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

Aristocrat

Naples, Florida --- “Looks nice from the outside, but be careful where you place your family.”  Mr. David Cravey warns about the beautiful façade of the long-term care facility where a 90-year-old was left in the 90° heat for three hours.  He died.  The Aristocrat in the picture to the right is located at 10949 Parnu Street in Naples, Florida 34109 was cited by the Department of Health and Human Services Center for Medicare and Medicaid service deficiencies.  The full report can be found at nursinghomesabuseadvocate.com.

Lockhart, Texas — “The call from the nursing home came just before dawn, jolting Martha Sherwood awake.  During the night, fire ants had swarmed over her 85-year-old mother, injecting their stinging venom into Natalie Sealy’s face, arms, hands and chest."

“She was just lying there being eaten alive,” said daughter Billie Pender, who said she and her sister had repeatedly complained about a broken windowsill in their mother’s room at the ParkviewNursing and Rehabilitation Center.  The September 2 attack devastated Sealy, a retired bank teller with dementia.  ‘She went steadily downhill,’ dying in late March, said Sherwood, who brought a lawsuit against the home” (You Don’t Want to Be Old in These States, Newsweek.  May, 2015).

The aforementioned article first appeared in the Kaiser Health News (KHN).  In short, if you are looking for nursing home for your mom, avoid Texas, North Carolina, Tennessee, Kentucky, Ohio, Pennsylvania and New York.  These are the states blamed for the worst problems in long-term care. “Lawmakers in several states, including Washington and Connecticut, are debating proposals to raise staffing standards to boost care.  Washington’s would require almost three and a half hours of direct care staffing per resident starting in July, and large urban nursing homes would need an RN on duty 24 hours a day. Connecticut’s proposal calls for 2.3 hours of staff time per resident each day, up from 1.9 hours (KHN)."

“In Texas, lawmakers are deliberating on a bill that would allow the state to yank the license of any home that gets three citations for problems causing immediate jeopardy to residents—the most serious category—within a two-year period.  The so-called three strikes measure has passed the Senate and has been referred to the House Committee on Human Services.  Another bill would close a loophole that allows homes to avoid paying fines on certain serious violations if they fix the problems” (Newsweek.  May, 2015).

“We’re at a point where we say enough is enough,” said Republican state Senator Charles Schwertner, during a February hearing on the three-strikes bill, which he sponsored (Newsweek.  May, 2015).

How many people residing in long-term care have to be victims of a three strikes approach to improving the system?  Mr. Garth Clark wrote on April 27, 2015, “It is sad that I am surprised when a corporation or individual acts in an ethical way.  I’m getting very cynical and certainly have lowered my expectations.  All we have to do is look back at the history of our nation in terms of free enterprise.  From oil to railroads to electricity, the focus was on profits and not the common good.  Our aging population presents a great source of generating dollars and there will always be someone ready to take advantage.  Unfortunately, it generally has to get worse before it has the chance of getting better.  Typically, it takes threatened loss of votes before we can expect our politicians to protect our newest cash cow, the aged.  I wonder if AARP is too vested in health care profits to pick up the banner and carry the message.”

According to Mr. Charles Brown, a partner in the law firm Brown, Wharton, and Brothers, “There’s plenty of profit being made by these facilities, but they’re shoveling it out to management contracts to themselves.”  Mr. Brown is representing the Sealy family in a lawsuit against Parkview.  “Many of these nursing homes are making profits, but they put profits over staffing,” said Ms. Charlene Harrington.  The debate over profits is complicated because it’s difficult to track profits and revenue, since many nursing homes are owned by private corporations or limited partnerships with complex ownership structures (You Don't Want to Be Old in These States,  Newsweek.  May,  2015 ) . 

True Stories:

Ms. Debbie VanHouten Foshee (May 13, 2015) shared this story.  “My father was never in assisted living, but spent his last days in the hospital with kidney failure.  My mom was the one with Alzheimer’s and she was what if I called a Ward.  It was heartbreaking.  She died in her sleep.”  Mr. Jim Tudor, May 11, 2015, talked about the decision he made to move his parents out of the metro area into a more rural location.  “It involved increasing the drive time.  Our reasons were simple, turnover.  In the metro area there is such a shortage of medical staff that constantly job shop, meaning there was no continuation of personal relationships. You might see a new face every week.  Mom and dad were together for two years before mom’s condition necessitated moving into a skilled nursing facility.  Dad, on the other hand, had the same major caregiver for the four years he was there.  He was Grandpa to the staff and even the cooks knew what to fix him on the days he wasn't particularly thrilled.  A couple of years ago, dad went under hospice care, but wanted to return home where the staff did a great job until he passed in his sleep.  What made this work for us was the fact that assisted living jobs were more valuable in the rural areas and as a result turnover was low.  The continuity of the relationships formed went a long way towards not only their happiness, but our peace of mind.”

Ms. Donna Moxley Isaacs points out, “The cost of these facilities for the average elderly couple is outrageous” (May 12, 2015).  However, the cost of long-term care keeps rising while there are many stories where families have gone bankrupt trying to finance the care of their loved ones.  How is this ethically justified in America?  Whether personal financing or facility financing, the issue keeps getting more complicated.  “Patient advocates are skeptical of arguments about inadequate financing, saying staffing can be good in some homes and poor in others when they operate in the same state and receive similar Medicaid payments” (You Don’t Want to Be Old in These States, Newsweek.  May, 2015).

What can be done?

May 11, 2015, Mr. Jim Tudor recommended getting to investigative reporters whether small or large markets.  He has completed 29 years of working with elected officials, and advocacy groups that have little financial support.  He explains the combination of multiple advocacy groups going after the same issue, or related issues which in some cases involves them in turf wars about who will get credit for doing good really impedes progress.  Advocacy groups tend to be low on the totem pole for getting responses.  With that in mind, no bureaucrat wants to explain to a boss why certain conditions continue to occur in these long-term care facilities.  Mr. Tudor recommends documenting everything.  Pitch the story to the media.  Where someone finds the story compelling, it will get to a broader audience.  He reminds everyone that the squeaky wheel gets attention.

Personal Note from NHAA Advocates:  “NHAA (Nursing Homes Abuse Advocate) shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety.  Aristocrat nursing home and many others across the country are cited for abuse and neglect” (Abuse Advocate Blog.  May 14, 2015).

Mr. David Berry stated in a communication on April 27, 2015, “My struggle these days is trying to justify the objectivity of my actual age with the subjectivity of my perceived age.  Reality has been winning more and more over idealism.  I infer that The Enemy is defeat.  In other words, when an assisted-living resident finally gives up, the end is near.  This self-actuated defeat is the result of assisted-living facilities' physical and psychological mistreatment, blended with a firm dose of apathy.”

Questions for Consideration:

In most long-term care facilities, there is a Resident Council meeting that usually takes place monthly in nursing and assisted-living.  While it may be good to document that every attempt was made to improve conditions, it rarely makes a difference internally.  This is a comprehensive list of what typically is problematic in long-term care.  The unfortunate side to this list is that the same items are repeated month after month.  What follows is an April, 2015, statement of concerns for the Assisted Living Resident Council meeting at Goodwill Retirement Community.  Why should any resident need to address these issues?  Are these ethical issues or a “dose of apathy” creating more stress for residents?

April 2015 GRC Assisted Living Council Suggestions:

1.  Speaker system is still problematic.  There are announcements from dietary that are extremely loud and other announcements that are barely audible.  No one should be yelling into the microphone system.  No one should use a ranting tone of voice to get the attention of someone in assisted living!  There is only one nursing aide per floor in assisted living and she could be in a bathing area, or bathroom area and unable to respond to the page.  Repeatedly paging the same floor in assisted living is noisy and unproductive.  Equally important is the fact that no one in assisted living should have to listen to messages for Nursing or Memory Lane.  The barrage of announcements over the speaker system simply means that people tune out!  Why is there a lack of interest in correcting this problem?

2.  Grammar Lesson for April:  It is not “I seen.”  The correct grammar is “I saw.”

Members of the staff need to answer the telephone in a more professional manner.  These are suggestions.

Second floor assisted living.  (This is the easiest answer and a lot of people use it.)

Second floor assisted living, this is Janet.  (I am just using Janet as a fill-in name.)

Second floor assisted living, how may I help you?

Second floor assisted living, this is Janet.  May I help you?

No one should be answering the telephone with “Hello.”  If the caller asks if this is Janet, then the correct response grammatically is, “This is she.”  The response is never “This is her.”

3.  Nursing Aides need to be more considerate in the dining area and stop throwing silverware into the bin.  It clangs and it is an obvious sign that these people are having a bad day, or something is making them unhappy.  I also think it would be best to have the Rubbermaid liners or the shelf liners that are in a roll and can be cut to fit the bin.  In that way, some of the bad sound effects could be minimized.  The trashcans and silverware bins need to be cleaned and sanitized three times weekly.  That includes the trashcan at the end of the kitchen counter area.

4.  Nursing Aides also need to be more considerate about the noise at the hot bar especially during times that we are trying to eat.  I know people are in a hurry with a lot to do, but that is stressful with the cleanup before some of us even get our food.

5.  Every place that fingers touch underside cabinets need to be thoroughly disinfected.  I even asked to have the plastic cracker container sent down to dietary for dishwashing.  Maybe plastic Ziploc type bags would be better for holding crackers?  These things that are touched frequently need to be cleaned weekly or more often and that means sent down to dietary for dishwashing.

6.  Every meal should have a different dish rag 7:30 AM, 11:30 AM, 4:30 PM.  These get bacteria ridden very quickly and especially with humidity in the room, dish rags do not dry out.

7.  Has anyone ever cleaned the swing gate to the nurses station?  It is time to disinfect areas where hands touch frequently.  Likewise, members of the staff have to stop eating at the computer.  No food should be around that keyboard and I shudder to think how many germs grow in that area!

8.  It is far more important to wash hands with soap instead of hand sanitizer than ever before.  I picked up something viral here.  Several members of the staff have the same problems with their ears that I experienced.  The Ebola outbreak taught everyone a lot.  It is not hand sanitizer that helps protect people.  Washing with soap and water is more important than ever before to protect against viral infections that are mutations and not helped with antibiotics.

9.  Cantaloupe on the cold bar has been wonderful.  Try to get more dark fruits such as blueberries as soon as they come in.  Please add Apple cobbler, blackberry cobbler, or even peach cobbler to the dessert menu.  The Dietary Manager needs to change the menu for week nine as there are far too many tomato-based items on that menu.  There are many residents who cannot eat tomatoes and I am one of them.

10.  It is time to revisit the entire 14 week menu cycle and start putting in more choices.  Rotation of foods for an extended 14 weeks does not help the situation since the same foods were rotated on the menu for 12 weeks.  We need variety.  We need different foods.

11.  It is also time to get members of the staff to diet.  Some of these people need to lose about 100 pounds.  More than a half-dozen nurses need to lose a lot of weight.  What is happening to them?  Encourage people to walk at least 10 minutes a day as per the latest suggestion from Dr. Oz.  This includes the delegating nurse.  Overweight people in this job have a lot more difficulty trying to do the work.  I hope something can be done in support of weight loss.

12.  All of the members of the staff need to be trained or retrained in what to do for a tornado warning.  Tornado warnings mean that conditions are right for the tornado to strike and be ready to take cover within seconds or minutes.  A tornado watch only means that people need to stay alert for a possible warning.  Just this past week, there was a great deal of confusion.  By the time we were moving out of our rooms, the tornado warning had lifted at 7:15 p.m..  There was only a severe thunderstorm watch for the entire area.  Perhaps a refresher course is a good idea, e.g. move everyone to the inner hallways and close the large fire doors.

13.  The floors need a floater!  GRC assisted living is losing most everyone from training classes and it is stressful!  There is no way that one woman can run up and down two flights of stairs to help people on first floor.  No aide can keep running down to first floor from second or third floor.  Abandoning the floor for any reason is unconscionable.  With high-level care there is a need for more staff.  High-level care residents pay more as in $160 a day (correct?) for care, so why not invest that money in another staff aide to ensure that nursing aides do not get overwhelmed and quit, or residents are not left on the floor without any nursing aide.

14.  The GRC assisted living needs a housekeeper.  There is no way one woman can clean upwards of 13 rooms in an eight hour shift.  Get real!  The cleaning is insufficient but the real problem is an unreasonable number of rooms to clean that have quite a bit of clutter in many cases.  One person simply cannot do the job in one shift.  It may be that a floater position can be combined with a cleaning position.  To be sure, the present system is not working!

15.  Nursing Aides need to be encouraged to stay on the same floor.  These women who jump around just make it so hard on themselves and the residents.  I have seen these jumpers who go floor to floor because they think one floor is easier, but it just makes it a great deal more challenging for the resident and fatiguing for the aide.  The residents on the floor are going to change because that is the nature of this business, but the aide who stays in one place learns the needs of the residents and is better able to do the job more efficiently.  I get very tired of hearing an aide say, “I have not been on this floor in a while, so you need to be patient with me.”  No, the nursing aide needs to work the same floor so that she is more competent in administering medicationsand efficient in addressing resident needs.

16.  Training classes with 3 to 5 trainees just barely provides one nursing aide to stay with GRC assisted living.  It costs 2 ½ times the salary to replace a nursing aide or anyone else who leaves a facility.  These are not fixed costs, but management and the Board of Directors need to realize that this problem needs to be addressed.  The money spent on replacement should be spent on retention of good employees. 

17.  Training classes need to include simulations.  A nursing aide can just be slumped over on the toilet and let trainees figure out what is going on.  She can be in a stroke situation and unable to speak.  Let the trainees figure out what is going on and how to handle the situation.  Too many of these trainees are overwhelmed once they get on the floor.  Something has to change with the instruction.  Trainees also need real practice with a simulation of a resident falling and taking vitals every 15 minutes.  It is obvious that the training classes do not work.  Do you have handouts that are interesting?  Do you use color graphics on the handouts?  Does each trainee have a manual?  Are you boring in your presentation?  Do you adequately assess the potential of each applicant and avoid wasting our time?  Something is very wrong with the screening and the teaching, or there would be more graduates finish the classes and move on to the floor.  Instead, if people finish the class they rarely stay in this GRC mix.  That is a big red flag that something is terribly wrong at the training level.

18.  Nursing aides need to have a better sense of when to project their voices.  I heard the entire conversation Sunday night at 1:40 a.m.  An elevated voice at any time in the evening or overnight is much louder without all the other background noises going on.  Quiet indoor voices between 10 p.m. and 6 a.m. are a must.  It should also be noted that nursing aides need to stop yelling.  Some nursing aides really yell and it is not necessary.  It exhausts anyone to yell.  Yelling is very rude and disrespectful and only confuses a resident.

19.  Life Skills:  There needs to be training in how to tie shoes.  One does not simply pull the top strings.  The top of the shoe opens in a sort of V, because the top of the foot is not flat.  Tia, although she left, was very good at tying shoes.  She also said that so many nursing aides did not know how to tie shoes properly and thought she had better make a video.  Another issue is cleaning the toilet.  The seat shouldbe lifted before anyone cleans inside the toilet.  The toilet is also cleaned under the rim, around the rim and on top of the rim where there may be splashes.  The outside of the toilet needs to be thoroughly cleaned along with disinfecting the flusher handle.

20.  Delegating Nurse:  This is a sensitive issue.  I realize that the delegating nurse is rarely in the facility.  However, she needs to wear scrubs.  No more street clothes.  She also needs to wear closed toe shoes and that is an OSHA regulation in the workplace.  No more sandals.  It is time to get a professional white jacket to improve her appearance.

*Regrettably, the only response to this list was an email referring food concerns to the Dietary Manager. 

May, 2015