Our nurse, Jason Bryan, was caring for a 76-year-old patient on our service. This patient was living independently, but quite deconditioned upon admission, and after a stay in the ICU and 5 days in the hospital he was severely weak and unable to stand unassisted or perform ADLs. Physical Therapy recommended a stay in a rehab facility, but the patient just wished to go home. His primary care team, wanting to honor his request, arranged for home therapy and nursing care. As the time of discharge neared, the patient’s wife confided in JB that she was afraid to take him home because he had frequently fallen there, and was so weak. She feared her husband would be upset with her for suggesting he go to rehab, and asked JB to help her broach the discussion with him. JB facilitated a positive discussion and the patient stayed overnight. The next morning, as day shift arrived, a BAT was in-process in the patient’s room because he was unable to arouse, even with a sternal rub. A CT, MRI, and EEG were performed, and luckily nothing neurological was found, but it is frightening to think what would have happened had the patient been home! The patient discharged to an acute care facility the following day. I was so impressed with JB’s assessment skills, and his willingness to advocate for a more aggressive discharge plan for his patient. The heartfelt way in which he handled the discussion was inspirational and made the wife feel validated and supported. JB was able to coordinate with the patient’s primary team, and our ancillary service providers to ensure a smooth transition at discharge. JB’s uncanny ability to sense that this patient was not as stable as he appeared likely saved the family from enduring a very unsettling situation while alone at home, and avoided a costly readmission to the hospital.