Medicare requires that a plan for care be developed with a social worker when a patient is about to be discharged and also for them to understand the plan. But just taking the word of the social worker isn’t always advisable, according to the Pittsburgh Post-Gazette in "Doublecheck when they say the rehab center doesn't have room."
The patient might need to be transferred to another facility, such as a nursing home or a rehabilitation center. The patients are sometimes told that their preferred facilities for care after being discharged from the hospital does not have room for them. Sometimes that is true, but not always.
Hospitals that have financial interests in other facilities very often try to steer patients into those facilities and away from others. For that reason, it is a good idea for patients and families to call facilities for themselves to ask about availability.
An elder law attorney can advise you, should you believe it is possible that the hospital is not doing what Medicare requires it to do.
Reference: Pittsburgh Post-Gazette (Feb. 26, 2018) "Doublecheck when they say the rehab center doesn't have room."