Post-Hip Fracture Delirium: The Referral That Already Has an Answer

Reasoning: the referral's framing (“clear her for SNF”) has already smuggled in a conclusion. My job is to describe current functional performance and the conditions that will determine where she can safely go.

• Do not administer a Mini-Mental or MoCA today. With acute onset, fluctuating attention, disorientation, and altered arousal she meets CAM criteria for delirium. A cognitive score obtained now is invalid, will be quoted for weeks, and treats a medical problem as a disposition problem. Document attention and arousal during a functional task and escalate suspected delirium to the physician.
• Time the session deliberately - after analgesia, before her enoxaparin dose, within her 20-minute window - and use an acute-care measure with a defensible baseline (e.g., AM-PAC 6-Clicks basic mobility and daily activity).
• Test the actual task, not the label. Attempt bed-to-chair-to-toilet with the walker and standby assist of two, tracking orthostasis, pain, and fatigue. Platelets of 68,000 do not contraindicate mobilization, but they make a fall far more dangerous: gait belt, clear path, no bed rest.
• Frame it as discovery, not proof. “Let's find out what you can do” reduces the fear-avoidance driving her refusal; “show me you're safe” guarantees a power struggle she cannot win today.

Reasoning: Mrs. R's preference and her daughter's preference are both data. Neither is the decision, and neither is mine.

• Make the consequences concrete. Ask each of them what they are picturing. Mrs. R may be picturing her own bed; her daughter is picturing overnight climbs out of bed and a 90-minute drive. Describe, using today's measurements, what a second-floor walk-up plus unreliable memory means for stairs, medication timing, and nighttime toileting. Describe what an SNF stay actually is - daily therapy, 24-hour supervision, a planned discharge home - so it can be heard as a step rather than a punishment.
• Stay in role on capacity. Capacity is decision-specific and time-specific and is determined by the physician or, if contested, a qualified clinician - not by the OT. My contribution is the evidence: does she understand the risk, retain and weigh it, express a consistent choice? With fluctuating attention today, capacity cannot be reliably judged; the honest answer is “reassess tomorrow,” not “route to SNF.”
• Convene the team (physiatrist, social work, nursing, PT) to treat the delirium first and hold a structured family conference afterward. If she still lacks capacity then, the state's surrogate hierarchy decides, and her daughter may or may not be that person - verify rather than assume.

Documentation: objective, behavioral, free of labels.

• Write: “Oriented to person only this a.m.; attention wandered after 3–4 steps of a 2-step command. Required verbal cueing ×2 and min assist of 1 with walker for 8 ft; stated she would fall and declined further standing. Session terminated at 12 min.” Include labs and enoxaparin timing only as they bear on precautions; note that cognitive screening was deferred as invalid during suspected delirium.
• Avoid “noncompliant,” “unmotivated,” “poor historian.” Describe the behavior and its likely context: “fear-avoidant; delirium suspected.”
• Assessment line: “Current performance does not support discharge alone to a second-floor apartment. Recommendation deferred pending resolution of delirium. OT recommends daily co-treatment with PT and a team/family conference.”
• Communication: send an SBAR to the physiatrist flagging delirium as a medical escalation, not a discharge snag. Give a warm handoff to the SNF if transfer occurs. The discharge summary must state the actual level of assistance and the cueing required - never “mod amb” alone. Do not transmit “needs SNF” as a conclusion without the data underneath it.