Patient’s Age: 87-years-old
Admission Date: 01/13/21
Admitted from: Good Samaritan Hospital
Discharged to: Home with home care services
Length of stay: 47 days
Reason for Stay: Altered Mental Status, COPD exacerbation. History of COVID-19 diagnosis. Two Falls in the community resulting in no injury. Decrease in strength, functional mobility, and transfers. Reduced ability to safely ambulate, reduced functional activity tolerance and reduced static and dynamic balance.
How did the patient hear about St. James? CMS rating in hospital

Details of Experience:
Mrs. Theresa F. is an 87-year-old, previously living in Deer Park, New York. Theresa lives alone in her private residence. She is supported by her family in the community and maintains frequent contact. Theresa was hospitalized at Good Samaritan Hospital after two falls in the community, recognized altered mental status, and presented with the COVID-19 virus. During her hospital stay, Theresa and her family were given a list of local nursing facilities and the choice to stay at St. James Rehabilitation and Healthcare Center was determined by its CMS rating.

Theresa was admitted to the St. James Community on January 13, 2020. Within an hour of arrival, she was evaluated by the unit nurse. Within the next 24 hours, she met the entire interdisciplinary staff, including Physical and Occupational Therapists, Social Work and Case Management Departments, Integrative Therapy and Therapeutic Recreation teams. Each department worked efficiently to develop an individualized care plan to meet Theresa’s specific needs. The Physical and Occupational Therapy teams initial evaluation determined that Theresa’s family’s goals were for her to increase bilateral strength in her legs to improve mobility, balance, ambulation, transfers, and safely ambulate distances with the use of a rolling walker, improve the ability to manage activities of daily living such as hygiene, grooming, toileting, dressing and bed mobility tasks. Theresa’s family’s focus is for Theresa to work hard with the rehab team, so she could return home and get back to being Mom and Grandma to her family.

Theresa’s work with the rehab team showed continued improvement throughout her time at St. James. Her Physical Therapist, Linda, was impressed by her determination and willingness to participate. She made steady progress with Physical Therapy, as she improved her strength in both legs, graduating to modified independence with functional transfers, increasing ambulation to over 250 feet with the use of a rolling walker and improved balance, so that she could maintain standing without constant support; most important, her work with Physical Therapy determined that she was at much lower risk of future falls, giving her family confidence that her care could be more easily managed at home. Theresa’s Occupational Therapist, Haley, was confident that her patient would do well in treatments with the right encouragement. She focused on Theresa’s ability to retain tasks and guided her through her treatments. Haley’s focus was to help Theresa develop and maintain proficiency during her stay. Theresa’s progress is promising, and her family is working closely with case management and therapy teams to craft a safe discharge plan for her. Theresa has been pleased with the quality of the care the rehab team provided, sharing that the rehab staff was very nice and helpful.

Through the duration of her stay at St. James, Theresa has been actively supported by the Therapeutic Recreation and Social Work Departments. She utilized both departments often when meeting with her family visits and video/phone calls. She is always happy that she could maintain her connection to home and her family through these visits. She participated in coffee and snack hour most days and connected with the therapeutic staff. Theresa frequently connects with her sons and daughters via FaceTime calls and phone calls. Theresa’s family has developed a good working relationship with the social work department, as they aid Theresa and her family through her adjustment to the facility and rehabilitation. Theresa’s family often calls the office to connect with their mother, and the social workers are happy to oblige. She made friends with several people in her unit and cultivated those relationships. Theresa has participated in the “on-unit” bingo games and likes to watch TV, relax and recover. Although Theresa does not have a discharge date as of now, the team all believes in the strides she has made and looks forward to helping her along her way back home.

The team wishes Theresa well as she continues on her healing journey.