HJBR Sep/Oct 2025

CARING TOGETHER 20 SEP / OCT 2025 I  HEALTHCARE JOURNAL OF BATON ROUGE   CASE STUDY: “WHEN GOING HOME TAKES A TEAM” A woman recovering from a fall was nearing the end of her therapy benefit. Staff informed her she would be discharged home within days. Her son panicked. He called the ombudsman: “Her home has several steps to the door. There’s no ramp. I work and can’t take care of her. What happens when she gets there?” The ombudsman met with the resident. She was eager to return home, but agreed that a safe plan was necessary. With her permission, the ombudsman helped coordinate a care plan meeting that included the social worker, director of nursing, administrator, physical therapist, and the son. Together, they created a path forward: • A home health agency was secured for post-discharge care. • The physical therapist visited the home and suggested modifications to offer more safety for his mother. • The son hired his trusted handyman to make the essential modifications. • A ramp was built, and grab bars were added in the bathroom. • Friends organized a rotation for groceries and check-ins and to fill in when the home health aide was not there. • The facility approved a short delay in discharge. • She returned home — not rushed out, but supported and ready. LESSON LEARNED Safe discharge takes time and teamwork. Advo- cacy empowers families and providers to ask the right question: “What do we need to do to help the resident return home safely?” CASE STUDY: “MISDIAGNOSIS RESOLVED, DISCHARGE AVOIDED” In an assisted-living facility, a normally sweet, gentle woman began lashing out. She cursed at staff and was argumentative with her meal mates. The staff nor family could explain the change in behavior. The administrator issued a discharge notice, citing aggressive behavior and safety risk. The family contacted the ombudsman, who visited the resident and the family together and asked a simple question: “Had the resident had a recent medical checkup?” The answer was no. A physician visit was arranged. Diagnosis: Urinary tract infection. Treatment: Antibiotics. Within days, her kind demeanor returned — and the discharge was rescinded. LESSON LEARNED Behavior is communication. Before discharging a resident for behavioral changes, facilities must investigate medical causes. UTIs, dehydration, pain, or medication can mimic confusion or aggression. Addressing the root cause can prevent unnecessary transfers and help residents remain in the setting they call home — with dignity and appropriate care. CASE STUDY: “ONE WOMAN’S PUSH FOR MOBILITY PAYS OFF” An 85-year-old nursing home resident had been making great progress in therapy — until insurance benefits ended. Staff told her therapy services would stop. She felt dis- couraged. “But I’m not done,” she said. “I want to walk again.” The resident called her ombudsman, who explained her rights under the federal Nurs- ing Home ReformAct (OBRA ’87): Residents are entitled to restorative care, even after Medicare-funded therapy ends, if it supports their highest practicable physical, mental, and psychosocial well-being. With her permission, the ombudsman raised the concern with facility management. A restorative therapy plan was approved. Three weeks later, she walked to the dining room with a walker, confident, proud, and cheered on by staff. LESSON LEARNED Payment may stop, but a resident’s right to progress doesn’t. Restorative services must reflect the individual’s goals, not just their insurance status.