Five Days to Discharge, One Willing Spouse
Mr. K, 80, is 3 weeks post left MCA stroke with right hemiparesis in a SNF. Modified Barthel 62/100: moderate assist for lower-body dressing, min assist for transfers, ambulates 40 feet with a rolling walker and min assist. He has mild left neglect - leaves food on the left of the tray, contacts left doorframes. Discharge home is scheduled in 5 days. Mrs. K, 76, has moderate hearing loss, uses a cane, and takes a sedating medication at night. The home has 4 steps with no railing, a 28-inch bathroom door, and no shower chair. Mrs. K says, "I'll do whatever it takes - I've been doing everything for him for 50 years."
1. What must the COTA gather and report to the OT before a discharge recommendation is made?
Read the worked answer
The COTA's contribution is performance-based data on the actual caregiver in the actual task, not a report of willingness.
Gather:
- Observed caregiving trials, not interviews: have Mrs. K perform a transfer and a lower-body dressing with the COTA coaching, and record the level of assist she physically provides, her safety awareness, and her fatigue afterward.
- Nighttime toileting: this is the highest-risk period given her sedating medication and her own cane use. Ask who will assist at 2 a.m. and what the route looks like.
- Neglect-related safety: he bumps left doorframes now; a 28-inch doorway with a walker and a left neglect will produce repeated contact. Ask about the left side of the bathroom and stairway.
- Equipment and environment: railing on 4 steps, shower chair, grab bars, raised toilet seat, bedside commode to reduce night trips, and who will install them before day 5.
- Hearing: how will she hear him call from another room?
Report all of it to the OT with a clear statement of the residual risk. The COTA supplies findings; the OT owns the evaluation and the recommendation.
2. Mrs. K insists she can manage. How does the COTA determine caregiver capacity, and what happens if the evidence says otherwise?
Read the worked answer
Willingness is not capacity. Test it:
- Teach-back and observed return demonstration - can she set up the walker, place the gait belt, and block a buckling knee? Verbal assurance is not a demonstration.
- Match the demand to her own body: she uses a cane and has hearing loss. A min-assist transfer performed 12 times a day is a physical load for a 76-year-old with her own mobility limitation.
- Ask about the backup plan - who covers when she is ill, and what happens at night. "No one" is a finding.
- Name the risk out loud, respectfully: "You've cared for him for 50 years. The question isn't whether you're willing; it's whether one person with a cane can safely catch him at 2 a.m."
If the evidence shows she cannot safely assist, the COTA reports that to the OT promptly so it can reach the team conference before day 5. Options to raise: extend the SNF stay, home health with a defined number of visits, adult day services, or a temporary rehabilitation stay for caregiver training. Do not simply document "spouse willing" and let the discharge proceed.
3. What decisions about discharge are outside the COTA's scope here?
Read the worked answer
The COTA contributes data; the OT makes the evaluation-based recommendation, and the physician orders the discharge. Specifically out of scope for the COTA:
- Performing the discharge evaluation or signing off that the patient is safe to go home.
- Making the discharge destination recommendation unilaterally, or telling the family "he can't go home" as a final determination.
- Discharging the patient from services or terminating the plan of care.
- Independently clearing the home environment or approving equipment funding.
What is squarely in scope: completing the treatment sessions, running the caregiver trials, contributing to a home safety assessment under the OT's plan, documenting the performance data, and escalating when the data do not support the proposed plan. The escalation should be timely - a concern voiced on day 5 is a crisis; the same concern voiced today is a care plan.