The culture of nursing homes and assisted living facilities has shifted far away from the use of restraints; most places are restraint-free by law these days. The hospital is one of the only places I can imagine restraints remaining in use, and that is simply because of the acuity (how sick) our patients there are. They cannot afford to be pulling out the lines that are giving them IV antibiotics and blood transfusions, because without those things, they will die.
Even at the hospital, restraints are considered a last resort. They frequently utilize one-to-one 'sitters' to watch and maintain safety of very difficult patients. I was pulled from my regular duties to act as one last night, for a confused elderly person who would not stop climbing out of bed (and was a fall risk), pulling out lines, and removing their much-needed supplementary oxygen tubing. Even with me there, the patient was very agitated, and trying to literally climb over the furniture to get out of the bed. I was willing to let her get up, but she was so damn fast she was apt to get away before I could gather up all the things that were attached to her so I could ferry them along after her to prevent them from ripping out.
Finally the MD returned the page from the nurse, and ordered a small dose of an antipsychotic. It didn't stop the patient from trying to get up, it just calmed the patient down enough to stop physically shoving me out of the way, which was good enough.
This was one of those situations where I think that chemical restraints would be so much more effective than physical. My patient has such poor short-term memory that s/he would forget what I had said literally 20 seconds before. Putting someone like that in physical restraints is going to be a huge safety risk because they're still anxious and panicky and energetic, and will focus all of that onto getting out of the restraints one way or another.
Whereas a strong sedative seems highly appropriate and could allow this person the time to absorb their antibiotics, fluids, and oxygen in order to begin healing.
Unfortunately, I don't think we have a specific policy and protocol for chemical restraints the way we do for physical ones. I understand they're risky in terms of oversedation; you don't want to accidentally kill someone! But I wonder, if I were the physician getting paged in the middle of the night, whether I'd view the sedatives I'm prescribing as restraints or 'sleep aids' or what?
Showing posts with label Nursing Assistant. Show all posts
Showing posts with label Nursing Assistant. Show all posts
Tuesday, February 28, 2012
Wednesday, February 15, 2012
Best of Both?
I had a rough, rough shift at work last night. Was working with a nurse that is new to our floor, and coming from a floor that's notorious for having RN/CNA conflicts up the wazzoo. So I made time to sit and catch up with NewNurse when he came on shift halfway through mine. I already had 13-14 patients of my own, and the way we have it set up, all the call lights come to the CNA's first. If we don't answer, then they are forwarded on to that patient's nurse. So you can imagine how busy I am on these nights. Of my 13-14 patients, I'm likely to have at least 5 diabetics who need their blood sugar checked before meals and at bedtime. Another 2-3 who are confused/fall risk/non-English speaking. And 4 or 5 who are fresh post-ops, which means they're in a lot of pain, bed bound, and possibly needing to be strapped in and out of devices to move or steady their joints.
NewNurse got pissed at me for two things, one of which I think was valid (although I had no way of knowing about it) and the other which was absolutely not; one of our regular floor nurses scoffed at NewNurse when she heard him getting angry at me about it in the nurses' station.
Anyway, everything turned out fine, all my patients were okay (although one did give me a terrible scare, then when it became clear that my fear had been because of one of the machines giving a wrong reading the first time, the patient asked "Are we in trouble? I'll cover for us. What should I say?" which made me laugh despite how upset I'd been).
But I'm now mentally comparing that to my shift last week when I filled in over at the inpatient rehab unit (physical rehabilitation, not drug or alcohol rehab). I had such a mellow night, I was able to cover most of the unit by myself. And if I got tied up with something, the nurses were aware of it and went and did things for their patients themselves. I even had time to help a very sweet older lady get her Kindle working again, which delighted her!
It was more like a nursing home, in that it's lower acuity and the patients are there for longer periods of time. But it's a smaller unit, so that makes teamwork easier. And it pays at the rate of the hospital, not at the rate of a nursing home.
Is inpatient rehab the best of both worlds? Less stress, more time with patients, and the same pay and benefits?
Could be...
NewNurse got pissed at me for two things, one of which I think was valid (although I had no way of knowing about it) and the other which was absolutely not; one of our regular floor nurses scoffed at NewNurse when she heard him getting angry at me about it in the nurses' station.
Anyway, everything turned out fine, all my patients were okay (although one did give me a terrible scare, then when it became clear that my fear had been because of one of the machines giving a wrong reading the first time, the patient asked "Are we in trouble? I'll cover for us. What should I say?" which made me laugh despite how upset I'd been).
But I'm now mentally comparing that to my shift last week when I filled in over at the inpatient rehab unit (physical rehabilitation, not drug or alcohol rehab). I had such a mellow night, I was able to cover most of the unit by myself. And if I got tied up with something, the nurses were aware of it and went and did things for their patients themselves. I even had time to help a very sweet older lady get her Kindle working again, which delighted her!
It was more like a nursing home, in that it's lower acuity and the patients are there for longer periods of time. But it's a smaller unit, so that makes teamwork easier. And it pays at the rate of the hospital, not at the rate of a nursing home.
Is inpatient rehab the best of both worlds? Less stress, more time with patients, and the same pay and benefits?
Could be...
Thursday, January 26, 2012
Oh, Gross! Again.
Now that I'm working in the hospital, I see waaaaaaaay more disgusting things than I did in assisted living. I won't say that hospital is definitely more disgusting than home care because sometimes people's homes are just beyond nasty. But assisted living tends to be pretty decent.
So now that I've been exposed to more things, I figured you all would be delighted to know what I find the most icky.
1. The Worst Smell Ever; when someone keeps vomiting blood and poo. It's just so, so bad. I mean it's three unpleasant things all mixed together. And it smells ungodly.
2. Trach suctioning. I know, not nice. It's necessary. Sometimes people need that tracheostomy (a hole at the base of their throat in front) to help them breathe. And sometimes that hole gets plugged up with mucous. And then that mucous must be suctioned out. And yep, it's exactly as oogy as it sounds. Especially if they're coughing and end up with puddles of phlegm pooling on their chest, which then also must be cleaned up.
3. Pulling out lines. This is more of an "I feel phantom pain imagining this" reaction on my part. The people who do this aren't with it enough to be as bothered by it as a normal, alert person would be. But the sight of someone ripping out their own IV, or (God help them) other lines or tubes just makes me shudder. Doesn't matter what the line is or what it's putting in or out of the body, the idea of them ripping out really grosses me out.
...and lastly, one that I'm surprised is not that bad to me? Wound packing and unpacking. When someone has MRSA or whatever and it eats a hole into them, that wound must then be frequently packed full of stringlike bandaging, then have that removed, and replaced with clean packing. It sounds awful, but it's actually pretty cool. It's what allows people to heal from the inside out, rather than the outside in. You wouldn't want your skin to close up over a big empty pocket in your body, because that wouldn't be structurally sound. So instead this way it heals properly. But it does look pretty weird.
So now that I've been exposed to more things, I figured you all would be delighted to know what I find the most icky.
1. The Worst Smell Ever; when someone keeps vomiting blood and poo. It's just so, so bad. I mean it's three unpleasant things all mixed together. And it smells ungodly.
2. Trach suctioning. I know, not nice. It's necessary. Sometimes people need that tracheostomy (a hole at the base of their throat in front) to help them breathe. And sometimes that hole gets plugged up with mucous. And then that mucous must be suctioned out. And yep, it's exactly as oogy as it sounds. Especially if they're coughing and end up with puddles of phlegm pooling on their chest, which then also must be cleaned up.
3. Pulling out lines. This is more of an "I feel phantom pain imagining this" reaction on my part. The people who do this aren't with it enough to be as bothered by it as a normal, alert person would be. But the sight of someone ripping out their own IV, or (God help them) other lines or tubes just makes me shudder. Doesn't matter what the line is or what it's putting in or out of the body, the idea of them ripping out really grosses me out.
...and lastly, one that I'm surprised is not that bad to me? Wound packing and unpacking. When someone has MRSA or whatever and it eats a hole into them, that wound must then be frequently packed full of stringlike bandaging, then have that removed, and replaced with clean packing. It sounds awful, but it's actually pretty cool. It's what allows people to heal from the inside out, rather than the outside in. You wouldn't want your skin to close up over a big empty pocket in your body, because that wouldn't be structurally sound. So instead this way it heals properly. But it does look pretty weird.
Sunday, November 20, 2011
I'm on it.
I'm off training and working on my hospital's orthopaedics floor regularly now, and I LOVE IT. Love, love, love it. I love that no matter what the problem is, there's always someone there for backup. Not sure how to use that whatchamacallit? Ask someone. Need a bariatric-sized something or another? Ask the unit secretary to call for one. Patient getting combative? You can always call security. We never run out of the basic stuff I use to care for patients (gloves, linens, hygiene supplies) and I'm never left completely on my own to just deal with a situation. It's great. That's the benefit of being at a facility many times over the size of the GreatRep, with all different sorts of staff available.
I've also gotten to see some pretty amazingly gross stuff, like the patient who came in with the complaint of "My toe is missing. I think maybe the dog bit it off". Sure enough, the whole thing was missing, and I could see the bone right in the middle of that toe stump. I get a lot of darling little old ladies who are getting hips repaired or replaced and who are just delighted to have a young lady being the one who helps them to the bathroom. We don't get all that many amputations, which is kind of too bad because I think those are really neat and I want to see how people get back to their regular activities after one (but that's more of physical therapy/rehab deal).
All in all, I'm being exposed to a lot of new conditions/procedures/equipment and the nurses on my floor are quite nice and pleasant to work with. I feel so lucky that I happened into a floor where patients (usually) go home happier and healthier than when they came in - it makes for such a different dynamic than I've experienced before. And I have health insurance! For myself and Mr. Polly both!
I've also gotten to see some pretty amazingly gross stuff, like the patient who came in with the complaint of "My toe is missing. I think maybe the dog bit it off". Sure enough, the whole thing was missing, and I could see the bone right in the middle of that toe stump. I get a lot of darling little old ladies who are getting hips repaired or replaced and who are just delighted to have a young lady being the one who helps them to the bathroom. We don't get all that many amputations, which is kind of too bad because I think those are really neat and I want to see how people get back to their regular activities after one (but that's more of physical therapy/rehab deal).
All in all, I'm being exposed to a lot of new conditions/procedures/equipment and the nurses on my floor are quite nice and pleasant to work with. I feel so lucky that I happened into a floor where patients (usually) go home happier and healthier than when they came in - it makes for such a different dynamic than I've experienced before. And I have health insurance! For myself and Mr. Polly both!
Tuesday, August 23, 2011
Day 9 - things that make me go gray
9 - What's something that you worry about for the future?
This is embarrassing, but the idea of global warming makes me so scared I want to go hide in my bathtub with a blanket over me, as if it were a tornado. I know I already do pretty well on not making a gigantic carbon footprint (I'm vegan, drive a low-emissions car and don't travel much, live in a small apartment, walk to most of my errands because I live downtown, and will be taking the bus to and from school once I start classes, and buy most of my clothing secondhand). But it's never enough. If I think about it in depth, I get an overwhelming terrified feeling and get dizzy. That's dumb, I know.
The other thing I worry about often is whether I'll be bitter and burned out by the time I finally finish my prereqs and get to apply to nursing schools. My financial aid/tuition waiver has been reduced from up to 18 credits a quarter to down to 10. So I can take 2 classes a quarter for the next 3 quarters. Upside, this will make working full-time totally possible. Downside, I won't finish all the needed courses in three quarters. So I'll be working and going to school ... indefinitely. I like my job still, but I have days when I think "I'm so glad this isn't what I'm going to do with the rest of my life. I couldn't spend every day forever in here". Or days when I just want to hide from the sundowning residents that are yelling at me when I tell them they can't go home, because home isn't there anymore. I want to keep my drive and keep my enthusiasm. I worry that I'll get worn out before I even get a chance to finish my schooling.
But whatever, right? I mean, worrying about it isn't going to prevent it, and I'm doing the best I can right now. So I'll keep finding those funny moments every day, and concentrate on keeping my GPA as high as I can make it, and suck it up. I can do this.
This is embarrassing, but the idea of global warming makes me so scared I want to go hide in my bathtub with a blanket over me, as if it were a tornado. I know I already do pretty well on not making a gigantic carbon footprint (I'm vegan, drive a low-emissions car and don't travel much, live in a small apartment, walk to most of my errands because I live downtown, and will be taking the bus to and from school once I start classes, and buy most of my clothing secondhand). But it's never enough. If I think about it in depth, I get an overwhelming terrified feeling and get dizzy. That's dumb, I know.
The other thing I worry about often is whether I'll be bitter and burned out by the time I finally finish my prereqs and get to apply to nursing schools. My financial aid/tuition waiver has been reduced from up to 18 credits a quarter to down to 10. So I can take 2 classes a quarter for the next 3 quarters. Upside, this will make working full-time totally possible. Downside, I won't finish all the needed courses in three quarters. So I'll be working and going to school ... indefinitely. I like my job still, but I have days when I think "I'm so glad this isn't what I'm going to do with the rest of my life. I couldn't spend every day forever in here". Or days when I just want to hide from the sundowning residents that are yelling at me when I tell them they can't go home, because home isn't there anymore. I want to keep my drive and keep my enthusiasm. I worry that I'll get worn out before I even get a chance to finish my schooling.
But whatever, right? I mean, worrying about it isn't going to prevent it, and I'm doing the best I can right now. So I'll keep finding those funny moments every day, and concentrate on keeping my GPA as high as I can make it, and suck it up. I can do this.
Monday, June 20, 2011
Dreaming about pills
I think my subconscious is getting anxious about going back to school in the fall. Or maybe just about my upcoming meeting with the advising person who'll look over my past transcripts and tell me which classes I need to take, which should then give me a rough estimate of how long I'll be at community college before I can apply to nursing school.
Last night my anxiety dreams were:
1. I'm enrolled at a med aide course at the community college, complete with practice med carts. I'm aware that I'm not supposed to pop the pills for all of the patients ahead of time, but since I don't know these patients I'm afraid I'll run out of time and do it anyway. The entire bottom drawer of my cart is filled with painstakingly organized little med cups with the correct dosages of pills for my med pass. And then I run it down a couple of stairs and when I open it I've got a huge mess of pills all out of the cups and it's going to take me HOURS to sort them all out so that I get the right ones to the right people.
2. One of our family friends that's just finished her freshman year in college is complaining of butt pain, so I offer to take a look at it and discover a huge stage 3 pressure sore on her butt cheek. I decide to measure it by pouring water in it to check the fluid volume of it and she screams in pain. ACK!
Yeah, not very realistic, are they? Anyway, at least it was easy to realize they were just dreams when I woke up.
My meeting with advising is next week, so I need to go tally up which subjects I have credits in from my first go-round at school. In real life, I'm very excited to go back to school, and have gotten some hopeful news about financial aid. If I can afford to, I'll go to school full-time and cut back on my work schedule. That way I can get my prereqs done more quickly and start applying to nursing schools.
If not, then I'll keep working full-time and go to school as much as I'm able to. Either way, it'll be me taking steps in the right direction!
Friday, June 10, 2011
Gotten Spoiled
Now that I do three 10-hour shifts weekly as a med aide, I typically just do one caregiver shift per week in order to stay full-time at my facility. This week I'm doing two, since I covered for one of my least favorite coworkers on Monday while she got all her top teeth pulled out.
Sidenote: a surprising number of my coworkers wear dentures. And the ones that do all smoke and have all been very poor their whole lives. Lesson? If you cannot afford routine dental care, don't spend your money on cigarrettes. I just went to the dentist for the first time in years and I had a couple of cavities but I'm keeping all my teeth. And I don't smoke.
Back to my original point, though, which is that I'm feeling sorry for myself for working 2 regular CNA shifts this week instead of just 1. I've gotten spoiled really fast, apparently, and would much rather pass meds than wrestle people into attending meals, using the bathroom, and going to bed. Also, I'm noticing more and more that the way evening shifts are structured is really not conducive to teamwork. Since one person must "watch the floor" ( meaning be out in the common areas to prevent falls, elopements, and altercations) and our dinner breaks go from 6pm-7:30pm, during that time whoever is doing care in the bathroom or a resident's room is on their own. One coworker is on break and the other is watching the floor. Not handy at all!
So, poor me, I've got to get ready for work now. Happily, my Certification raise should kick in today!
Sidenote: a surprising number of my coworkers wear dentures. And the ones that do all smoke and have all been very poor their whole lives. Lesson? If you cannot afford routine dental care, don't spend your money on cigarrettes. I just went to the dentist for the first time in years and I had a couple of cavities but I'm keeping all my teeth. And I don't smoke.
Back to my original point, though, which is that I'm feeling sorry for myself for working 2 regular CNA shifts this week instead of just 1. I've gotten spoiled really fast, apparently, and would much rather pass meds than wrestle people into attending meals, using the bathroom, and going to bed. Also, I'm noticing more and more that the way evening shifts are structured is really not conducive to teamwork. Since one person must "watch the floor" ( meaning be out in the common areas to prevent falls, elopements, and altercations) and our dinner breaks go from 6pm-7:30pm, during that time whoever is doing care in the bathroom or a resident's room is on their own. One coworker is on break and the other is watching the floor. Not handy at all!
So, poor me, I've got to get ready for work now. Happily, my Certification raise should kick in today!
Friday, June 3, 2011
Best of Shift Reports, part 2
The other morning I got a really funny shift report, which was "Charge nurse on evening shift discovered resident trying to order pay-per-view movie entitled 'Slutty Girls Do It For Money'. Resident was not successful." my DON's comment was "Are you sure? I thought 'slutty girls' did it for free." and the dayshift charge nurse suggested that "No it's homely girls that do it for free.". What other line of work would you be having this chat at 7 in the morning?
Anyway, it reminded me I haven't shared any of my favorite shift reports with you people lately, and that's a shame!
So here's one "Caregiver accidentally bumped resident's head on headboard while transferring into bed. Resident did not complain of pain, but stated that she was now dead, and that the caregiver had killed her. Resident shows no signs of injury or death."
"Resident complaining of tiredness, has been walking around all day looking for her 'midget'. None has been found."
"Mr. X and Mrs. Y may not be seated at the same dinner table any more due to throwing food and splashing liquids at one another." came after a 102 yr. old woman started a food fight.
"Resident given an anti-anxiety drug due to her persistent belief that her roomate's oxygen concentrator was going to
kill her, despite it not being turned on."
Anyway, it reminded me I haven't shared any of my favorite shift reports with you people lately, and that's a shame!
So here's one "Caregiver accidentally bumped resident's head on headboard while transferring into bed. Resident did not complain of pain, but stated that she was now dead, and that the caregiver had killed her. Resident shows no signs of injury or death."
"Resident complaining of tiredness, has been walking around all day looking for her 'midget'. None has been found."
"Mr. X and Mrs. Y may not be seated at the same dinner table any more due to throwing food and splashing liquids at one another." came after a 102 yr. old woman started a food fight.
"Resident given an anti-anxiety drug due to her persistent belief that her roomate's oxygen concentrator was going to
kill her, despite it not being turned on."
Friday, April 29, 2011
Promotion
My facility is fairly small, as assisted living facilities go. We've got just under 70 residents, and usually have 1 charge nurse on shift supervising 6 caregivers/aides who take care of approximately 10 residents per shift. During regular working hours we also have the Director of Nursing and a med-tech.
All told, we've got maybe 2-3 different charge nurses for each shift, and they just take turns, and have 2 med techs. One does M-F, one does Sat-Sunday.
That doesn't leave a lot of wiggle room for call-outs, so sometimes our charge nurses end up having to work a double, and this last weekend our Director of Nursing (DON) had to come in and work a med tech shift, which she didn't like doing since she also had to come be the charge nurse simultaneously. Oops! That means she had to do all the routine med passes, PLUS all the treatements and assessments PLUS all the charting by herself. Ouch.
Med techs/med aides are a fairly new position that mainly work just in nursing homes and assisted living facilities. They can hand out routine meds to people who are able to actually take them independently - meaning that I could hand them a little med cup, say "here's your medicine" and they could then take those pills. If they had to have them crushed and in applesauce, or they weren't able to comprehend that they're taking medication, the nurse has to administer it to them.
Med techs have to be trained, need to have a basic understanding of pharmacology (how drugs interact, what they do, when to give them vs. when to hold them) and be responsible enough to handle narcotics honestly and chart appropriately.
Our DON decided we need another med tech because right now there is no backup if one of our two gets sick or goes on vacation.
Normally she would advertise within the facility to see who might like to apply for it, but this time, at our meeting, she apologized for not doing so but said that she had one person in mind for the job for a while now and was glad that this person accepted the position. She'll be training the new med tech starting this week. The new med tech is ... ME!
That's right, guys, Polly is going to learn a lot of new skills, be paid a little more, get to wear cute scrubs for the first time, and get more responsibility!
This is huge for me. I'm really excited, proud, and nervous.
Med Tech Polly, coming soon!
All told, we've got maybe 2-3 different charge nurses for each shift, and they just take turns, and have 2 med techs. One does M-F, one does Sat-Sunday.
That doesn't leave a lot of wiggle room for call-outs, so sometimes our charge nurses end up having to work a double, and this last weekend our Director of Nursing (DON) had to come in and work a med tech shift, which she didn't like doing since she also had to come be the charge nurse simultaneously. Oops! That means she had to do all the routine med passes, PLUS all the treatements and assessments PLUS all the charting by herself. Ouch.
Med techs/med aides are a fairly new position that mainly work just in nursing homes and assisted living facilities. They can hand out routine meds to people who are able to actually take them independently - meaning that I could hand them a little med cup, say "here's your medicine" and they could then take those pills. If they had to have them crushed and in applesauce, or they weren't able to comprehend that they're taking medication, the nurse has to administer it to them.
Med techs have to be trained, need to have a basic understanding of pharmacology (how drugs interact, what they do, when to give them vs. when to hold them) and be responsible enough to handle narcotics honestly and chart appropriately.
Our DON decided we need another med tech because right now there is no backup if one of our two gets sick or goes on vacation.
Normally she would advertise within the facility to see who might like to apply for it, but this time, at our meeting, she apologized for not doing so but said that she had one person in mind for the job for a while now and was glad that this person accepted the position. She'll be training the new med tech starting this week. The new med tech is ... ME!
That's right, guys, Polly is going to learn a lot of new skills, be paid a little more, get to wear cute scrubs for the first time, and get more responsibility!
This is huge for me. I'm really excited, proud, and nervous.
Med Tech Polly, coming soon!
Wednesday, March 9, 2011
Vasovagal EXTRAVAGANZA!
We had a new nurse on 2nd shift tonight, so all us aides were trying really hard to be helpful, make sure she knew who each resident was so she wouldn't give them the wrong meds, tell her who to take seriously when they did/or said things and who to ignore and they'll stop.
But because she's new, she didn't know the difference between "Polly gently flagging down the charge nurse to come into a resident's room" and "Polly panicking and trying desperately to get your ass in here STAT but I can't leave this woman alone right now". So NewNurse wasn't as fast as I wanted. But it all turned out okay.
You see, there's a little thing called "vasovagal response" or, as you may learn to call it "fainting because you need to poop or are pooping".
This clip from Scrubs illustrates it very nicely:
Yep, it's a real thing. Pooping and fainting. What a combo.
There are a few of my old ladies that have this occasionally, but the one I was working on tonight had not ever done so since I've been working at the GreatRep. So you can see why I was alarmed when Nellie lay limp and unresponsive (but not dead! I checked that first!) in her wheelchair. I patted her hands with increasing force. Called her name with increasing volume. Patted her face. And then I brought out the big guns. Nellie HATES it when you touch her mouth or brush her teeth, and the absolute most annoying thing you can do to her is stick your fingers in her mouth. I popped on a glove and stuck a few in there, to and got no reaction, which is when I panicked and desperately waved NewNurse to come in NOW.
She also couldn't get Nellie to come to for a while, but after we both hollered and patted and pestered the hell out of her for a bit, Nellie cracked one eye open to glare at us, at which point I started breathing again. And got a whiff. And then a big, poo-shaped light bulb went off over my head. It spelled out VASOVAGAL in morse code. And Nellie woke up in time to have the biggest BM I've ever seen her have in my life. I mean softball sized, and round like one too.
Sheesh.
So my little poop-weasel is all right, and was back to normal within a few minutes of passing that beast.
And you know what? Seeing it didn't make me faint too. Whew!
PS Next weekend is my last weekend of clinicals which means I'll have a real live day off on St. Patrick's day! I cannot wait!
But because she's new, she didn't know the difference between "Polly gently flagging down the charge nurse to come into a resident's room" and "Polly panicking and trying desperately to get your ass in here STAT but I can't leave this woman alone right now". So NewNurse wasn't as fast as I wanted. But it all turned out okay.
You see, there's a little thing called "vasovagal response" or, as you may learn to call it "fainting because you need to poop or are pooping".
This clip from Scrubs illustrates it very nicely:
Yep, it's a real thing. Pooping and fainting. What a combo.
There are a few of my old ladies that have this occasionally, but the one I was working on tonight had not ever done so since I've been working at the GreatRep. So you can see why I was alarmed when Nellie lay limp and unresponsive (but not dead! I checked that first!) in her wheelchair. I patted her hands with increasing force. Called her name with increasing volume. Patted her face. And then I brought out the big guns. Nellie HATES it when you touch her mouth or brush her teeth, and the absolute most annoying thing you can do to her is stick your fingers in her mouth. I popped on a glove and stuck a few in there, to and got no reaction, which is when I panicked and desperately waved NewNurse to come in NOW.
She also couldn't get Nellie to come to for a while, but after we both hollered and patted and pestered the hell out of her for a bit, Nellie cracked one eye open to glare at us, at which point I started breathing again. And got a whiff. And then a big, poo-shaped light bulb went off over my head. It spelled out VASOVAGAL in morse code. And Nellie woke up in time to have the biggest BM I've ever seen her have in my life. I mean softball sized, and round like one too.
Sheesh.
So my little poop-weasel is all right, and was back to normal within a few minutes of passing that beast.
And you know what? Seeing it didn't make me faint too. Whew!
PS Next weekend is my last weekend of clinicals which means I'll have a real live day off on St. Patrick's day! I cannot wait!
Sunday, January 23, 2011
Antipsychotic Drugs and Chemical Restraints
At the GreatRep, and pretty much all long term care or memory care facilities, there is a Bill of Rights list for all the residents posted prominently around the building. One of these rights is "to be free of all restraints, including chemical restraints". Logical, right?
As an aide, I have very little to do with the residents' medications. I report symptoms to the charge nurse, who then decides what to do from there. A few of the residents are on frequent doses of the same medications for certain behaviors or symptoms and so we all know what they will probably get in response to our reports of their symptoms. Lillian has severe pain and it's very obvious when it's not being controlled well, so when she hurts we all know she needs her Morphine. LuLu repetitively hits herself, which lets us know it's time for more Haldol or Ativan for her.
A lot of science news articles state that the use of antipsychotic drugs for dementia is a bad practice. It's not intuitive, because if you look at the list of symptoms of say, schizophrenia:
"They include disorganized thought processes and disorganized behavior as well as delusions and hallucinations. The disorganized thought processes are seen primarily in speech such as rambling and 'word salad'. The patient may babble about various different topics one after another, which to the normal person, do not appear to be connected in any way. The phrase 'word salad' describes a patient’s incoherent speech, which lacks correct grammar and any obvious purpose. Disorganized behavior will be discussed in a following section. Hallucinations are false perceptions; patients believe they can hear voices others can’t and sometimes see or feel things others don’t. Delusions are misinterpretations of events and their purpose such as when patients believe the CIA is plotting against them or that their psychiatrist is involved in an assignation attempt against them. Schizophrenics cannot be reasoned with over their delusions; reasoning and discussion leads to the patient’s mistrust and anger." (1)
All of that is very typical of dementia patients as well. You'd think since the symptoms are so similar that the treatments can be as well. But apparently not, since the use of antipsychotics in dementia patients increases their death risk, for reasons unknown(2).
To be clear, it seems like Doctors are warning against antipsychotics to control behavior that is merely "annoying" for caregivers such as wandering, agitation, uncooperativenesss, etc. For behavior that is truly dangerous for the patients or everyone around them (self-injury, extreme combativeness that can physically injure both caregivers and the patient, etc) I think it can still be merited.
Which is why when I read articles like this one, "Alzheimer's Therapy Focuses on Care: Giving Alzheimer's Patients their Way, Even Chocolate"(3) part of me gets really frustrated. It seems like outsiders and the media tend to think that some of the interventions we routinely do on our patients are for our own convenience, and therefore wrong. I loved that it explained about emotional states lasting longer than the patient's ability to recall or explain the reason for the emotion; however I would have liked to have seen a few more realistic examples of how this can be implemented. Things like when one of my widowed residents becomes anxious, thinking her husband is injured and missing, it's more productive to let her talk about that briefly, then steer the topic to her children, who are all alive and well. She calms down and gets happier as she tells us about what they were like when they were little, and shows us the quilt her daughter made her. That way, when the conversation ends, it ends on a happier note, which is more likely to stop her anxiety cycle about her husband. And of course there are the more conventional redirections like trying to get her involved in an activity or focused on something else.
I just hate the idea that we're somehow failing LuLu because sometimes medication is the only way to get her to stop hitting herself. You can redirect her, feed her, hold her hands gently, all sorts of things, but if she's in that mood she will not be deterred and it's not safe for her.
Patients have the right to refuse care, for example. But an incontinent person who refuses to be changed for 8+ hours isn't making a reasonable choice and is endangering themselves by hugely increasing their risk for a pressure ulcer. So sometimes we just have to force someone to let us perform very basic hygeine on them. And it sucks. And sometimes the only way to do that without anyone ending up seriously hurt is to premedicate them, and sometimes even that doesn't work. I wish there were a magic wand to make combative people cooperate when you're trying to help them.
But for all the caregivers and family members who read that article, I want to tell them that baby dolls and chocolate are a part of the answer, and can be good tools, but we need more solutions. And that even as a profession, caregiving is rarely "convenient"; that's not why we do this work. So please give your facility the benefit of the doubt and ask first before assuming they're chemically restraining people for no good reason. It's a last resort, but sometimes it's the only way.
And I don't know if it really belongs on any patient's Bill of Rights. Because the truth is, they do have the right not to be restrained unless they're hurting themselves or others and nothing else will stop them.
1. About schizophrenia http://healthpsych.psy.vanderbilt.edu/AntiPsychoticMeds.htm
2. Antipsychotics and death risk increase http://www.webmd.com/alzheimers/news/20080616/antipsychotics-for-dementia-up-death-risk
3. Giving Alzheimer's Patients Their Way http://www.nytimes.com/2011/01/01/health/01care.html?_r=2&pagewanted=1
As an aide, I have very little to do with the residents' medications. I report symptoms to the charge nurse, who then decides what to do from there. A few of the residents are on frequent doses of the same medications for certain behaviors or symptoms and so we all know what they will probably get in response to our reports of their symptoms. Lillian has severe pain and it's very obvious when it's not being controlled well, so when she hurts we all know she needs her Morphine. LuLu repetitively hits herself, which lets us know it's time for more Haldol or Ativan for her.
A lot of science news articles state that the use of antipsychotic drugs for dementia is a bad practice. It's not intuitive, because if you look at the list of symptoms of say, schizophrenia:
All of that is very typical of dementia patients as well. You'd think since the symptoms are so similar that the treatments can be as well. But apparently not, since the use of antipsychotics in dementia patients increases their death risk, for reasons unknown(2).
To be clear, it seems like Doctors are warning against antipsychotics to control behavior that is merely "annoying" for caregivers such as wandering, agitation, uncooperativenesss, etc. For behavior that is truly dangerous for the patients or everyone around them (self-injury, extreme combativeness that can physically injure both caregivers and the patient, etc) I think it can still be merited.
Which is why when I read articles like this one, "Alzheimer's Therapy Focuses on Care: Giving Alzheimer's Patients their Way, Even Chocolate"(3) part of me gets really frustrated. It seems like outsiders and the media tend to think that some of the interventions we routinely do on our patients are for our own convenience, and therefore wrong. I loved that it explained about emotional states lasting longer than the patient's ability to recall or explain the reason for the emotion; however I would have liked to have seen a few more realistic examples of how this can be implemented. Things like when one of my widowed residents becomes anxious, thinking her husband is injured and missing, it's more productive to let her talk about that briefly, then steer the topic to her children, who are all alive and well. She calms down and gets happier as she tells us about what they were like when they were little, and shows us the quilt her daughter made her. That way, when the conversation ends, it ends on a happier note, which is more likely to stop her anxiety cycle about her husband. And of course there are the more conventional redirections like trying to get her involved in an activity or focused on something else.
I just hate the idea that we're somehow failing LuLu because sometimes medication is the only way to get her to stop hitting herself. You can redirect her, feed her, hold her hands gently, all sorts of things, but if she's in that mood she will not be deterred and it's not safe for her.
Patients have the right to refuse care, for example. But an incontinent person who refuses to be changed for 8+ hours isn't making a reasonable choice and is endangering themselves by hugely increasing their risk for a pressure ulcer. So sometimes we just have to force someone to let us perform very basic hygeine on them. And it sucks. And sometimes the only way to do that without anyone ending up seriously hurt is to premedicate them, and sometimes even that doesn't work. I wish there were a magic wand to make combative people cooperate when you're trying to help them.
But for all the caregivers and family members who read that article, I want to tell them that baby dolls and chocolate are a part of the answer, and can be good tools, but we need more solutions. And that even as a profession, caregiving is rarely "convenient"; that's not why we do this work. So please give your facility the benefit of the doubt and ask first before assuming they're chemically restraining people for no good reason. It's a last resort, but sometimes it's the only way.
And I don't know if it really belongs on any patient's Bill of Rights. Because the truth is, they do have the right not to be restrained unless they're hurting themselves or others and nothing else will stop them.
1. About schizophrenia http://healthpsych.psy.vanderbilt.edu/AntiPsychoticMeds.htm
2. Antipsychotics and death risk increase http://www.webmd.com/alzheimers/news/20080616/antipsychotics-for-dementia-up-death-risk
3. Giving Alzheimer's Patients Their Way http://www.nytimes.com/2011/01/01/health/01care.html?_r=2&pagewanted=1
Saturday, January 22, 2011
What a Winkle
I absolutely love the weird conversations I have with my dementia residents, and there's one that pretty much always takes the cake. "Cookie" hallucinates and can be very difficult to deal with, but she's often very focused on wanting to see a doctor and wanting every person she sees to be a healthcare professional. So I usually address her as Ms. Oven instead of Cookie, and emphasize that I'm a nursing assistant rather than a caregiver in order to get her cooperation. I once had to wrestle a wet incontinence brief away from Cookie, who gave it up only when I told her I needed the sample for the Doctor. Gross.
Anyway, over the weeks, Cookie has come up with some good ones; telling me the Borg are trying to get her when I go to wake her up in the morning, hitting on the life-size dancing Santa that we had up at Christmas, telling my female coworker what a "gorgeous guy" she is.
The other day I went to get Cookie up out of her armchair to go use the bathroom, and she had a little stuffed animal sitting on her walker. "Look at my Baby!" she said, as I approached her, "Isn't he cute? What should I name him?"
Her stuffed animal was a little moose, so I said "How about Bullwinkle?"
Cookie blinked at me for a long moment, then said "He's from . . . where? He's a Winkle, you say? Is he a Winkle?"
I answered "I think he might be, what do you think?"
"Yes, probably. A Winkle."
Oh, Cookie!
Anyway, over the weeks, Cookie has come up with some good ones; telling me the Borg are trying to get her when I go to wake her up in the morning, hitting on the life-size dancing Santa that we had up at Christmas, telling my female coworker what a "gorgeous guy" she is.
The other day I went to get Cookie up out of her armchair to go use the bathroom, and she had a little stuffed animal sitting on her walker. "Look at my Baby!" she said, as I approached her, "Isn't he cute? What should I name him?"
Her stuffed animal was a little moose, so I said "How about Bullwinkle?"
Cookie blinked at me for a long moment, then said "He's from . . . where? He's a Winkle, you say? Is he a Winkle?"
I answered "I think he might be, what do you think?"
"Yes, probably. A Winkle."
Oh, Cookie!
Wednesday, January 12, 2011
P-P-Pollyface has a P-P-P-Plan
The other day I got to play that dancing game for the kinect at a friend's house, and it is SO FUN. But now I think everything in a Lady Gaga way, which is why the title of this entry is full of P-P-P's like P-P-P-Pokerface. I also have been saying scu-ruh-huh-huh-hubs instead of scrubs.
Anway, the point is I have a Plan. Remember how I said I needed to get my butt into school to be a nurse so that I don't have to work this hard for this little money for the rest of my life? Well, I'm registered.
First I'm going to finally go get my CNA Certification, which will get me a (tiny) raise at my current job, and make me qualified to work in a Skilled Nursing Facility if I decide to leave my current job for a different place. I'll also be qualified to work in a hospital but that's more of a pipe dream; most CNA's would like to work in one, but pretty much every CNA works in long term care instead.
Secondly, I did my admission to our local Community College for fall quarter of 2011 to start doing my prereqs. Yeah buddy! I'll keep working while I'm in school, of course, so I'll probably just do one class per quarter. We'll see. I need to get good grades in them so I can be admitted to that baccelaureate program I want to get into to convert my BA into a BSN. So if I want to be a Straight-A Polly, I should probably make sure I'm also Has Time To Sleep Polly.
Look at me, I'm bettering myself! Not buttering myself. Maybe if I buttered myself, I could join the Haus Of Gaga. But buttering myself wouldn't be vegan. Or pleasant.
Anway, the point is I have a Plan. Remember how I said I needed to get my butt into school to be a nurse so that I don't have to work this hard for this little money for the rest of my life? Well, I'm registered.
First I'm going to finally go get my CNA Certification, which will get me a (tiny) raise at my current job, and make me qualified to work in a Skilled Nursing Facility if I decide to leave my current job for a different place. I'll also be qualified to work in a hospital but that's more of a pipe dream; most CNA's would like to work in one, but pretty much every CNA works in long term care instead.
Secondly, I did my admission to our local Community College for fall quarter of 2011 to start doing my prereqs. Yeah buddy! I'll keep working while I'm in school, of course, so I'll probably just do one class per quarter. We'll see. I need to get good grades in them so I can be admitted to that baccelaureate program I want to get into to convert my BA into a BSN. So if I want to be a Straight-A Polly, I should probably make sure I'm also Has Time To Sleep Polly.
Look at me, I'm bettering myself! Not buttering myself. Maybe if I buttered myself, I could join the Haus Of Gaga. But buttering myself wouldn't be vegan. Or pleasant.
Wednesday, January 5, 2011
Bathing the Reluctant: a How-To.
It's my first day off (finally!) after being on for 6 days in a row, so I'm predictably spending the day at home. On the couch, in the bed, or the bathtub. I plan to do laundry and roast some vegetables later, but that's about as enthusiastic as I'll get today. I'm Tired with a capital T.
So when I got a call from the HomeCare agency this afternoon (I'm still "on call" with them, though I've yet to actually go and work a shift for them since switching from regular employee to on-call) I screened it. And then was pleasantly surprised when it was a voicemail from the office staff saying that my former client Gary has recently begun refusing to bathe for his caregiver, the one that took over for me when I left. She wanted to know if I'd be willing for Gary's new caregiver to call me and talk it over with me to see if I could help. Sure!
So now I'm feeling like a (tired) Shower Expert. And wanting to share my super-important knowledge with the world. So if you've ever wondered "how the hell am I going to get that cranky old coot to take a shower?", this one's for you.
Step 1: Assess the need/reluctance:
Lots of elderly people don't like to bathe. They truly don't need to as often (2x a week is just fine - they have thin skin and tend to perspire less than younger folks, and dry out easily if you wash them too frequently). They hate being cold, don't want to get naked in front of anyone, are afraid of falling on a wet, slippery floor, and may have medical equipment (indwelling catheters, ostomy bags) that make showering a hassle. No wonder they say no when you ask them to go hop in. So think about it first; do they actually need one? If yes, do you need to shampoo their hair as well, or can you give them a shower cap and just wash their body, and shampoo their hair in a sink later? Figure out the bare minimum of what needs to happen today, so you know what you're willing to negotiate down to.
Step 2: Prepare.
Before you even mention the word shower to them, go get it set up. Heat up the bathroom so it's uncomfortably hot for you. Make sure their shower chair/stool is in there, as is their shampoo and everything else. Bring more towels than you think you'll need. If possible, put bathmats down from the toilet to the shower. Bring in the clothes you'll be dressing them in afterward.
Step 3: Approach.
Hopefully you already have gotten to know whoever it is you're trying to bathe, so you know what approach works for them. Some people hate surprises, so you really need to tell them ahead of time where you're going. Pitch it in a positive way, with a smile and enthusiasm, "Hey Betty! Guess what? Since today is your shower day, I went and got your bathroom all nice and warm for you, and pulled out that lavender soap you like! C'mon, let me show you what I did!". Others, it's a mistake to mention the word shower until they're already in the bathroom. I have several residents like this. For them, I just say "Let's go use the restroom" and walk them in there. Once they're seated on the toilet, I go ahead and remove their briefs, pants, shoes and socks (this is where the bathmats come in; no bare feet on cold floors). Then and only then do I say, "Okay, Bill, we've already got you halfway ready, which is great! Today is your shower day, so I've got the warm water running, and if you just walk along these mats to the shower, I'll help you get settled in and get all warmed up in there."
Step 4: Overcome resistance.
Once you've pitched the idea, you'll probably get some resistance. Common ones, and responses to them are things like
"I don't need a shower, I just took one"
"It's hard work being beautiful, isn't it?"
or "Time flies, doesn't it? Today is Tuesday, so it's been about a week since last time. It's going to feel so good to get that warm water on, isn't it?"
"Why are you in such a hurry to get me wet?"
"We're not in any hurry. But I want your skin to be clean and healthy, so we need to get you washed up for that to happen."
"I don't want to get in there! I don't want to get wet!"
"I know you don't always like it, but I set everything up really nicely for you today. I think you'll enjoy it. Give me 2 minutes to try it out, and if you don't like it, I'll help you get out and get dressed."
"I don't want my hair wet!"
"Okay, here's a shower cap"
or if that's not an option "Here's a dry cloth to hold over your eyes. I'll aim the water so it stays off your face."
If your patient has advanced dementia and can't really talk or be reasoned with, still set it up nicely, talk them through it in a positive way. They're likely to get combative when you start to undress them, so it might be best to get a buddy to come and help you get through that part as quickly as possible so they don't get any more riled up than they have to. It's fine to leave on socks, for example, if they really won't give them up. They'll want them off later once they're wet.
Step 5: Bathe.
Do whatever it is you promised to do. If you promised not to wet someone's hair, don't surprise them by suddenly hosing down their head. That's not nice. Get them settled on the shower chair, check the water temperature on your inner arm (above your gloves). Chances are, most elderly people will want their shower cooler than you'd take yours. Approximately body temperature. Have them check the temp with their hand first. If they're not able to do that and give you feedback, start at their feet and move up slowly, so they get a chance to acclimate before feeling the temperature on their chest or back. Have them help and participate as much as possible, even if that's only to hold a washcloth to (hopefully) stop them from punching you. Keep talking through what you're doing in a gentle voice "Okay, Sally, here's some warm water for your back. Now I'm going to wash your back with this cloth, and then we'll rinse off all the bubbles. Good! Next let's do your chest" etc. If they're freaking out, do it as fast as possible, and concentrate on armpits and pericare.
Step 6: Finish.
As soon as you turn that water off, cover them in towels as much as is possible. If they walk, put down a dry towel on top of the (closed) toilet lid and help them walk over to it and sit down. If they don't, wrap up their shoulders and back, drape one over their lap, and keep one to start drying their arms and legs. Get them dry, lotioned and dressed as quickly as you can. Usually once they realize you're putting clothes on and not off, they'll relax and help more.
Pat yourself on the back, wipe the sweat off your face, pick up the zillions of wet towels, and spray down that shower with bleach. You did it!
So when I got a call from the HomeCare agency this afternoon (I'm still "on call" with them, though I've yet to actually go and work a shift for them since switching from regular employee to on-call) I screened it. And then was pleasantly surprised when it was a voicemail from the office staff saying that my former client Gary has recently begun refusing to bathe for his caregiver, the one that took over for me when I left. She wanted to know if I'd be willing for Gary's new caregiver to call me and talk it over with me to see if I could help. Sure!
So now I'm feeling like a (tired) Shower Expert. And wanting to share my super-important knowledge with the world. So if you've ever wondered "how the hell am I going to get that cranky old coot to take a shower?", this one's for you.
Step 1: Assess the need/reluctance:
Lots of elderly people don't like to bathe. They truly don't need to as often (2x a week is just fine - they have thin skin and tend to perspire less than younger folks, and dry out easily if you wash them too frequently). They hate being cold, don't want to get naked in front of anyone, are afraid of falling on a wet, slippery floor, and may have medical equipment (indwelling catheters, ostomy bags) that make showering a hassle. No wonder they say no when you ask them to go hop in. So think about it first; do they actually need one? If yes, do you need to shampoo their hair as well, or can you give them a shower cap and just wash their body, and shampoo their hair in a sink later? Figure out the bare minimum of what needs to happen today, so you know what you're willing to negotiate down to.
Step 2: Prepare.
Before you even mention the word shower to them, go get it set up. Heat up the bathroom so it's uncomfortably hot for you. Make sure their shower chair/stool is in there, as is their shampoo and everything else. Bring more towels than you think you'll need. If possible, put bathmats down from the toilet to the shower. Bring in the clothes you'll be dressing them in afterward.
Step 3: Approach.
Hopefully you already have gotten to know whoever it is you're trying to bathe, so you know what approach works for them. Some people hate surprises, so you really need to tell them ahead of time where you're going. Pitch it in a positive way, with a smile and enthusiasm, "Hey Betty! Guess what? Since today is your shower day, I went and got your bathroom all nice and warm for you, and pulled out that lavender soap you like! C'mon, let me show you what I did!". Others, it's a mistake to mention the word shower until they're already in the bathroom. I have several residents like this. For them, I just say "Let's go use the restroom" and walk them in there. Once they're seated on the toilet, I go ahead and remove their briefs, pants, shoes and socks (this is where the bathmats come in; no bare feet on cold floors). Then and only then do I say, "Okay, Bill, we've already got you halfway ready, which is great! Today is your shower day, so I've got the warm water running, and if you just walk along these mats to the shower, I'll help you get settled in and get all warmed up in there."
Step 4: Overcome resistance.
Once you've pitched the idea, you'll probably get some resistance. Common ones, and responses to them are things like
"I don't need a shower, I just took one"
"It's hard work being beautiful, isn't it?"
or "Time flies, doesn't it? Today is Tuesday, so it's been about a week since last time. It's going to feel so good to get that warm water on, isn't it?"
"Why are you in such a hurry to get me wet?"
"We're not in any hurry. But I want your skin to be clean and healthy, so we need to get you washed up for that to happen."
"I don't want to get in there! I don't want to get wet!"
"I know you don't always like it, but I set everything up really nicely for you today. I think you'll enjoy it. Give me 2 minutes to try it out, and if you don't like it, I'll help you get out and get dressed."
"I don't want my hair wet!"
"Okay, here's a shower cap"
or if that's not an option "Here's a dry cloth to hold over your eyes. I'll aim the water so it stays off your face."
If your patient has advanced dementia and can't really talk or be reasoned with, still set it up nicely, talk them through it in a positive way. They're likely to get combative when you start to undress them, so it might be best to get a buddy to come and help you get through that part as quickly as possible so they don't get any more riled up than they have to. It's fine to leave on socks, for example, if they really won't give them up. They'll want them off later once they're wet.
Step 5: Bathe.
Do whatever it is you promised to do. If you promised not to wet someone's hair, don't surprise them by suddenly hosing down their head. That's not nice. Get them settled on the shower chair, check the water temperature on your inner arm (above your gloves). Chances are, most elderly people will want their shower cooler than you'd take yours. Approximately body temperature. Have them check the temp with their hand first. If they're not able to do that and give you feedback, start at their feet and move up slowly, so they get a chance to acclimate before feeling the temperature on their chest or back. Have them help and participate as much as possible, even if that's only to hold a washcloth to (hopefully) stop them from punching you. Keep talking through what you're doing in a gentle voice "Okay, Sally, here's some warm water for your back. Now I'm going to wash your back with this cloth, and then we'll rinse off all the bubbles. Good! Next let's do your chest" etc. If they're freaking out, do it as fast as possible, and concentrate on armpits and pericare.
Step 6: Finish.
As soon as you turn that water off, cover them in towels as much as is possible. If they walk, put down a dry towel on top of the (closed) toilet lid and help them walk over to it and sit down. If they don't, wrap up their shoulders and back, drape one over their lap, and keep one to start drying their arms and legs. Get them dry, lotioned and dressed as quickly as you can. Usually once they realize you're putting clothes on and not off, they'll relax and help more.
Pat yourself on the back, wipe the sweat off your face, pick up the zillions of wet towels, and spray down that shower with bleach. You did it!
Sunday, January 2, 2011
Money Money Honey
You know what sucks? The pay. I make less than a dollar above minimum wage. Let's let that sink in. I'm someone who spends 8 hours a day feeding, toileting, grooming, talking with, dressing, and ambulating people with dementia. I notice changes in condition and report them to my charge nurse. I make sure their oxygen is on and at the correct flow setting. I chat with their family members, and update them on how their loved one is doing.
Most of my coworkers are on food stamps or some other form of public assistance. All of the ones who are single parents are.
The average cost per resident at an Assisted Living facility in my state is a lot of money per month. Remember, I'm in the Pacific Northwest:
The place I work at is always at least 95% occupied. We provide really good care to our residents (and their family members). The management is fair and reasonable. But we make just above a poverty wage, depending on how many people are in our households.
If my husband didn't earn any money, we'd be screwed. A lot of my coworkers also clean houses or do one-on-one care as a second job.
I don't know what the solution is here. Obviously individual families can't afford to pay more rent for their loved ones. Medicare subsidizes some of our residents, but some are private pay.
I don't have a solution for the whole system, but for myself, it's to get my ass back in school. I have a BA in Psychology, but found that I really don't enjoy the type of work in that field that a BA qualifies me for - it's direct care with very difficult populations. Tried it out, hated it, was unhappy, and fled to childcare instead. Then we relocated and I started working with seniors and have really enjoyed that.
I recently found out that I can do an advanced baccalaureate program to convert my BA into a BSN in just 5 quarters. As long as I complete my prereqs at community college first and get good grades in those. HALLELUJAH! My backup plan will still be to go to a technical college and get my LPN, but for almost the same amount of time, I could get my BSN (Bachelor of Science in Nursing) and be qualified to be an RN.
So that's my big goal of 2011. Get into school. Take my prereqs that I'm missing (microbiology, anatomy and physiology with lab, etc.). Because as much as I love my job and the people I care for there, I don't want to get stuck being broke forever.
So I won't.
Most of my coworkers are on food stamps or some other form of public assistance. All of the ones who are single parents are.
The average cost per resident at an Assisted Living facility in my state is a lot of money per month. Remember, I'm in the Pacific Northwest:
The place I work at is always at least 95% occupied. We provide really good care to our residents (and their family members). The management is fair and reasonable. But we make just above a poverty wage, depending on how many people are in our households.
If my husband didn't earn any money, we'd be screwed. A lot of my coworkers also clean houses or do one-on-one care as a second job.
I don't know what the solution is here. Obviously individual families can't afford to pay more rent for their loved ones. Medicare subsidizes some of our residents, but some are private pay.
I don't have a solution for the whole system, but for myself, it's to get my ass back in school. I have a BA in Psychology, but found that I really don't enjoy the type of work in that field that a BA qualifies me for - it's direct care with very difficult populations. Tried it out, hated it, was unhappy, and fled to childcare instead. Then we relocated and I started working with seniors and have really enjoyed that.
I recently found out that I can do an advanced baccalaureate program to convert my BA into a BSN in just 5 quarters. As long as I complete my prereqs at community college first and get good grades in those. HALLELUJAH! My backup plan will still be to go to a technical college and get my LPN, but for almost the same amount of time, I could get my BSN (Bachelor of Science in Nursing) and be qualified to be an RN.
So that's my big goal of 2011. Get into school. Take my prereqs that I'm missing (microbiology, anatomy and physiology with lab, etc.). Because as much as I love my job and the people I care for there, I don't want to get stuck being broke forever.
So I won't.
Saturday, December 11, 2010
Up to the minute technology
Okay not really. But I do like to try out new little tech stuff, even though I barely ever actually KEEP using it (sorry foursquare, I abandoned you a long time ago). So I was listening to one of the podcasts I like and they were answering questions they received via formspring. So now I have a formspring. Which I know very little about.
Basically it's so anyone can ask me questions anonymously, it seems like. In that little pink box over there to the right. And then I'll answer them, woo-hoo!
Let's all give it a shot and see if we can figure it out, huh?
And as long as we're on the topic of podcasts, here are some that I love:
1. The Nursing Show: News, Tips, and Commentary for Nurses and Students
(usually really, really informative and up to date, plus I LOVE the interviews with people that work in different branches of nursing and hearing how they ended up there).
2. Stuff You Should Know
(short overviews of a huge variety of topics, from Jack the Ripper to saunas to why we feel full after eating. Handy and entertaining).
3. Answer Bitch
(hollywood gossip & news, very funny, awesome for long drives or while I'm doing the dishes).
You can find any of them by searching in iTunes or whatever it is you use to listen to podcasts.
Formspring me!
Basically it's so anyone can ask me questions anonymously, it seems like. In that little pink box over there to the right. And then I'll answer them, woo-hoo!
Let's all give it a shot and see if we can figure it out, huh?
And as long as we're on the topic of podcasts, here are some that I love:
1. The Nursing Show: News, Tips, and Commentary for Nurses and Students
(usually really, really informative and up to date, plus I LOVE the interviews with people that work in different branches of nursing and hearing how they ended up there).
2. Stuff You Should Know
(short overviews of a huge variety of topics, from Jack the Ripper to saunas to why we feel full after eating. Handy and entertaining).
3. Answer Bitch
(hollywood gossip & news, very funny, awesome for long drives or while I'm doing the dishes).
You can find any of them by searching in iTunes or whatever it is you use to listen to podcasts.
Formspring me!
Wednesday, December 8, 2010
Odds & Ends
I finished up my evening shift training this week, and it's official: I like 2nd shift better. Not having to wake up at 5am is a big plus, as is only having one meal (dinner) during the shift. The sundowning residents are a drawback. The biggest reason is the coworkers, though. The eve shift coworkers are much more laid back and helpful - day shift coworkers have (99% of the time) been helpful with me (probably because I'm new) but with one another? Not always. Plus one showed up with a disgusting infected finger and was about to go out on the floor to work until we all basically tackled her and got the charge nurse to look at it and send her to a clinic STAT. Ew. No common sense on that coworker, that's for sure.
Tip for the common sense impaired: if any part of your body is swollen and infected, and especially if it's leaking pus, GO HOME AND GO TO THE DOCTOR. Infection can spread to your bloodstream and kill you.
Moving on.
Funniest conversation I had with a resident this week:
Lady (freshly out of the shower, seated safely on dry chair & towel): Can you dry my back?
Me: Sure, here we go.
Coworker pops in, hands me a med cup full of ointment: This is her ointment from the nurse, can you put it on when you do her pericare?
Me: Sure, where?
Coworker: (makes incomprehensible hand gestures)
Me: Bottom or vagina?
Coworker: vagina.
Me: okay thanks.
Lady: Are you gonna put that on my vagina?
Me: Yes Ma'm, I am.
Lady: Do you know what you're doing?
Me: Yes Ma'm, I have my gloves on so I won't give you any germs, and I do know how to do this.
Lady: Well... all right then. Wait a minute. Are you married? (giving me the suspicious stink-eye)
Me (heroically not laughing): Yes Ms. Smith, I'm married. I promise this will not be a personal thrill for me, I just want you to stay healthy, and this is my job. Okay?
Lady (relived): Oh all right then.
I swear, I never know what these people are going to come up with. And what was up with my coworker's crazy gestures? I'm going to do that to her next time I see her. In no world is what she did a gesture for vagina. Maybe "pick up a lobster this way" or "the elves heads are shaped this way" but not "vagina not hiney".
Coolest medical phenomenon I saw this week: Raynaud's phenomenon. It's not harmful or painful or anything, just a startling color change in extremeties when someone is exposed to temperature change. Such as getting out of a warm shower. One of my resident's fingers looked a lot like this photo from wikipedia (the bananafingers not the blue ones). Charge nurse checked and confirmed that was all it was, and they were back to normal very quickly. I'd heard about Raynaud's on a podcast but hadn't seen it in person before, so that was cool.
Other than that, I'm doing my state-required training for the last 3 days of the week, so that'll be boring but maybe useful, and definitely not too tough. Which is good since I burned up my throat with an unfortunate burrito-from-taco-truck choice yesterday and it's still sore, so it's nice not to have to speak EXTRA LOUD for anyone for a bit. Sidenote - wish I could handle spicy food better.
Tip for the common sense impaired: if any part of your body is swollen and infected, and especially if it's leaking pus, GO HOME AND GO TO THE DOCTOR. Infection can spread to your bloodstream and kill you.
Moving on.
Funniest conversation I had with a resident this week:
Lady (freshly out of the shower, seated safely on dry chair & towel): Can you dry my back?
Me: Sure, here we go.
Coworker pops in, hands me a med cup full of ointment: This is her ointment from the nurse, can you put it on when you do her pericare?
Me: Sure, where?
Coworker: (makes incomprehensible hand gestures)
Me: Bottom or vagina?
Coworker: vagina.
Me: okay thanks.
Lady: Are you gonna put that on my vagina?
Me: Yes Ma'm, I am.
Lady: Do you know what you're doing?
Me: Yes Ma'm, I have my gloves on so I won't give you any germs, and I do know how to do this.
Lady: Well... all right then. Wait a minute. Are you married? (giving me the suspicious stink-eye)
Me (heroically not laughing): Yes Ms. Smith, I'm married. I promise this will not be a personal thrill for me, I just want you to stay healthy, and this is my job. Okay?
Lady (relived): Oh all right then.
I swear, I never know what these people are going to come up with. And what was up with my coworker's crazy gestures? I'm going to do that to her next time I see her. In no world is what she did a gesture for vagina. Maybe "pick up a lobster this way" or "the elves heads are shaped this way" but not "vagina not hiney".
Coolest medical phenomenon I saw this week: Raynaud's phenomenon. It's not harmful or painful or anything, just a startling color change in extremeties when someone is exposed to temperature change. Such as getting out of a warm shower. One of my resident's fingers looked a lot like this photo from wikipedia (the bananafingers not the blue ones). Charge nurse checked and confirmed that was all it was, and they were back to normal very quickly. I'd heard about Raynaud's on a podcast but hadn't seen it in person before, so that was cool.
Other than that, I'm doing my state-required training for the last 3 days of the week, so that'll be boring but maybe useful, and definitely not too tough. Which is good since I burned up my throat with an unfortunate burrito-from-taco-truck choice yesterday and it's still sore, so it's nice not to have to speak EXTRA LOUD for anyone for a bit. Sidenote - wish I could handle spicy food better.
Wednesday, November 24, 2010
Dementia in Groups
The GreatRep (where I work) is an Alzheimer's and Dementia care facility. It's secure, which means in order to get outside, you must know the keycode and enter it to get the doors to open. Well, there are secure courtyards outside that anyone can go into whenever they like, but this time of year they don't get much use. Although one of my coworkers did build a tiny snowman outside the window and then took each resident to the window to see it and look at it and talk about the snow for a while, which was cute.
My friend Annie just wrote a post on her blog about her first visit to see her Mom at a facility much like the one I work at. Go read it, she's great, her Mom is great, and her Dad is too! http://tinyurl.com/28tgzbf
What cracked me up about it is that we give graham crackers out every day at 10am at my job! And what made me think is when Annie said "In my head I guess I wanted to imagine that, while we don't understand her in her disease, once she got around other people who had the same disease they could somehow find each other out there in that place where Alzheimer's takes them. But I guess it just takes everyone somewhere different."
I think it's pretty fascinating to watch the ways my residents interact with one another. We have one set of roomates that we refer to as "the twins" even though they aren't related, because these ladies can often be found strolling around together, or in their room reorganizing the closets for the zillionth time, or reading aloud to one another. One of the younger residents there strolls around all the time, patting the hands of whomever she comes across, or just sitting with someone for a while. She doesn't often strike up conversations, but she seems to really like the companionship of just sitting next to someone on the couch.
We've got a few married couples that room together, one of whom hardly talk to each other (or talk much at all anymore) but every day after breakfast we put them next to each other on the couch, and the wife leans over and falls asleep resting her head on her husband. They don't sleep together in the same bed anymore (that sadly doesn't work out very well when there's catheters and memory loss involved) but they're in the room together and they doze next to one another on the couch. The other ones still walk and talk, and they bicker bicker bicker just the way I bet they've always done.
On the more acute wing, mostly the residents don't really talk to one another very much. They're far gone enough that if you want their attention, you need to address them by their name, try to make eye contact or hold their hand, and speak up pretty loudly. So obviously since they all need that, none of them can really do that for one another. There are a few exceptions, of course. One of my favorite people there, Bonnie, is also on the younger end and has excellent hearing. When I'm feeding her lunch, she'll quietly respond to what someone on the other side of the dining room says, so if a coworker way over yonder says "Is Maxine ready for dessert?" Bonnie will say, so only I can hear her "Yep, she sure is". Bonnie is the one who says really cute things sometimes, like when a coworker told her "Oh, Bonnie, you are something else!" after she'd cracked us up, Bonnie answered "No I'm not I'm always just a Bonnie".
With dementia, it seems like those little moments mean a lot to those of us on the outside. Little peeks into the universe our loved ones are living in right then. And when they connect with each other, and I'm watching, it can make me so glad to have been there. I love walking away after settling someone at the table and overhearing two of my little old ladies that I see every day go "I don't know who that is, but she sure is a nice girl" and another reply "I don't know either but I think she's very sweet". I even got happy when one of my most confused ladies gave me a kiss on the cheek and told me "You're a nice boy".
I know some of the people with dementia feel lonely a lot, because they don't know that you've just spent 20 minutes holding their hand and talking to them; if you're not doing it right then, it doesn't count. But I think a lot of them have some pretty rich inner lives, given the stuff that will occasionally come through in those moments of clarity. I just wonder if they value those moments any differently than all the rest of their time. I know us outsiders do, because those are the moments we feel like we really connected with them.
But today I worked West 1 again (remember how I got my ass kicked all day last time?) and when I went to get Genivieve up, her daughter was sitting, watching her sleep, and holding her hand. Her daughter kissed her Mama goodbye and chatted with me for a few minutes, then headed out so I could start getting Genvieve ready for the day. And you know what? Genvieve was shockingly gentle and relaxed for me. She didn't hit, bite, scratch or spit. She let me help her, and even gently patted my hands. Even though she was asleep while her daughter was with her, I wonder if that didn't make a difference for Genvieve. Maybe it was a coincidence, but maybe not.
My friend Annie just wrote a post on her blog about her first visit to see her Mom at a facility much like the one I work at. Go read it, she's great, her Mom is great, and her Dad is too! http://tinyurl.com/28tgzbf
What cracked me up about it is that we give graham crackers out every day at 10am at my job! And what made me think is when Annie said "In my head I guess I wanted to imagine that, while we don't understand her in her disease, once she got around other people who had the same disease they could somehow find each other out there in that place where Alzheimer's takes them. But I guess it just takes everyone somewhere different."
I think it's pretty fascinating to watch the ways my residents interact with one another. We have one set of roomates that we refer to as "the twins" even though they aren't related, because these ladies can often be found strolling around together, or in their room reorganizing the closets for the zillionth time, or reading aloud to one another. One of the younger residents there strolls around all the time, patting the hands of whomever she comes across, or just sitting with someone for a while. She doesn't often strike up conversations, but she seems to really like the companionship of just sitting next to someone on the couch.
We've got a few married couples that room together, one of whom hardly talk to each other (or talk much at all anymore) but every day after breakfast we put them next to each other on the couch, and the wife leans over and falls asleep resting her head on her husband. They don't sleep together in the same bed anymore (that sadly doesn't work out very well when there's catheters and memory loss involved) but they're in the room together and they doze next to one another on the couch. The other ones still walk and talk, and they bicker bicker bicker just the way I bet they've always done.
On the more acute wing, mostly the residents don't really talk to one another very much. They're far gone enough that if you want their attention, you need to address them by their name, try to make eye contact or hold their hand, and speak up pretty loudly. So obviously since they all need that, none of them can really do that for one another. There are a few exceptions, of course. One of my favorite people there, Bonnie, is also on the younger end and has excellent hearing. When I'm feeding her lunch, she'll quietly respond to what someone on the other side of the dining room says, so if a coworker way over yonder says "Is Maxine ready for dessert?" Bonnie will say, so only I can hear her "Yep, she sure is". Bonnie is the one who says really cute things sometimes, like when a coworker told her "Oh, Bonnie, you are something else!" after she'd cracked us up, Bonnie answered "No I'm not I'm always just a Bonnie".
With dementia, it seems like those little moments mean a lot to those of us on the outside. Little peeks into the universe our loved ones are living in right then. And when they connect with each other, and I'm watching, it can make me so glad to have been there. I love walking away after settling someone at the table and overhearing two of my little old ladies that I see every day go "I don't know who that is, but she sure is a nice girl" and another reply "I don't know either but I think she's very sweet". I even got happy when one of my most confused ladies gave me a kiss on the cheek and told me "You're a nice boy".
I know some of the people with dementia feel lonely a lot, because they don't know that you've just spent 20 minutes holding their hand and talking to them; if you're not doing it right then, it doesn't count. But I think a lot of them have some pretty rich inner lives, given the stuff that will occasionally come through in those moments of clarity. I just wonder if they value those moments any differently than all the rest of their time. I know us outsiders do, because those are the moments we feel like we really connected with them.
But today I worked West 1 again (remember how I got my ass kicked all day last time?) and when I went to get Genivieve up, her daughter was sitting, watching her sleep, and holding her hand. Her daughter kissed her Mama goodbye and chatted with me for a few minutes, then headed out so I could start getting Genvieve ready for the day. And you know what? Genvieve was shockingly gentle and relaxed for me. She didn't hit, bite, scratch or spit. She let me help her, and even gently patted my hands. Even though she was asleep while her daughter was with her, I wonder if that didn't make a difference for Genvieve. Maybe it was a coincidence, but maybe not.
Monday, November 8, 2010
Quickly
I'm tired and haven't even really thought about making dinner yet (there's always bread, hummus, and spinach salad, right?) so this will be very brief. I started my new job today at the GreatRep, and I LOVE it.
There are enough staff that we get to actually take good care of our residents, the facility is designed and run well, there's an excellent housekeeping staff that does all the things that need to be done so that the care staff can concentrate on direct care, and there's lots of teamwork among the caregivers.
I really think I'm going to be happy there!
And dayshift (06:00-14:00) goes by really quickly, which is nice. I hadn't done it before, only evening (14:00-22:00) and noc (22:00-06:00. Three more days of training on dayshift, and then a WEEKEND (as in TWO CONSECUTIVE DAYS OFF) for me!
Love love love love love love love . . .
There are enough staff that we get to actually take good care of our residents, the facility is designed and run well, there's an excellent housekeeping staff that does all the things that need to be done so that the care staff can concentrate on direct care, and there's lots of teamwork among the caregivers.
I really think I'm going to be happy there!
And dayshift (06:00-14:00) goes by really quickly, which is nice. I hadn't done it before, only evening (14:00-22:00) and noc (22:00-06:00. Three more days of training on dayshift, and then a WEEKEND (as in TWO CONSECUTIVE DAYS OFF) for me!
Love love love love love love love . . .
Friday, October 29, 2010
Choosing a Nursing Home Part 2
I did my last noc shift night before last, which means I have more time now again! In fact, my new job is split day/eve shift, but never both in one day, and I'll always have 2 days off in a row; isn't that called a weekend? I can't remember. It sounds heavenly though.
So now I have time to share my hard-learned lessons on choosing a nursing home to live or work in. I think they can be the same post, because if a nursing home is bad to work in, it's probably bad to live in. The reason residents are there is to get care, and if the employees are miserable, the care is going to be substandard. If the employees are happy, the residents are happy, and it creates a happy cycle.
I made some big mistakes on my last job hunt; I let schedule and pay dictate which facility I chose, and overlooked some red flags. I'm actually pretty embarrassed about that, but at least I can come clean here so any readers (hopefully) won't do the same things. I was just so focused on finding a job that would allow me to keep my homecare job that I chose the wrong facility. If I'd been willing to give up my security-blanket job at the homecare agency earlier, I think I'd have chosen differently. Oh well, here I am about to start at the GreatRep, so it all is for the best now!
Mistakes I made:
1. On my tour of the facility, I didn't insist on seeing into any of the resident rooms.
Realistically, this may not have saved me, because usually you don't get to see one that's currently occupied. The "model" room or apartment is usually empty and therefore looks perfect. But at the Crapdorable place, I had no idea that around 20% of the residents sleep on mattresses on the floor. It's for safety, to keep them from falling out of bed, which makes sense and all, but is incredibly hard on the caregiver's body that has to try to change their briefs and reposition them while kneeling on the ground next to them. This is why I was limping after each 4 day rotation there. The other reason to ask to see the rooms is to see what type of beds they have (if the facility provides them) and whether they're adjustable or appropriate for employee and resident safety.
2. I didn't ask the hard, slightly rude questions.
I did ask about aide to resident ratios, length of shifts, etc. But I didn't ask about how long management had been in place, whether there were any recent or upcoming changes there (new Executive Directors, new Administrators, etc). I didn't ask about their employee retention rate (20% at the Crapdorable place - huge red flag that I wish I'd known before I began there). I didn't ask about their call-out policy; if the answer is "you can't leave until the next shift arrives" this probably isn't a good place. Of course you can't leave, that's common sense that you cannot abandon patients. However, a good answer is "If there's a no-call no-show, your manager will find someone to come in, and will make sure the floor is covered in the interim". An excellent answer is "We provide an incentive for anyone who comes in on their day off so it's usually pretty easy to find coverage". A typical, reasonable (in my mind) policy is that if you call out, you must find your own replacement. The idea here is to discourage people from calling out hungover, or for other fishy reasons. Each employee gets a phone list, and usually if you're calling out for a real reason and have tried to find coverage and can't, a good manager will help you from there.
Another big question that's good for families AND employees to ask is "how full is your facility?" (aka what is your census like). If it's very nearly empty, proceed with caution. Sure, there's a recession, and more people are trying to make do with home care. But the good places will still be fairly full. Because locals have heard good things about them and prefer to put family there, rather than the sketchy ones. And if the answer is "lower than normal because of stop-admittance orders" RUN AWAY. Remember, that means they did something so bad they cannot allow new residents to move in for a set period of time. BAD.
3. Take a good look at the residents and employees you see during your tour. Do the residents look clean and kempt? Is their hair greasy, or is it combed pretty neatly. Do they themselves smell bad at all? Are their clothes weather appropriate and fairly clean? If it's a dementia facility, lower your standards a bit, because the residents often resist care, but still should get as much as possible. If they look visibly dirty, or unwashed, or their clothes obviously haven't been changed for days, this is a bad place. Now how about the employees? Are their uniforms clean? Is their hair reasonably done? Are they wearing inappropriate makeup? Do they look professional, or do they look like they should be smoking out back of a gas station? I know I'm judgemental here, but if the employees look trashy, it's a warning sign. If the employees look like they could be posted on www.peopleofwalmart.com it's not a great sign.
4. Lastly, smells. Any bad smells should be temporary. Or have a specific reason for them. If the entire place smells like old pee, it's because it's covered in old pee. The hallways absolutely shouldn't stink. Individual rooms sometimes might, especially if the resident living there has a habit of peeing on the floor (many do) or has frequent UTI's. Nonetheless, staff should be working on it to keep it to a minimum. A stinky place is probably not a clean place.
So now I have time to share my hard-learned lessons on choosing a nursing home to live or work in. I think they can be the same post, because if a nursing home is bad to work in, it's probably bad to live in. The reason residents are there is to get care, and if the employees are miserable, the care is going to be substandard. If the employees are happy, the residents are happy, and it creates a happy cycle.
I made some big mistakes on my last job hunt; I let schedule and pay dictate which facility I chose, and overlooked some red flags. I'm actually pretty embarrassed about that, but at least I can come clean here so any readers (hopefully) won't do the same things. I was just so focused on finding a job that would allow me to keep my homecare job that I chose the wrong facility. If I'd been willing to give up my security-blanket job at the homecare agency earlier, I think I'd have chosen differently. Oh well, here I am about to start at the GreatRep, so it all is for the best now!
Mistakes I made:
1. On my tour of the facility, I didn't insist on seeing into any of the resident rooms.
Realistically, this may not have saved me, because usually you don't get to see one that's currently occupied. The "model" room or apartment is usually empty and therefore looks perfect. But at the Crapdorable place, I had no idea that around 20% of the residents sleep on mattresses on the floor. It's for safety, to keep them from falling out of bed, which makes sense and all, but is incredibly hard on the caregiver's body that has to try to change their briefs and reposition them while kneeling on the ground next to them. This is why I was limping after each 4 day rotation there. The other reason to ask to see the rooms is to see what type of beds they have (if the facility provides them) and whether they're adjustable or appropriate for employee and resident safety.
2. I didn't ask the hard, slightly rude questions.
I did ask about aide to resident ratios, length of shifts, etc. But I didn't ask about how long management had been in place, whether there were any recent or upcoming changes there (new Executive Directors, new Administrators, etc). I didn't ask about their employee retention rate (20% at the Crapdorable place - huge red flag that I wish I'd known before I began there). I didn't ask about their call-out policy; if the answer is "you can't leave until the next shift arrives" this probably isn't a good place. Of course you can't leave, that's common sense that you cannot abandon patients. However, a good answer is "If there's a no-call no-show, your manager will find someone to come in, and will make sure the floor is covered in the interim". An excellent answer is "We provide an incentive for anyone who comes in on their day off so it's usually pretty easy to find coverage". A typical, reasonable (in my mind) policy is that if you call out, you must find your own replacement. The idea here is to discourage people from calling out hungover, or for other fishy reasons. Each employee gets a phone list, and usually if you're calling out for a real reason and have tried to find coverage and can't, a good manager will help you from there.
Another big question that's good for families AND employees to ask is "how full is your facility?" (aka what is your census like). If it's very nearly empty, proceed with caution. Sure, there's a recession, and more people are trying to make do with home care. But the good places will still be fairly full. Because locals have heard good things about them and prefer to put family there, rather than the sketchy ones. And if the answer is "lower than normal because of stop-admittance orders" RUN AWAY. Remember, that means they did something so bad they cannot allow new residents to move in for a set period of time. BAD.
3. Take a good look at the residents and employees you see during your tour. Do the residents look clean and kempt? Is their hair greasy, or is it combed pretty neatly. Do they themselves smell bad at all? Are their clothes weather appropriate and fairly clean? If it's a dementia facility, lower your standards a bit, because the residents often resist care, but still should get as much as possible. If they look visibly dirty, or unwashed, or their clothes obviously haven't been changed for days, this is a bad place. Now how about the employees? Are their uniforms clean? Is their hair reasonably done? Are they wearing inappropriate makeup? Do they look professional, or do they look like they should be smoking out back of a gas station? I know I'm judgemental here, but if the employees look trashy, it's a warning sign. If the employees look like they could be posted on www.peopleofwalmart.com it's not a great sign.
4. Lastly, smells. Any bad smells should be temporary. Or have a specific reason for them. If the entire place smells like old pee, it's because it's covered in old pee. The hallways absolutely shouldn't stink. Individual rooms sometimes might, especially if the resident living there has a habit of peeing on the floor (many do) or has frequent UTI's. Nonetheless, staff should be working on it to keep it to a minimum. A stinky place is probably not a clean place.
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