by Tyra Phipps, Ed.D. (tyra.phipps@gmail.com)

Ayres Health and Rehabilitation Center is located in Trenton, Florida.  It does provide long-term care.  David Cravey wrote on June 1, 2014, about the long waiting list to get into this facility.  He described country people who are deeply embedded in the community caring for residents in the facility.  He gave kudos to the staff and the facility.  “This is what care should be.  I met with many families and patients there to discuss hospice services.  I had a cousin placed there for rehab in his early fifties after months of hospitalization and intensive care.  When he expended all the time his insurance would allow, his wife took him home and cared for him two more years until he passed.  On the day he left, staff lined the halls with patients standing and in wheel chairs who cheered for him being able to go home.  Whenever I walked into this facility to meet with a family I would get my neck hugged by the administrator and many of the staff calling me Mr. David.  Unfortunately this is the exception rather than the rule.”  David Cravey is a hospice worker and experienced with many healthcare facilities.

There are some assisted living, skilled nursing, and long-term care facilities with good administrators who are visible.  In making a decision about going to any of these kinds of facilities, make a visit on a holiday and see if any administrators are around.  I reside in assisted living, but administrators are absent over weekends and holidays including a Memorial Day weekend.  Not just Christmas, but on any given holiday administrators are gone for about five days.  Some are not even available online.  This creates numerous problems.  If the Internet connection is lost, or someone has a serious fall, or there is a move in with so many questions, an administrator should be available at all times and visible!  It may not be necessary to get hugs from the administrator as Mr. Cravey described in the aforementioned paragraph, but it is important to have at least one administrator available and on-site at all times.

When interacting with the CEO or manager or director in any healthcare facility, trust your gut instinct.  Investigate what is the training and background of the administrator.  There are healthcare administrator degrees at the graduate level.  While states may only require a high school diploma to manage an assisted living unit, search for facilities with trained, educated, experienced administrators who can communicate clearly and possess strong interpersonal skills.  Every organization needs effective internal communication.  Good communication starts with the CEO or president.  Otherwise, the workforce suffers from low morale and low productivity with little or no trust in organizational leadership (ON24).  The result is chaos and dysfunction which means poor treatment of residents.  On May 30, 2014, Ms. Pam Hageman wrote, “If management does not set and demand that proper standards be maintained, then the trickle-down effect takes place.”

Make unannounced visits to long-term care facilities.  Even unannounced visits can result in witnessing residents slumped in their chairs only one arm working going around and around in their wheelchairs in the hallway.  “There are many times that blank stares sometimes respond to a kind word or smile, but clearly the resident is a shell of the former person.” As David Cravey continues, “This broke my heart as much as anything.  People were abandoned by their families to slowly slip away until their money runs out.”

At that point, the state takes over with Medicaid.  The family may have exhausted all of the funds for the resident, but this is a human being with real needs.  Make note of the attitudes when visiting any facility and making a decision about leaving home.  While the smell of urine or worse may be clearly evident upon entering a long-term care facility, how does the staff respond?  Is there an attitude of indifference?  If you call attention to a problem, does a member of the staff make every effort to correct it?

What about the staff in long-term care facilities?  These are predominantly women who experience everything from being urinated on, and much worse.  They can be pregnant and hit in the stomach by a dementia patient.  Their arms are frequently bruised by finger marks of residents.  They endure long hours of work with sometimes getting mandated for two shifts or sixteen hours.  Many endure degrading remarks from residents, yet continue to smile when greeting the next resident.  They do not have an easy job, but good management can make a difference in helping the members of the staff feel appreciated and valued.  Unfortunately, what prevails in most of these institutions is a lack of appreciation and indifference contributing to low morale, and job burnout.

Did you know that residents in long-term care facilities do not have a choice of physicians beyond what is affiliated with the facility?  The physicians that serve the facility are the choices for any resident or family to utilize.  For the physician, the workload is tremendous.  Most of the physicians that serve facilities also have private practices.  I have heard physicians talk about how they love their patients, or how important it is for somebody to care for these people especially those with multiple conditions.  How much can one person do?  Physician suicide is at least one per day and some statistics are as high as 400 per year.

Even though the technology may allow faster communication that is linear or one way, a physician needs to rely on well-trained, educated and experienced staff to carry out orders.  The communication breakdowns can be as simple as trying to understand the physician faxes, inability to reach the physician, or lack of aptitude on the part of the staff to deal with any situation.

Dr. Ronald Phipps is a former Assistant Secretary of Higher Education in Maryland and Secretary. of Higher Education in Alaska who commented on, “the disgraceful conditions of assisted living” (March 16, 2014).  He called attention to the contributions of Senator Daniel P.  Moynihan.  Defining Deviancy Down is about finding a limit to the amount of deviant behavior that any community can afford to recognize.  Moynihan believed, “We have been redefining deviancy so as to exempt much conduct previously stigmatized, and also quietly raising the normal level in categories where behavior is now abnormal by any earlier standard” (1993).

Dr. Ronald Phipps points out that Sen. Daniel P Moynihan, “was very prescient!”  Is a declining lack of civility contributing to poor elderly care?  Is the problem worsened by an unprepared and uneducated workforce?  Even if civility and trained workforce are in place, what about attitudes?  Are there people who want to work?  More important, are there people who want to do the job of caring for elderly, disabled, or Alzheimer’s patients?  The training classes at Goodwill Retirement Community frequently start with as many as five or six students, but usually decline to just two.  Even worse, trainees frequently move on and do not even complete their one year of service for the training provided.  What is management to do?  Even good managers need a work force.  What if management is stuck with employees who are unmotivated, unwilling to work, but instead just waiting for a paycheck?

A reader who preferred not to be identified contributed this story on May 30, 2014.  “As we baby boomers reach our senior citizen years we better start making the appropriate arrangements for our later years.  We better start making noise about the accommodations available and the deplorable conditions often found when visiting.

I recently had to admit my father to an assisted living/rehab facility for rehabilitation after a hospital stay.  I visited all the facilities available in my hometown.  I thought I had found the best for him and maybe in reality it was but it was far from humane in my book.  Fortunately my town is small, and I was able to visit him daily and sometimes twice a day.  Although the facility had some nice amenities such as a lunchroom where relatives could eat with the patients, the actual care was far less than acceptable.  Upon arriving to visit my father I would on numerous occasions find him in diapers that were soaked through and onto the bed sheets.  Lord only knows how long he was stuck like that before I arrived.  Because he has some dementia I couldn't rely on his assessment and finding anyone that could tell me anything was near impossible.  He wasn't bathed daily, sheets were not routinely changed, no one checked to see if he was eating, I questioned whether he was receiving his medications regularly, the doctor was there twice in six weeks!!  Although he was supposed to meet twice daily with a physical therapist I know this did not happen.  I had to make up a spreadsheet and require the staff to initial when they did their job.

Appointments with officials of the facility were not kept and as I said it was nearly impossible to find anyone that could answer simple questions.  I guess a chart of his care was not maintained properly or it could have been shared.  I shudder to think what I will do when the time comes to move him permanently to an assisted living facility and I know that day will be here far too soon.

Anyone that goes to the hospital, rehab facility or assisted living home better have an advocate that is willing to speak up on their behalf!”

Another reader contributed this quote about trying to get information of his mother's status.  He was trying to advocate for a mother diagnosed with congestive heart failure.  Dr. Gary Sparks wrote on May 29 2014, “Not getting a nurse to call?  Not getting a single, person to return a call, never, nohow, from day one to the end.  Her doctor prescribed a heart monitor for her.  She never got it--this is for a woman with CHF.  She was to get physical therapy in the morning, and often no one bothered to get her up or get her on the way to p.t.  The physical therapists had to do that.  Goddamn gangsters, it's that simple.” 

Is it that simple?  Proximity helps enormously to be located close to family and friends.  Abusers like to get their partners farther away from any support group so beware.  Many of these facilities are located in areas far away from populated towns or cities.  Never listen to management when they tell you to stay away and let the person adjust when first moving into assisted living, nursing, or dementia units.  Be there frequently and observe what is going on.  Keep in mind that nursing aides are not told what a new resident has in the way of problems or medical issues.  So everyone is guessing and there is much room for trouble including accidental death as presented in Life-And-Death in Assisted Living (PBS June, 2013).

Dr. Travis Shipp, Retired Professor from Indiana University in Bloomington, Indiana commented March, 2014, “We had to put my father in assisted living and at first everything went really well.  Then I started to realize that the food was not good and he wasn’t getting the care I thought he needed.”  If not at the outset, realizing that expectations are not being met in getting the care for a loved one means more difficult decisions about relocating, filing complaints with the state, or taking legal action.  Trying to work through an ombudsman and resolve differences is time-consuming to say the least.  Younger family members have families of their own and jobs that can be very demanding leaving few personal days to help parents and grandparents residing in assisted living or nursing facilities.

People who are unable to speak, or have had their cognitive skills robbed from them through strokes or other medical issues need advocates.  Dr. Linda Hoss sent a reminder of a quote from Mark Twain on February 14, 2014.  “Whenever you find yourself on the side of the majority, it is time to pause and reflect.”  Confrontation is frequently necessary to make a difference.  Civil discourse is a good place to start, but oftentimes falls on deaf ears.  Watch for a management that works to appease.  In other words, passive aggressive behavior can be advantageous for a manager, or CEO, or a nurse.  Nodding in agreement and offering assistance, then walking away and doing absolutely nothing is commonplace.  Many times the reason is overload.  There is only so much any one person can do in an eight hour shift.  There are only so many complaints a manager can hear and act on in one day.  Understaffing is reported as the biggest single problem in all of these kinds of facilities across the country.  However, is that the real issue?

In many ways people who live in nursing facilities are prisoners of their own bodies and minds.  On a macro scale, prisoners of war deal with debility, dependency, and dread.  On the micro scale, residents of assisted living, nursing and dementia units have the same struggles.  Residents are dependent on people for help and there are the dreaded members of staff coming to help.  These are nurses or aides who can be quite sadistic and take joy in someone else’s suffering or elevate themselves by putting someone else down.  Even worse, a group mentality is such that when one member gets behavior corrected, frequently the group turns on the administrator doing the correct thing.  This creates even greater dysfunction for management in the facility.

Psychological stress is at the forefront of living in assisted and nursing facilities.  Dealing with cognitive dissonance is a daily struggle when living in a facility.  Even though human beings like internal consistency, dissonance of any kind can cause great psychological stress and impairment.  The theory of cognitive dissonance belongs to Dr. Leon Festinger.  Without internal consistency, there is dissonance that can cause irrational behaviours, physical suffering, and death.  This theory does not just apply to residents in care facilities, but also administrators and management level personnel.

Even on the best of days in nursing facilities, crisis can occur within seconds.  Although people die, sometimes it is sudden and unexpected making the passing of a loved one even more difficult.  The difficulty is also for staff, not just family members.  People residing in care facilities become support groups.  They are not a family, nor neighbors, and may not even be friends, but rather individuals from various walks of life who all have special needs.  Finding a place that meets the needs of a loved one is the challenge, but it is possible.  On June 8, 2014, Ms. Susan Aycock Webb wrote, “We were very fortunate when Jerry’s dad had a TBI to find a wonderful caring facility.  That being said, if they had not participated in the Veterans Assistance Program which paid half of his expenses per month, none of us would have been able to afford it.”

The bottom line for any administrator running an assisted living, nursing, or long-term care facility is money.  As Mr. Dave Berry wrote on May 29, 2014, “The fruits of profits are distasteful...  literally!”  People intending to reside in assisted living and even transition to nursing need money.  Most of the facilities helping disabled or elderly people are for-profit.  Can you afford to pay $4000 a month for the rest of your life?  Can you afford to pay $6000-$10,000 a month for the rest of your life?

The harsh reality is that even nonprofit needs to have a balance sheet in the black.  The logistics of running any of the caring facilities means a good workforce has to be in place.  There has to be a good dietary plan providing excellent food with high nutritional value.  There needs to be clean pleasant surroundings.  Rehabilitation and physical therapy units have to be held accountable for their work.  There may not be cheers and standing ovations, but there has to be an upbeat attitude of appreciating every moment of life and making every day great.

Questions for Consideration:

1.  When visiting a facility, meet the CEO or president.  Question the management skills of this individual.  Is this person interested in crisis management as in waiting for the crisis and then doing something?  Does the CEO have good interpersonal skills or does this person hide in an office rarely interacting with anyone?  Is this person also a psychologist?  Does the CEO possess a healthcare administration degree?  Administration works from the upper to lower ranks.  Does the CEO convey a positive attitude or do you get the feeling that this person is not trustworthy?

2.  Does the facility have amenities?  Is there an ATM, small theater, barbershop, beauty shop, spa, podiatrist, a small food supply store, small drugstore, gift shop, exercise room, swimming facilities, library, computer room, chat rooms or areas for engaging conversations?

3.  Does the facility have lowered light switches, lowered hand sanitizers that people in wheelchairs can reach?  By the same token, are there sinks that are lowered?  Are there roll in showers?  Is there housekeeping throughout the facility, or is that a function of nursing aides in addition to nursing duties?

4.  Can a potential resident live in the facility ahead of time?  Robin Bonar, Home Healthcare Attendant states, “People should be able to try for a week at a time what these places are like before making a  decision.  Their family should also accompany in order to experience the daily activities and see what the regimen is like.  ” (May 18, 2014).

5.  Visit the facility and stay a while.  Just listen.  Is there a cacophony of sounds?  Is there a loudspeaker with announcements continually running day and night?  Does the same voice repeat many times during the day, “Dietary order on the elevator.”  Are there announcements for areas that should be directed to other parts of the facility?  Are you hearing announcements for the Alzheimer’s unit, nursing, or dietary while you are sitting in the assisted living unit?  What is the sound system like?  How loud are the televisions?  Where are the televisions placed?  Are televisions allowed to run while meals are being served?  Listen for something that can become quite a bit more annoying over time.  Do nursing aides keep the swing gate from slamming every time they walk in and out of the nurses station?  The slamming sound of a closing gate can be very tiring.  Sit very quietly and listen for repetitive sounds that can be extremely annoying. 




June, 2014