Mary-Carol Feeney's Medicare coverage was running out, and in mid-February, her nursing home in Montgomery County told her she would have to leave. She still had a pressure sore on her tailbone and was recovering from multiple illnesses - including congestive heart failure - that had bounced her between hospitals and nursing homes for three months.
Though residents have rights, including one to appeal Medicare's denial, Feeney didn't know that.
She was discharged to her daughter Jolene's one-bedroom apartment in Fox Chase. She lasted there only a week before being rushed by ambulance back to a hospital with fluid retention in her lungs. She never made it back home; she died in another nursing facility in late June at 65.
"To me, you don't send a sick person home who shouldn't be home and can't do anything for themselves," said Jolene Feeney, 35. "It's crazy, and I'm stuck picking up the pieces."
Advocates for nursing-home patients say Feeney's case illustrates a growing problem that is poorly understood.
Medicare - public insurance for the elderly and disabled - covers most of the costs of skilled nursing for up to 100 days after a hospital stay. But many patients do not realize that, when Medicare coverage stops, they have other options - because, advocates say, the facilities fail to inform them.
"What they say is, 'Medicare has stopped paying, so you're going home tomorrow,' " said Mark Davis, long-term care ombudsman at the Center for Advocacy for the Rights and Interests of the Elderly (CARIE) in Philadelphia.
Patients have the right to appeal termination of coverage, and they also have the option of paying out of pocket or applying for Medicaid, which reimburses facilities at a fraction of their rates.
Davis said his agency had received eight complaints, including the Feeney case, over the last 18 months. He and colleagues believe that's a small fraction of the total, because many residents accept being discharged without knowing their rights.
The problem for homes is that Medicaid pays far less than Medicare or private payers.
A 2011 report posted by the Pennsylvania Health Care Association, an industry trade group, found that homes lost $9,500 a year for each Medicaid patient. Medicare, by contrast, paid 21/2 times more for the typical patient than Medicaid, giving homes a double-digit profit margin on that care, the report found.
In the last three years, 11 homes in Southeastern Pennsylvania have been cited for failing to give residents proper discharge information, federal records show.
Pennsylvania has fewer complaints than many states. In 2011, the most recent data available, one in every 1,000 residents complained about discharge planning in Pennsylvania, compared with 6.5 per 1,000 nationwide.
In New Jersey, the rate was seven per 1,000, according to ombudsmen who monitor complaints.
"These are kind of the bread-and-butter issues that ombudsmen deal with," said Laurie Brewer, chief of staff at the New Jersey Office of the Ombudsman for the Institutionalized Elderly. She said that some homes had a history of improper discharges, but that most complaints were caused by a lack of knowledge among residents and their relatives.
Other ombudsmen also report receiving complaints regularly. "We get at least two a week that we know of," said Kathy Forrest, long-term care ombudsman for Bucks County. "Two is the tip of the iceberg. People are simply not informed of their rights."
Those who do complain, advocates say, generally win. Cynthia Garrison, 60, was admitted to the Watermark at Logan Square nursing home last September after being hospitalized with pain in her hip. Medicare paid most of her way for the first 100 days, but after her time ran out, she said, the home's social worker told her she'd have to leave in three days.
"I didn't see the point and why should I have to go somewhere else? They never gave me a clear answer on that," Garrison said by phone from her bed at the Watermark.
She called CARIE's Davis, and, within days, he had spoken with a social worker and the home's executive director to secure Garrison a long-term bed through Medicaid.
"If I or a family member speak up, the facilities back off, because they know it's an easy case to resolve," Davis said. "It's so black-and-white, they can't argue about it."
Like other homes, Watermark said its executives could not discuss individual cases, but that their discharge planning was thorough.
"We do our best to provide as much notice about a specific discharge date as possible," said Jennifer Tapner, Watermark executive director. "The best advice I have for patients facing a short- or long-term care stay in the Philadelphia area is to do your homework and plan ahead. Don't wait for a health crisis to become informed about your options."
Mary-Carol Feeney was discharged on a rainy February morning from the Hopkins Center in Wyncote. Her dirty clothes and a bag of medications were tucked beside her in the wheelchair, her daughter said.
Hopkins did not inform Feeney and her daughter of their right to apply for Medicaid or to appeal Medicare's denial of coverage, according to a complaint filed with the state by Community Legal Services.
But the home did send a notice of those rights to Jolene Feeney's out-of-town sister, the state Health Department found.
"My sister didn't even know where my mom was," Jolene Feeney said. "They just told me the date that she would be home."
The agency also found no wrongdoing on the home's part, and that's typical. "Traditionally, when these types of concerns have been brought to our attention, we have not been able to identify deficiencies," said Susan Williamson, director of the Health Department's division of nursing care facilities.
Feeney's daughter took her in and did the best she could, buying and setting up a hospital bed in the small living room.
"I'm thinking, 'I don't know when was the last time she had medication.' I knew that she had a bed sore, but I had no knowledge of how to take care of that," Jolene Feeney said. "They literally sent this woman home. That's it, like she just came home from the food store."
Genesis HealthCare, the for-profit firm that owns the Hopkins Center, said federal rules prevented it from discussing individual cases. "When a Hopkins patient is determined to no longer qualify for skilled nursing services, he or she is given proper notice as required by state regulations," the firm's statement said.