What I've posted is based on many years working as a nurse, mainly doing geriatric care. Also, I've heard things from others who are nurses or home attendants.

I spent some time working gero-psych in a psychiatric hospital. Some folk who are unable to care for themselves are unwilling to accept any help. They won't even let home attendants enter where they live. If their situation is dire enough, they can be forcibly admitted to a gero-psych unit. A doctor can decide that initially. If the patient protests, a court hearing is held in the hospital within a few days to a week or so. Every inpatient psych facility has a room that can be used as a court room. A judge shows up and listens to testimony from staff and also from the patient (and possibly family/friends.) The nurse's main responsibility is to observe and document how much help the patient needs to bathe, dress, eat, use the bathroom, etc. Also: is the patient aware of danger . . . confused, seeing or hearing things that aren't there . . . belligerant, assaultive toward staff . . . and anything else that could be relevant. No doctor can order someone into a nursing home or confine them in the psych hospital for long. Only a judge can do that. Taking away someone's freedom and self-determination is not a medical decision. It's a decision for a judge to make, after considering the opinions of doctors and others and of the patient.

I knew someone who was in a nursing home, short-term, to get physical therapy. Acting on behalf of the family, I wanted him admitted longterm to the nursing home on Medicaid because he could not cope at home alone, mainly due to dementia, but also due to physical impairment. Toward the end of the rehab, the hospital was saying they could discharge him home and he'ld be fine. The physical therapist assessed him as competent to go home alone. The social service staff said he'ld be okay on his own. So I talked to the nurses. They totally agreed with me. I had to strongly push the issue, but I got him admitted longterm with a pending application for Medicaid, which was awarded to him.

Professionals sometimes have wrong opinions. A psychiatrist told me that the gentleman I just described was pretty competent, mentally. I told her to go ask him where he lived because I knew he wouldn't be able to tell her. She did ask him and was surprised that he didn't know his own address. So you cannot depend even on experts to reach appropriate conclusions. It really takes a caring advocate to get the elder into the care setting that will be best for him or her.

You must always ask yourself, "What incentivization is driving the decisions of the people involved?" M O N E Y has a lot to do with it. The nursing home didn't want to admit someone who might not get approved for Medicaid. If my friend were denied that, then the nursing home wouldn't get paid for the time he spent there after the rehab was finished. (Medicare pays for that.) So the administration weren't eager to admit him to a longterm bed. Some staff are very attuned to what the administrators want and they push things in the direction that earns them brownie points from administration.

My friend would probably have been found dead in his apartment, were it not for me advocating for him. My point is not to get a pat on the back for what I did, but to illustrate how tough it can be to steer things toward an appropriate outcome. Were it not for my experience in nursing, I probably would have felt helpless to influence what would happen.

My friend lived in a HUD-subsidized apartment complex for seniors. A number of his fellow tenants were discovered dead in their apartments over the years that he lived there. I'm not sure who to blame, but it seems we could come up with a better way to monitor isolated elders.