OTR Acute Care: Discharge Planning After Hip Fracture With Delirium

Do not discharge Ms. R home alone tomorrow. Recommend continued institutional rehabilitation, such as a skilled nursing facility or inpatient rehab if she meets criteria, until cognition, ADL safety, and caregiver plans improve. The evidence is functional and environmental: she needs moderate assistance for lower-body dressing, cannot safely complete a toilet transfer, forgets hip precautions, and is impulsive. She also has fluctuating confusion, poor sleep, and oxycodone use, which raise concern for delirium and reduce her ability to compensate. Her home has stairs and an upstairs bathroom, and there is no overnight caregiver. Patient insistence does not override foreseeable risk. Immediate next steps include delirium workup and medication review with the physician, a home safety evaluation before any discharge home, caregiver identification, and continued ADL and transfer training. A trial of home with home health alone would be unsafe because home health is intermittent and cannot manage overnight safety or cognitive impulsivity.

Prioritize safety-critical performance and discharge environment over routine strengthening. First, assess arousal, orientation, attention, and ability to learn and retain hip precautions; fluctuating confusion changes the plan. Second, evaluate bed mobility, toilet transfer, dressing, and functional mobility with the walker, documenting assistance and cues. Third, screen pain and medication effects because opioids may worsen sedation and confusion. Fourth, assess the discharge environment, including stairs, bathroom setup, and caregiver availability, and request a home safety evaluation if home remains a goal. Intervention should include brief, repeated ADL practice, hip-precaution training, energy conservation, and caregiver education. Coordinate with PT, nursing, social work, and the physician about delirium and placement. Do not spend limited acute-care time on nonessential upper-extremity exercise while the discharge plan is unsafe. Reassess daily because delirium and function can change quickly.

The OTR should retain the initial evaluation, interpretation of cognitive and functional data, discharge recommendation, goal setting, home safety evaluation, and communication with the team about placement and delirium. The OTR also decides when the plan needs revision. The COTA can implement delegated intervention: repeated ADL retraining, transfer practice with the walker, reinforcement of hip precautions, collection of objective data on assistance and cues, and patient education within the established plan. The COTA should report changes in confusion, pain, transfer safety, or ability to retain precautions promptly. Delegation must follow state law, facility policy, and the OTR's supervision plan. The key judgement is that the COTA supports data collection and practice, but the OTR makes the complex discharge decision because it requires integrating medical, cognitive, environmental, and caregiver factors. If the COTA observes new impulsivity or a fall attempt, the OTR should reassess before continuing the same program.