Yesterday on this blog I ended by talking about the essential role as “advocate” for anyone who has some responsibility for an elder in a nursing home through some appointed position or because of the bonds of relationship. I promised to answer the question of where one goes to gain that knowledge necessary to be an effective advocate.
I offer the following as a partial fulfillment of that promise. My day gave me the opportunity to address the concept of advocacy in a way I wish I did not have to do. My sister-in-law has found herself in a nursing home following a fall which resulted in a fractured hip and subsequent surgery. That fall happened over a month ago. My sister-in-law is in a kind of limbo because she needs rehabilitative therapy, but that cannot be provided until her surgeon says it is okay to put weight on the affected leg.
So her three adult and devoted children are looking for a nursing home that is closer to them rather than to the surgeon – one that will provide the best rehab therapy, provide the best services for their mother who needs increased support in her daily life, one that will honor her dignity, her individuality, her needs and her preferences. The three of them are visiting nursing homes closer to their home. My nephew called today with that news and with information about a couple they were looking at. I offered to provide some things they should look for or be aware of as they visit these nursing homes.
I include them here as issues that any good advocate should be cognizant of for any nursing home resident for whom they hold some sort of responsibility through appointment or the bonds of love and loyalty.
I told my nieces and nephew to look for and be aware of these things. And this is just an initial list:
1. Are there ‘slumpers’? These are elders who slump in their wheelchair, sleeping or totally unaware and unengaged in their environment. BAD. They have escaped an intolerable environment and gone to their own inner world. (Not my analysis. Read the book OLD AGE IN A NEW AGE by Beth Baker.)
2. Are there elders lined up in wheelchairs or circling the nurses’ station? BAD. It means there is no meaningful engagement for individual residents.
3. What is the tone of the relationship evident between the staff and the residents? Does the staff even see the resident? Does she meet their gaze, address them? Is it patronizing or is it genuine, expressing a sense of mutuality in their relationship?
4. What is the tone of the caregivers (CNAs and licensed nurses) when they are interacting with the residents? Is it person-to-person or is it more impersonal, task oriented, and schedule-bent?
5. If you are able to be there at lunch time you can observe how the serving staff and the kitchen staff interact with the residents.
6. Are residents “parked” in the dining room for a long time (30 minutes is a long time) waiting for the scheduled meal time to take place?
7. Does everyone wear a bib? DON’T LET THEM DO THIS TO YOUR MOTHER! As your instinct will tell you, this is a dignity issue. She has the right to say no. Or better yet, Hell no.
8. Is there any conversation at the individual tables or is there a sense of disengagement or low level depression expressed in utter silence and isolation?
9. How is the food served? Is it appealing in color and arrangement on the plate? Would you consider the style of the meal service more like a restaurant, a home or a hospital?
If these events or the ambiance within the nursing home are present, the residents need good advocates who will address these issues. Knowledge of the regulations, called the "Minimum Standards of Care" are important. But there are some things that are so obvious that when we see them we know they are not right. In my beginning days within the traditional nursing home culture, I was troubled by much of what I saw. Because I was totally ignorant of 'the system' I thought, "I guess that's just the way it is." I learned soon that the words of an early mentor rang true and still ring true: "If you think it is not right, it probably isn't. Never get used to poor care."
Tuesday, April 22, 2014
Monday, April 21, 2014
Good! Maybe She’ll Wake Up!
This is a true story told to me many months ago by a woman I’ll call Sylvia. Sylvia got a call from the nursing home where a long-time friend of hers was living. Sylvia was not power of attorney for this nursing home resident, but the nursing home knew she was a close and long-time friend and that she was planning an out-of-town trip. Staff called to tell Sylvia that her friend was being put on hospice care.
In a sense it was not a surprise to Sylvia. Through the course of her faithful visits, her friend had “deteriorated” cognitively. She did not always recognize Sylvia; often she could not engage in meaningful conversation or call Sylvia by name. On more than one occasion Sylvia could not rouse her friend. “Dementia” the nursing home said.
“I’m going to be out of town for four days,” Sylvia said with some anxiety. “It’s okay”, she heard the voice reply. “She’s stable now. We are enlisting hospice and we will be taking her off her routine meds.”
To her later amazement, Sylvia heard her say to the staff person, “Good. Maybe she’ll wake up.”
She did!
The nursing home resident is no longer on hospice. She is alert, always recognizes Sylvia and calls her by name; she shares stories of earlier days when they lived on the same block in a tight-knit neighborhood. She laughs. She asks about this one and that one as if -- as if -- she is actually engaged with life again!!
Such is the tragedy of over-medication, or possibly drug interactions resulting from what is called polypharmacy. The topic of over medication has been addressed in the blog many times. It is a major concern to governmental regulatory agencies that have strict guidelines about the use of “Unnecessary Drugs”.
It is a concern for those long-term care practitioners who sincerely want to execute that part of the nursing home reform statute (commonly called OBRA ’87) that mandates that their organization “must” provide the necessary care and services to enable the resident “to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”
A resident cannot attain or maintain her highest practicable level of functioning when she is medicated to the point of obvious sedation, or sometimes even to the point of being so sedated that she cannot be roused, cannot open her eyes or even lift her head which is at a 90 degree angle to her body as she sits in her wheelchair.
It’s not right. It's that simple. I hope that anyone reading this blog who has some responsibility for or bond with a nursing home resident will be on the lookout for such obvious markers of over medication. The response should be that of an advocate. A strong, loving advocate.
If one would hire a person as an attorney who has no knowledge of the law, how smart would that be? The answer is obvious. The same is true when we are called to advocate for another. If it is a resident in a nursing home, then the advocate must know what the standards of care are before an issue can be adequately addressed.
Where does one go to learn what the minimum standards of care are? And do these minimum standards matter if the person in the nursing home is not in a licensed nursing home? Tune in tomorrow!
In a sense it was not a surprise to Sylvia. Through the course of her faithful visits, her friend had “deteriorated” cognitively. She did not always recognize Sylvia; often she could not engage in meaningful conversation or call Sylvia by name. On more than one occasion Sylvia could not rouse her friend. “Dementia” the nursing home said.
“I’m going to be out of town for four days,” Sylvia said with some anxiety. “It’s okay”, she heard the voice reply. “She’s stable now. We are enlisting hospice and we will be taking her off her routine meds.”
To her later amazement, Sylvia heard her say to the staff person, “Good. Maybe she’ll wake up.”
She did!
The nursing home resident is no longer on hospice. She is alert, always recognizes Sylvia and calls her by name; she shares stories of earlier days when they lived on the same block in a tight-knit neighborhood. She laughs. She asks about this one and that one as if -- as if -- she is actually engaged with life again!!
Such is the tragedy of over-medication, or possibly drug interactions resulting from what is called polypharmacy. The topic of over medication has been addressed in the blog many times. It is a major concern to governmental regulatory agencies that have strict guidelines about the use of “Unnecessary Drugs”.
It is a concern for those long-term care practitioners who sincerely want to execute that part of the nursing home reform statute (commonly called OBRA ’87) that mandates that their organization “must” provide the necessary care and services to enable the resident “to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.”
A resident cannot attain or maintain her highest practicable level of functioning when she is medicated to the point of obvious sedation, or sometimes even to the point of being so sedated that she cannot be roused, cannot open her eyes or even lift her head which is at a 90 degree angle to her body as she sits in her wheelchair.
It’s not right. It's that simple. I hope that anyone reading this blog who has some responsibility for or bond with a nursing home resident will be on the lookout for such obvious markers of over medication. The response should be that of an advocate. A strong, loving advocate.
If one would hire a person as an attorney who has no knowledge of the law, how smart would that be? The answer is obvious. The same is true when we are called to advocate for another. If it is a resident in a nursing home, then the advocate must know what the standards of care are before an issue can be adequately addressed.
Where does one go to learn what the minimum standards of care are? And do these minimum standards matter if the person in the nursing home is not in a licensed nursing home? Tune in tomorrow!
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