Thanks again to all for your help.. I am just trying to support DW in this..
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Juliasmygma Jan 2021
My advice would be to build a relationship with FIL's Primary Care team. That's what got my gma in and semi-settled in her ALF. I talked to the primary care team 2-3x a day that first week advocating for rescue aggression meds for my gram. We ended up getting past that first week by getting crush rescue meds prescribed and slipping them in her guilty pleasure (ice cream) 3x a day until the home-health team (through primary care) came and re-evaluated and made medication changes for the long term. Also, I would suggest having a candid discussion on any homes your DW is talking to. Let them know the stuff that happened in the past, the things your DW are doing to make sure they won't happen again (med changes, better relationship w/ primary care team, etc). Also, it's very nice that you are on board with helping your DW during this time period. I had to do all the above by myself and it was very hard. I'm glad that your DW has a good support system.

Good luck, it was a 9 month process for me to get to the point of finding and getting my gma in a ALF and she's been there for 2 months and has another upcoming home-health appointment to get another med change. I think that's the reason why she hasn't been asked to leave since I have been jumping through hoop after hoop to keep her settled. (It's my worst nightmare - for her to be asked to leave.)
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Thanks, that all matches what we are experiencing. It is extra frustrating to have gone thru at least 3 attempts to place him without knowing exactly what behavioral issues must be causing the original ALF to blackball him.
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Agree with all you say... DW now realizes all of this, and needs her siblings to get to the same place.

I did not say that his wife of almost 70 years still lives alone, but has her own mental and memory issues... it has been heartbreaking for them to be apart, and of course this has pretty much all happened exactly in the Covid lockdown timeframe.

The hope was to find a place for them to be together, but it seems increasingly unlikely.
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Where is FIL currently? Still in rehab? Unless rehab is planning to keep him long term (nope) they WILL find a way to get him moved.

Has rehab applied pressure for family to take him in 'just until this is worked out'?

Is he still legally responsible for himself?
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cherokeegrrl54 Jan 2021
Nope, dont do it! Let them (facility) find a place for him. Do not accept him back home under any circumstances. Especially if they say “ oh we can work it out, we will get you plenty of help”. Thats baloney and they are not doing their job.
Sounds like at this point, he needs memory care not ALF....
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I also think that his issues put him beyond AL and now, a Skilled Nursing Facility or NH with a Memory Care unit is where he needs to go.
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All ALFs take people at THEIR discretion and can turn down anyone they feel would not be suitable for their community. It sounds like your FIL would be better suited to either a Memory Care AL or a Skilled Nursing Facility, since I'm not sure there are many Memory Cares that take Medicaid. Again, you are at their mercy as far as who they will accept or turn down. Dementia residents are not best suited for AL because they require locked exterior doors where they can't get out and wander, like they can do in AL. That's another reason AL is not the best choice for a person with dementia: it's not safe.

ALs in general are looking for residents who have the least issues and who will present the least amount of care problems and/or behavioral issues so ALL the residents will be happy and content living there.

SNFs, on the other hand, are less picky about who they take and have a tendency to accept a wider variety of people with behavioral issues.

Good luck!
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