It happened around 1985. Mom, her two brothers and my Grandpa (reluctantly) came to the conclusion, it was in the best interests of both my grandparents that Grandma live in a nursing home. He still wanted to care for her and was still resistant but agreed that she needed round the clock care a nursing home could provide, that could not be provided at the family farm.
She had been having transient ischemic attacks (ITA) or mini strokes for a while. My grandfather had given more and more of the farm work he was still doing to my uncle so he could care for her. Sometimes he would come in from milking the cows, haying, planting, etc. to find his wife of over 58 years passed out on the floor. Even as the multi-infarct dementia (from all the strokes) set in and he was having trouble taking care of her and taking care of the house, he still insisted, despite his age of 86, that he would take care of her(84).
So when the decision was made my mother began to pack her bags for another long trip from Denver to her childhood home in the center of Kansas. Through the conversation she had gotten the task of choosing the nursing home, and she didn’t know what to look for. She wanted me to go, but I couldn’t, so I sent a list with her.
Choosing a nursing home can be a scary process. It's much like choosing a day care, except this is 24/7 with many more blind spots, especially if you live far away.
In 1985 there weren’t readily available lists like the government (pdf) and many organizations put out now. The linked list is very good (and I do encourage you to look at it and use it), but it is an overview. The list I gave my mother was created by my vantage point as as a Certified Nurses Aid or Certified Nursing Assistant (CNA). I had worked within the spectrum of nursing home/respite/convalescent care available, from the very best nursing homes to the okay nursing homes, to a temp from a private agency sent to cover the staff shortage at some very poor nursing homes. I had also worked as a private in home CNA for the agency. At that time I was still working weekends for the agency to help offset our expenses.
The job aids/orderlies/CNAs do cannot be overstated. They are the nursing home staff most involved in direct resident care. They are the ones who move residents from bed to wheelchair, they are the ones who bath the resident (whether a bed bath, real bath or shower), they brush the teeth, comb the hair, feed, clean up after the resident, make the beds, position and reposition the bedridden and wheelchair/geri chair bound, they are often the first to detect changes in a residents overall well being (such as slurred speech, the drooping of one side, etc.), and yes, change the diapers and wipe the butts. Aids/orderlies/CNAs need to be versed in basic nursing and care skills including CPR.
Up until the rise of the assisted living facilities and hospice, nursing homes were the catch all for those needing assistance. From those needing minimal nursing care (daily vitals to making sure medication was taken on time) to those needing to be made comfortable before death. It wasn’t uncommon to have a floor or wings dedicated to the various needs. Those needing only needed occasional help, vitals taken once a day and to make sure medication was given and taken on time. These were the floors/wings were located in the front of the facility, often they were it's "shining" face.
The back wings/floors were where you’d find the "skilled care" residents. Those who needed a lot more care. They could be: totally bedridden, or ambulatory but confused and/or in need of a lot of daily assistance, cognitively "all there" but are paralyzed due to accident or disease, and everything in between. Now nursing homes are considered in total "skilled care facilities."
The "skilled care" residents are the ones I chose to serve and care for. Skilled care is where the good and great aids/orderlies/CNAs shine and where those who care little to none and who are there because they can find a job no where else are exposed. I was part if the former group, but I am sorry to say the later are in far too large a number. And of that far too large number a very small percentage of them are sadists.
I have told the story here at Dkos of working at a nursing home that had a large number of holocaust survivors as residents. One night orderly got his jollies by walking into their room while they were sleeping and yelling "Heil Hitler!" just to watch the panic and terror in their faces.
This is a tough, often dirty, physically demanding job that wears you out on a daily basis, pays little, does not offer health insurance (or if it does it is more expensive than your pay check), and is often not unionized. When economic times are good it is the toughest position to fill (and keep filled) in a nursing home or private agency. When economic times are bad, that’s when there are more applicants than there are jobs. It is when a nursing home administrator can be assured of complete staffing and have the chance to rid themselves of the horrid aids/orderlies/CNAs, knowing that the vacant much needed position will be quickly filled.
The shortage in willing staff for the aid/orderly and CNA positions during great economic times is often taken up by legal immigrants and undocumented workers (illegal immigrants). This is a position that cannot be vacant, in some communities there is a mandated minimum for the number of aids/orderlies to residents. Falling below that puts both over worked aids/orderlies and the residents who depend on them, at great physical risk.
That "toss off" statement of "illegals needed to wipe elderly butts" has more truth than one may realize.
This is a hard and dirty job:
** because that "red meat every man" 55 year old man who is all there mentally but now in a wheelchair didn’t stop having gas and diarrhea when he entered a nursing home. And sometimes when he is being cleaned up and changed the two mix together in what the aids/orderlies/CNAs darkly call "explosive diarrhea."
Some of the aids/orderlies/CNAs carry an extra set of clothes to work in a duffel bag. Often these care givers don’t even have their own lockers.
** Or the 36 year old woman who has MS. She didn’t stop having a period when the disease took her ability to control her arms and legs, which can lock into uncompromising positions. Maxi pads are impossible to use in this situation.
** Then there is the 40 year old medical doctor who was struck down by a brain disease who now finger paints his bedrails, sheets, bedside table, even himself, with his own bowl movement in the diaper that was clean not 5 minutes before.
** Or the cute little confused old man of 75, he is still ambulatory, which is fantastic, but he looks at any possible receptacle in the nursing home as a toilet, and when he’s got to go, he’s got to go.
It’s not just grandma (as if minimizing and marginalizing her care is okay). I doubt you will ever see Mike Rowe doing an episode of "Dirty Jobs" as an orderly in the toughest wards/wings or floors in a nursing home. Even though I'm sure many have emailed the idea in.
My list, for my grandmother's care, tried to encapsulate everything I had learned and saw in the various nursing homes I worked in. I say "list" like it was just one, but there were really two. One to evaluate the nursing facility my mother was looking at. The other, what to do for grandma to make her as comfortable as possible in the nursing home.
The first list is offered below with commentary of why many of these items are important or indicators of how well a nursing home is doing. Beyond the hype and sales pitch you may receive from an administrator. Many points ended with "don't put grandma there."
Due to the limited time my mother had she could not spend a few days looking at the top choices for her mother's care. I would recommend spending a day or two visiting the top choices at varying times. Some items on the list are "exchangeable" but only if you or a family member are going to be visiting at least once a week.
The second list will be presented tomorrow as I fear this diary will be too long if I include both.
What to look for in nursing homes and questions to ask
- Enter the nursing homes you are looking at the 7am shift change. What does it smell like? If the nursing home smells like urine, talk to the administrators.
- Wander throughout the facility and check out residents rooms. Also check on the shower fixtures, tiling, etc. If the rooms (especially corners) are dirty, have broken furniture, the tiling in need of repair and the shower fixtures broken, don't put grandma there.The administration should be okay with you wandering around the facility and staying as long as you like (so yo can get the feel of the place).
- Look at the residents, are they dressed appropriately? If all they have on is thin clothing, not the sweaters needed because generally older people are cold, don't put grandma there.
- Check out the closets of several people. do they have a few days worth of clothing or does clothing on average seem sparse. If the average is sparse, don't put grandma there.
- Watch how the staff treat the residents, do they respect them, especially their modesty wishes. If not, don't put grandma there.
- Do the aids/orderlies and CNAs work as a team? If not, don't put grandma there.
- What is the aid/orderly/CNA ratio to residents? The lower the better.
- Stay through lunch and/or dinner in the wing where the residents need the most help and see how they feed them. Does everyone get fed at every meal, or is it hit and miss. Hit and miss, don't put grandma there.
- Ask the CNAs and orderlies, out of ear shot from the administration, would they put someone they love in the facility. IF not, don't you.
- Check the way beds are made. Is it made as a half the blanket the long way, or put in on the fully cover the bed (and the resident) if it's in half, don't put grandma there.
- Does the facility use flat sheets as the bottom sheet or fitted. If they use flat sheets, that should count against them.
- Are the wheelchairs, geri chairs, bedrails, corners in rooms clean. Or do they look like they have a few days worth of food etc.
- Who takes care of passive restraint? if its a nurse, cna or aid/orderly without training, don't put grandma there
- What is their record on accidents and injuries to the residents?
- What do they do when they are short staffed in aids/orderlies and CNA?
- How do they handle residents and family complaints about staff and facility?
- Does the staff (aides/orderlies/CNA's and nurses) follow universal precautions? Does the direct care staff routinely wash their hands before coming into contact with a resident?
(1.) Enter the nursing homes you are looking at the 7am shift change. What does it smell like? If the nursing home smells like urine, talk to the administrators.
If it smells like urine it could mean that the nursing facility is understaffed at night and the aides/orderlies/CNAs are overwhelmed. Night under staffing is something that certain administrators an owners due to save money, because it's less likely to be caught. They could also honestly think that the work is less at night. It's not, just different.
If the night before was a full moon, or close to a full moon, come back another morning to make the evaluation. Despite what the experts say a full moon does effect nursing home residents. They are often restless on those nights.
It could also mean that they are using old fashion draw sheets and rubber mattress protectors. The reason this is bad is because this could mean urine stays next to the skin at night (especially if it's been a busy night and they are understaffed) which causes a break down of the skin making the skin susceptible to infections especially decube (decubitus ulcers/pressure ulcers/bedsores).
The best nursing homes work very hard not to have any cases of decube. The best nursing home I worked in the only cases of decube were brought in either transfers from other nursing homes or hospitals, and the nursing staff, aids/orderlies/CNAs worked very hard to heal those as quickly as possible.
I was taught to turn and reposition bedridden and low movement patients/residents every half hour. Those in a wheelchair need to be repositioned at least every one to two hours.
Rubber mats don't wick away that moisture like a paper with plastic chux does. While a chux can be itchy, a cloth draw sheet over the chux cures that and even then it wicks away better than a draw sheet over a rubber mat or just a draw sheet alone for an incontinent resident.
(2.) Wander throughout the facility and check out residents rooms. Also check on the shower fixtures, tiling, etc. If the rooms (especially corners) are dirty, have broken furniture, the tiling in need of repair and the shower fixtures broken, don't put grandma there
Most nursing homes are for profit entities. They are making money, if there is broken furniture and dirty facilities that money is going somewhere but not to resident health and comfort.
Dirty facilities also increase infection rates. Both a dirty facility and broken furniture (which decreases the safety of the facility for staff, residents and visitors) help to demoralize residents and increase depression.
(3.) Look at the residents, are they dressed appropriately? If all they have on is thin clothing, not the sweaters needed because generally older people are cold, don't put grandma there.
and
(4.) Check out the closets of several people. do they have a few days worth of clothing or does clothing on average seem sparse. If the average is sparse, don't put grandma there.
Things get lost in facilities, that's a given. But there is a vast difference between the occasional thing going missing and things disappearing every week.
If a facility cannot keep track of residents clothing (which is done in the facility's laundry) there is a lack of respect, and care. Disappearing clothing, clothing washed but never given back to it's owner, has definite health implications.
This will be explored more in part 2.
(5.) Watch how the staff treat the residents, do they respect them, especially their modesty wishes. If not, don't put grandma there.
There is a point when expediency and "we are professionals" needs to yield to the wishes of a resident. Staff must realize that for the most part residents have lost a great deal of control over their own lives. So if they want someone of the same gender to help them bathe, and there is an aid/orderly/CNA of that gender available, let the resident have that much control back. Accede to their wishes.
Likewise other accommodations to modesty, where ever possible need to be made. Let them keep that measure of dignity and self respect.
It can be hard for aids/orderlies/CNAs to see residents as people, not things. This is especially true if they work the 11-7 shift and rarely see the resident awake, other than getting them up and ready for breakfast. Ways to counter that will be discussed in part 2.
Some of the respect, or lack there of, issue is also tied to cultural misunderstanding. Immigrant communities that work as aids/orderlies/CNAs can come from cultures where the family is expected to take care of their elderly and infirmed. Since this is not happening in a nursing home there is sometimes the false impression that the residents must be horrible people if their families are unwilling to take care of them.
False cultural impressions work both ways.
This will also be explored more in part 2.
(6.) Do the aids/orderlies and CNAs work as a team? If not, don't put grandma there.
and
(7.)What is the aid/orderly/CNA ratio to residents? The lower the better.
At the best nursing home I worked each aid/orderly/CNA was assigned 4 rooms, which had double occupancy, so 8 residents. We were also assigned a buddy. Singly we were responsible for water, comfort needs, etc. of "our" residents.
Together we would assist each other in bed to wheel chair/geri chair transfers if need be, changing a soiled bed while the resident stayed in the bed, morning care and dressing (it was faster to work as a team) and anything that required two people for safety.
The worst nursing homes either gave you a very high resident to aid/orderly/CNA ratio or let you on your own, without a team mate. Moving larger people or combative people is hard enough with someone helping, it is nigh impossible and dangerous for staff member (and resident) to do on their own.
(8.) Stay through lunch and/or dinner in the wing where the residents need the most help and see how they feed them. Does everyone get fed at every meal, or is it hit and miss. Hit and miss, don't put grandma there.
One of the facilities I work at was dedicated to Alzheimer care. Again by choice I worked on the floor where the residents were the most out of it and needed the most care.
When it came to meal times these residents were wheeled to the tables and aids/orderlies/CNAs would spoon pureed whatever into their mouths. This is time consuming, especially when you need to be patient with the resident to make sure more food ends up inside them and not on their bib and clothes. Often an aids/orderly/CNAs lunchtime would be called before everyone that they were charged to feed was fed.
All would leave when their lunch time came taking their lunch thinking while thinking that the missed residents would fed at the next meal. I had worked double shifts at times and knew that this wasn't true. Often times the same residents were missed, just because the were placed in the same location as they had been for the earlier meal.
I refused to take my meal, because I could feed myself at any time. These residents could not. Some a thought I was nuts (at best), or showing them up(at worst) and a nurse let me know the front office didn't like that I was skipping. I didn't care.
In this same common area was a man whose wife came every day to take care of him. With our help she would get him up and dressed for the day. She would clean him up, feed him, talk to him, etc. Everyday she was in that common area feeding her husband and watching what was going on with the other residents. From her I received kudos.
(9.) Ask the CNAs and orderlies, out of ear shot from the administration, would they put someone they love in the facility. IF not, DON'T YOU.
I think this is pretty self explanatory. Aids/orderlies/CNAs know what's going on. All that you can't see. The know which charge nurse fosters a good time and which doesn't. They know who is rough with the residents, and what short cuts, if any, are being taken. Just don't ask one, ask a few.
They know what other aids/orderlies/CNAs do and what is covered up.
For instance there was a case of an aid swaddling a troubled and wondering resident so she could not move (for hours) and get out of bed. Before rounds this aid would go into the room unroll/unbound the resident and fix the bed and her vest restraint to look like it had been this way the whole night.
The aids game and abuse was only reported when the other aids/orderlies/CNAs discovered it and reported her.
(10.) Check the way beds are made. Do the half the blanket the long way, or put in on the fully cover the bed (and the resident) if it's in half, don't put grandma there.
and
(11.) Does the facility use flat sheets as the bottom sheet or fitted. If they use flat sheets, that should count against them.
The half blanket may not be nursing home policy, it may be a lazy aid/orderly/CNA who thinks giving a resident only half a blanket to keep them warm will keep down the amount of linens used to change a soiled bed in the middle of the night.
If you find one bed made this way, check them all. Whatever the result ASK the administration (if a lot of beds it points to an administration thinking that this saves money).
Many nursing homes have gone to fitted sheets for beds. Fitted sheets can be pulled tight across beds decreasing and removing wrinkles the lead to pressure points and skin breakdown. (Despite arguments to the contrary)
But some are still enamored with the flat sheet and hospital corners. Few people know how to do hospital corners correctly and now since most hospital/nursing home mattresses are vinyl covered flat sheet slip and hospital corners are pulled out, even if the resident doesn't move much. This often leaves sheets (and draw sheet/chux) in a wrinkled cold mess under the resident.
Far easier on the resident and aid/orderly/CNA is a fitted sheet. And yes, some of what you want to do is make things easier for the aid/orderly/CNA because the easier it is for them, the better your loved one is cared for. (also explored in part 2)
(12.) Are the wheelchairs, geri chairs, bedrails, etc. clean. Or do they look like they have a few days worth of food etc.
Like everything else, they should have a wipe down at least once a day. Wheelchairs can be the worst offenders as they are easily over looked. But food falls between the cushion and the arm and they do need to be cleaned.
In some nursing homes there is a once a month "wheelchair wash." It happens at night where all the wheelchairs on a floor are rounded up and taken to the shower room to be washed and hosed down and then returned to their owners/users rooms ready for the morning.
(13.) Who takes care of passive restraint? If its a nurse, cna or aid/orderly without training, don't put grandma there.
The use of passive restraints in a nursing home is controversial. Passive restraints are more than keeping a residents with dementia from wondering off or getting out of bed and hurting themselves. Passive restraints also keep residents that are placed in wheelchairs and geri chairs from sliding forward and falling.
Passive restraints are not without risk and only those trained in them should be applying them.
For example, in the alzheimer dedicated nursing home I worked in we had a resident die because they slide down in their wheelchair but their vest restraint was set ridgedly to keep their back up right (so the resident wouldn't slump). So, in effect the resident was hung on the neck of the vest restraint.
Passive restraints (or as many call them Poseys after a company (sort of like "Kleenex" is used to refer to all facial tissue) have advanced a lot in 20 years. Our old netting across the top of a bed to keep wanders in their bed has evolved to an entire tent system. But they are still dangerous and must be used properly by those who are trained in their correct application.
Some facilties do not use passive restraints preferring sedation instead.
Some use passive restraints only as a last resort, getting creative instead. For example; using the same security clips department stores use to keep clothes from walking away unpaid for, are clipped to a confused wandering resident. When they try to go through a door they shouldn't, alarms sound. Otherwise they are free to roam about the facility and it's court yards.
(14.) What is their record on accidents and injuries to the residents?
A certain amount of accidents are normal. Residents either try to do something they are no longer able to (like get out of bed without assistance because they are stubborn and in denial), or fall because the chair is not where they thought it was.
Sometimes the accident is a series of issues that multiply. For example one of my residents was a woman who had a form of dementia and had reverted back to the language of her youth, German (language reversion happens). Since the only ones who spoke German were her sons, she was, for most part isolated until the weekend. This isolation did not help her mental state but we tried the best we could.
One night she had been agitated and the 3-11 shift put her in a geri chair with a cup of water hoping that the change would calm her.
Buy the time my shift (11-7) came on, had our briefing and assignments she was calmed down enough that I could put her back to bed. This was a normal one person pivot for which I didn't need help.
But a series of things happened that night. First, I didn't realize that she had spilled her water on the white tiled floor. Second, while I had her in my arms pivoting her from chair to bed, she for some reason stiffened up. (Since I could not communicate with her I can only assume something startled her) This changed the dynamic of the pivot and it would have been salvageable had it not been for the water on the floor.
I slipped and down we both went. She hit her head on the hardware of the bed and was taken to the hospital as a precautionary measure. While I was annoyed with the police officer who charged in trying to find elder abuse in the accident, I knew he was just doing his job.
There are real cases of elder abuse both physical and mental (as noted above). These cases often happen at night, when there are less people to see and take note. Residents who have involved families likely to be the victims of abuse. They are also the ones that make the nursing home better for everyone. Without their noticing too many bruises that defy "accidents," or that some resident doesn't seem to be dressed appropriately and that happens a lot, they are the advocates not only got their loved ones, but for the ward/floor and home in general.
What parents do when their children are in nursery and preschool (noting bruises, accidents etc.) the same must also be done for a loved one in a nursing facility.
(15.) What do they do when they are short staffed in aids/orderlies and CNA?
Do they just make do, risking resident care and the safety of their staff? Do they offer over time for aids/orderlies/ CNA's to stay and work, and if they don't offer it or their staff cannot do they then call an agency for temps.
Some nursing homes will only resort to calling in temps if the laws demand that they do.
Do they take short staffing seriously? Does short staffing happen a lot?
All this directly affects the quality of care and the total care your loved one receives.
(17.) Does the staff (aides/orderlies/CNA's and nurses) follow universal precautions? Does the direct care staff routinely wash their hands before coming into contact with a resident?
Yes, hand washing is still an issue. I was taught to wash upon entering and upon leaving a patient's/resident's room. People thought I was obsessive but in my various stays in hospitals I have observed that it is still not being done.
Tomorrow, part 2: Making your loved on comfortable in a nursing home.
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Thank you to KelleyRN2, ulookarmless, nchristine, and bablhousfor pushing me to write this diary (well both). And to all those who recced the original comment because they also pushed.
Please also see:
Dementia: Firsthand -- It sucks.
HELL: 6 Weeks in a Convalescent Home
Nurse Kelley Sez: Find me a nurse, STAT!
Thanks also to lgmcp's comment:
Also do due diligence
of looking up official ratings and complaints made to the Medicare system.
Medicare: Nursing Home Compare
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There were problems getting this diary posted which has pushed it into "pick up the kids" time. So while I am on the road NurseKelly will be manning the comments. When I get back I will read and comment. Thanks and sorry that I have to go for a bit.