It's an all too common scenario in U.S. nursing homes a 90-year-old resident with moderately advanced Alzheimer's disease, congestive heart failure with severe left-ventricular dysfunction and chronic pain from degenerative joint disease develops a nonproductive cough and a fever of 100.4 degrees. The night nurse calls the on-call physician who is unfamiliar with the patient and is instructed to send the patient to the emergency room. In the ER, the patient is found to have normal vital signs except for the low-grade fever and a possible infiltrate on the chest x-ray. The patient is admitted to the hospital and treated with intravenous fluids and antibiotics. On the second night, the patient becomes confused and agitated, climbs out of bed and falls, fracturing a hip.
One week later, the patient is discharged back to the nursing home with coverage under the Medicare Part A benefit. This episode results in approximately $10,000 in Medicare expenditures, and discomfort and disability for the patient.

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