Leaving a Skilled Nursing Facility for an RCFE: Questions to Ask Before Discharge

What has changed since admission?

Request a plain-language summary of the illness or injury, therapy gains and remaining limitations. Ask whether the person’s performance is consistent or varies with fatigue, pain, medication timing or cognition.

Families should share what the person’s baseline looked like before the event. The receiving RCFE needs the current reality, while the history helps explain whether further improvement is expected.

Can the RCFE support the current functional level?

Ask therapy and nursing staff to describe transfers, toileting, bathing, dressing, eating, walking and wheelchair use. Then ask the RCFE how it will support each activity, with what equipment and at which times.

A resident who transfers with one trained person in therapy may need two people when tired or anxious. If the care plan depends on a best-case performance, it is not robust enough.

• How much physical assistance is needed?
• What cueing or supervision prevents unsafe movement?
• Which equipment is required, and who owns it?
• Are there weight-bearing or movement restrictions?
• What would trigger a higher level of care?

Which skilled services will continue?

Clarify whether home health, physical therapy, occupational therapy, speech therapy, wound care or another licensed service will continue after discharge. An RCFE may coordinate with outside providers, but its caregivers do not become skilled clinicians.

Ask whether orders have been sent, which agency accepted them and when the first visit will occur. “A referral was placed” is not the same as a scheduled service.

Is the medication and equipment handoff complete?

Request a current signed medication list and compare it with the RCFE’s record. Confirm pharmacy delivery, first-dose timing, controlled medications and any monitoring instructions. Identify who will obtain refills after the short discharge supply ends.

For equipment, verify delivery location, fit and training. A hospital bed delivered after the resident arrives may make the first night unsafe. A wheelchair that does not fit through the bathroom door is not a completed plan.

What is the backup plan?

Ask whom the RCFE should call if the resident falls, refuses medication, cannot transfer as expected or develops a new symptom. The answer should distinguish routine provider follow-up, urgent assessment and emergency response.

For more detail on functional planning, read mobility, fall risk and equipment during a care transition.