Case Study: The Enclave at Rye Rehabilitation and Nursing Center (February 2017)

Patients Age: 80
Admission Date: 12/9/16
Admitted From: Skilled Nursing Facility
Discharge Date: 2/23/17
Discharged To: Home
Length of Stay: 2 ½ months
Reason for Stay: Recuperate from Thrombectomy
How did this patient hear about the Enclave? Referred by Skilled Nursing Facility

Details of Experience:

Mrs. Jeannette Pfeiffer arrived to The Enclave at Rye Rehabilitation and Nursing Center on December 9, 2016 from a nearby skilled nursing facility where she had spent three weeks rehabilitating following a thrombectomy. The extensive pain and wound care management severely limited her mobility and functionality and culminated in her being non-ambulatory upon admission to The Enclave. She required an extensive assist of two people for bed mobility and transfers and an extensive assist of one for all other activities of daily living (ADLs.) Her weakened state and the prospect of a lengthy period of therapy was a concern that contributed to her prognosis.

Upon admission, Mrs. Pfeiffer was greeted by multiple professionals that comprised The Enclave team, including physicians, clinicians, concierge, and administrative staff. Her nurse, Liby, actively began managing her wound care, which included a stage 3 pressure ulcer in addition to her surgical wound. Collette, the occupational therapist, began working to improve her muscle tone and strength. Two weeks after admission, Jeannette graduated to extensive assist of one for transfers and increased mobility in therapy. On the unit, however, she complained of significant pain, which kept her up at night and prevented her from participating fully in daily activities. While she was gaining strength as her ADL’s improved, the pain prevented her from becoming more mobile and she was referred to the community physiatrist.

The physiatrist diagnosed Jeannette with nerve damage to her lower left extremity and placed her on a special pain management plan. The communication between the nurses and therapists allowed the team to maximize the time Jeannette was spending in therapy and by early February, Jeannette began ambulating on the unit with minimal assist. By this time, her stage 3 pressure ulcer also fully healed. The quick progress that was made in such a short time, encouraged discharge discussions and Cassandra, the social worker, began the discharge planning.

Riding this wave of momentum and intent on getting Jeannette as independent as possible, the team referred Jeannette to an orthopedist who recommended an AFO to hold up her foot. Shortly thereafter, Jeannette began to walk with a rollator on the unit. On February 23, Jeannette was discharged home, much sooner than she had anticipated when she first entered our community. She is now fully capable of performing all ADLs independently, and she is ambulating with a rollator under supervision and can perform transfers under light supervision. Due to the pain management care planning, the pain has largely subsidized, and she will be following up with her community doctor to prevent relapse. Cassandra had also referred Jeanette for continued skilled nursing and therapy at home. Both she and her family were grateful for the warm, embracing staff whose only goal was to get Jeannette back home and independent as quickly as possible! Congratulations on the exceptional progress made, Jeanette!