Choosing a Nursing Home: Part 1

Since I'll be leaving my current Assisted Living facility soon, I'm on the hunt for a new job. But not just any new job, one that I'll actually be able to stay at for more than a few months. It occurred to me that now that I've been "behind the curtain" at one facility, I'll have a much better idea of what to look for in the future, so hopefully I won't get burned again. And if anyone out there who's reading this wants to know how to find a decent facility for yourself (work) or to live in (for a family member) maybe reading my thought process on this will be helpful. Since I don't want to give out the real information about where I live, I'll do this as if I were looking for one for my faithful reader Annie's Mom, in Chicago IL.

I'll start by looking up nursing homes in Cook County, Illinois on the medicare.gov site.

This search gave me waaaaaaaay too many results, so I'm choosing to narrow it down by searching only for nursing homes with Resident and Family councils. I want this because it makes it easier for me to address issues if I have questions or dislikes about the way my parent is being cared for. Now we're down to just 59 nursing homes, which is tons more than we have in my whole county where I actually live. This is more results than I'm used to! What should I sort by now? STAFFING RATING. Using the pulldown tab, I can re-arrange the 59 homes in Cook County with Councils so that the most-staffed are on top. Staffing is so important because it doesn't matter how great the CNA's, nurses, and med techs are at any one place; if there aren't enough of them, the care will suck. And if a place is always understaffed, the staff there won't be great; the good ones will get out asap and all that'll be left are the people who won't or can't go find a better job.

You need plenty of staff in order to answer call bells in a timely manner, prevent falls from residents who get frustrated with wating and try to do things for themselves, prevent neglect that can lead to bedsores, and reduce medication errors that can happen when one person is overworked and trying to dose a huge number of patients. Staffing is key. Here are my 59 homes sorted now.


Next I'm going to look for some that are nearby, because I want to be able to come in regularly to see my family member. This is another great way to be sure someone is being cared for: be present. Don't bug staff if you can't find Mom's nonskid sock when she has more in the drawer, or to ask why she's not going to such-and-such activity if it clearly isn't within her skill set (hint: she should be able to move her hands and arms, hear, and see if you want her going to BINGO). But if she's not eating, offer to sit and help feed her for a meal; sometimes confused or stroke patients really need a lot of time and help to eat and staff just can't do it every time. Does she seem to be in pain? Ask about her meds: do they need to be increased? Do you need to call her doctor to get an order for this? That kind of stuff is invaluable.

From list I have now, I'm looking for ones that are in proximity to my home, are well-staffed, and have a decent overall star rating. Don't weight this star rating as heavily as you may be tempted to. In the county where I actually live, the highest rated home is only 3 stars, and the one that I personally (though observation) think is the best is only a 2. These are not crappy places and the people there aren't suffering. I don't know why they are rated so low, but I'd be happy to work or live in them.

The thing that I would check before making a final decision is to see what specifically, if anything, the facility is under "enforcement letters" for. This will tell you what deficiencies state inspections found and what they were, plus what the consequences for the facility were. In general, the more $ the facility had to pay the state, the more serious the problem. If they had to stop accepting new residents, it's because the wrong thing was considered serious. If they had to stop accepting residents for a long time and then that time got extended? I wouldn't want to live or work there. Management isn't able to resolve problems with any speed.

This is where it gets to be a pain in the ass. Not every county and state tells you exact details about this stuff online. Your best bet is to go via the county health department website, like this.


In my state, you can read the entire text of the enforcement letters. The facility I currently work at had some because staff wasn't then in the habit of searching residents' rooms for smoking paraphernelia or escorting them out to smoke every time, so it was deemed a fire hazard. This was corrected within the first "stop admittance" period, so I wouldn't say it's an unsafe place to live.

Another facility closer to my house that I was thinking about applying at has enforcement letters for failing to protect residents in the locked memory care unit from being abused by another resident. Yikes. This could be as simple as that Mr. Hennessey goes nuts with sundowning every evening and smacks whoever is in reach of him. But if that's the case, staff should be able to obtain an order for a sedative to be given to him every evening in order to keep other residents from being smacked. And since the type of abuse wasn't specified, I'm staying far, far away from that one.

Coming up in part 2: So now that we've narrowed it down to homes near your house, with good staffing, and no outstanding problems, we're ready to go visit in-person and see what we think.

(Temporarily) Hanging up my Stethoscope

Nursing Assistants are held to different standards of education and certification from state to state. Where I live, one can be a Nursing Assistant Registered (which I am) with very little classroom education. All of the practical skills I've learned, from taking vitals to transferring to catheter care, have been through on-the-job training and experience. If I were to become a Nursing Assistant Certified (which is my next goal) I'll re-learn a lot of those skills in a classroom environment combined with "clinical hours" at a participating facility. 75 hours worth of education, to be exact.

In order to be employed at an Assisted Living facility as an NAR (that's me!) I have to take this shorter, simplified training that is intended to cover all the basic caregiving skills. When I got hired at my current facility, the woman who hired me told me they'd be giving me that basic caregiver training. This is pretty standard for old folks' facilities in my state.

Now that the due date for that training is approaching, the woman that hired me has taken that promise back. She told me that I must pay for the training myself, and also that the facility won't pay for any of my training time. With the cost of the course plus lost hours & wages I'd be losing a full week's pay. A fourth of my monthly budget.
Nice, huh?

I went through all the channels, talked to the Nursing Director, and to Labor and Industries. Turns out this is a legal demand for them to make.

Which leaves me with just one option: quitting.

I turn in my notice tomorrow, and by the end of September, I won't work there anymore. No more Lanie disassembling her air conditioner, no more coworkers asking God "Where's my husband? I need someone to bang!" during dinner break. No more "flight risk" posters, or shift reports about someone's "butt cheeks". Sad!

And since my other job is as a private (nonmedical) caregiver, I'll be hanging up my stethoscope until I can find a replacement job.

The bright side is that by not wasting my education budget on a caregiving course, I will keep saving up for the Nursing Assistant course I really want to take. That'll open a lot more doors for me in terms of being employable not just in Assisted Living, but also in Skilled Nursing facilities or hospitals.

But until then, I'm frustrated and angry.

Aides and Caregivers are the ones who spend the most time with our elderly. We're the ones who know their quirks and personalities, the ones who are most likely to catch symptoms and advocate for treatments before a condition gets out of hand. We work incredibly hard for very low pay. And unfortunately, the management at this facility isn't at all unusual; a lot of times they suck. Being a Nursing Assistant means having to be vigilant to ensure you're actually paid for all the time that you work, and trying to avoid being put in impossible situations by management.

When I come up with a good solution for this dynamic, I'll be sure to let you all know. Obviously, the system isn't working right for the workers or the elderly. I know my residents will miss me, and I'll be worried about some of them. There are one or two right now that seem to only cooperate in getting bathed and dental care when I am doing it. Hopefully they'll form good relationships with whoever replaces me, and not refuse cares. But I'd rather be there doing it, and I'd guess their families would rather I was too. Something needs to change, here.

I just don't know how to do it.

Neglect

I see some weird situations in my line of work. Families who get up in arms about every little thing (such as how many fun-sized candy bars in the "for staff" dish are being eaten daily) and families who are almost impossible to get a hold of so we end up improvising mightily to try to get the resident's needs met. Old people who insist on wearing multiple pairs of underwear, or none at all. People who swear up and down that they lost a box of puppies, or that I work for the railway.

But the weirdest and saddest thing I see is neglect.

We got a new resident this weekend at my facility, who apparently was moved in by his private caregiver, to whom he pays the ungodly amount of $4,000 per month. Caregiver dropped him off and then took the weekend off. The marketing director at my facility apparently thought this was okay, even though she did the intake interview (not the director of nursing, which is who should have been given the opportunity to assess him before he moved in) and should have known that he cannot walk unassisted AT ALL. This is her job. To find out if people are a good match for what we can offer them, and to be sure they will be cared for adequately if they move in with us. She didn't do that. She failed, completely, at her job in this case.

So, since he was supposedly independent and his caregiver took off, this poor man spent the night in his armchair, peeing into a cup when he needed to pee. In the morning he tried to get up, and fell. Was taken to the hospital in an ambulance, and was readmitted to our facility and now suddenly needs to be on assistance. So I'm in his room, trying to figure out what stinks of urine (everything) and how I'm going to get this man cleaned up. His daughters have flown in from another state, horrified at the situation. They're in there, and I'm giving them a shopping list (waterproof bed pads, vinegar, briefs, hernia belt, etc.) and directions on how to get to the stores that sell this stuff.

The marketing director, who, along with the criminally neglectful "caregiver", created this mess, comes breezing in and pulls me into the other room to tell me to "call him Sir" rather than Mr. So-and-So, which I was doing. Then, as if to soften that blow, mouths "Don't worry, you're doing a good job" to me.

Oh. Hell. No.

Normally I appreciate hearing thanks or validation about my work. I love it when my residents say "Thank you so much honey" and give me hugs when I tuck them into bed. It makes me a little teary when they say "I'll miss you, doll, come say goodnight if you have a chance before you go home. Drive carefully!". This is a job where I feel I am making a difference every single day. And I love that.

But do I need validation from this woman who created a situation where the Director of Nursing's BEST option was to let this man fall so his family would see he needs help from sane people? No, no, no, I do not.

I'm not ashamed to admit that I fantasized about putting his filthy blankets in her office and suggesting that she wash them for Sir. Or tossing her the most disgusting hernia support belt I've ever seen in my life and watching her catch it with bare hands. Or telling her to brush this man's teeth, which were so discolored at this point, I won't even tell you what it looked like when I finally did get him to let me clean them.

What I do is difficult. And I don't need any fake-ass "compliments" from people who just don't get it, even if they work in eldercare and should know better.

And this poor man's "caregiver"? The family is prosecuting her. So my new resident is being cared for, and the person that neglected him is caught. Now that's a happy ending in my book. Though I may still have to find a way to put something disgusting in the marketing director's office ... and then tell her what a good job she's doing while she cleans it up.

Shift Reports: Take it to the next level

Even though we use shift reports to communicate among nursing staff about what our residents have been up to, sometimes a resident will misbehave so outrageously or so consistently that management decides ALL the employees should know about it and be on the lookout. This usually comes down to the people who keep trying to escape (ie "flight risk") and those who really, really, REALLY don't want to be on any kind of diet.

You wouldn't think those two things would be on par with one another in terms of inconvenience, but you've never seen an octogenerian ranting and raving in the dining room about having to eat "grass" at every meal (salads) or about not being able to get a second dessert. They can get loud!

So when someone takes it up to that next level, management prints up a flyer or 10 and leaves them in employee-only areas: kitchen, break room, nursing station, and by all employee exits. That way, when the teenage boys from the dish pit are headed out back to smoke, they know that if they hear someone on the other side of the fenced courtyard saying "Open the gate, let me out!" that they shouldn't. For example. Or when the waitstaff sees Mr. Whomever sitting there for an hour waiting for shift change so he can order a second lunch, they need to call an aide (like me) to convince him to move it along and wait until dinner time.

My favorite thing about these flyers is how much they look like Wanted posters at the post office. I like to imagine the "flight risk" residents strolling away from the building in slow motion, with Bon Jovi's Wanted Dead or Alive playing in the background. Who says that the "steel horse I ride" can't be a walker or mobility scooter instead of a motorcycle?

Add to that the complete awkwardness of most of the photos used in the flyers, and you end up with something like this:

RESIDENT NAME: Mrs. Ballyhoo
[followed by an awkward photo of said resident, such as this one I found by googling "Grandma"]

ATTN: FLIGHT RISK
DETAILS: Resident has Alzheimer's and is a flight risk. If you see resident unattended, please escort her back to the memory care unit. Under no circumstances should you open a door for this resident.

or something more benign, like:

RESIDENT NAME: Mrs. WhoDat
[another google result for Grandma]

ATTN: Diabetic
DETAILS: Resident is noncompliant with diabetic diet. Offer her the "special" pie and do not say it's sugar free. Resident will stay at table and order multiple lunches. Call nursing staff if this happens. Small portions only.

For whatever reason, these fliers crack me up. Especially when a lot of people have been rebelling and the walls are practically plastered with them. The kitchen always has a lot, saying who needs thickened liquids (ew) and who needs their food mechanically softened. But when the back door to the facility starts getting filled up, you know it's been a long week!

Shift Reports

One of my absolute favorite parts of my job at the facility is coming in and catching up on the week's shift reports. Each shift (day, evening, noc/overnight) the aides and nurses write down anything notable that applies to our residents. That way, each shift, as they come on, gets a verbal report where we hit the highlights (Mr. Smith needs to catch the bus to go to the bank, Mrs. Jones fell earlier, Mr. Brown is drunk again) and then can read in the shift report for any further details.

Generally what makes the reports funny is what our residents have been up to. This week, for instance included the following gems:

Noc shift "Mr. X paged at 4am. When I responded to his call light, he asked where his daughters are. I told him they had gone home two days ago and would be back to visit again soon. Resident was confused, asked, 'Well ain't I in heaven?'. Told him he's still alive and was probably dreaming. He said 'ok' and went back to sleep."

Apparently heaven is a giant nursing home where we all have page buttons to ask the big questions in life, or get our briefs changed. Who knew?

I also liked: Noc shift "Went in at 3am for location verification check on flight-risk resident in apt. 123. She woke and started screaming for me to 'Get the hell out'. Resident was in correct location, as expected."

Then there are the ones that are funny because of typos or spelling errors that the staff has made. I was signing off on all our new care plans for our new residents yesterday, and saw that apparently one old man is "ablaze to get in and out of bed unassisted". Damn, he must be motivated!

I also like ones along the lines of "resident has a bruise on butt cheek" or "small sores on both sides of the crack". Descriptive and clear, just not professional. Same with "Evening shift please remember to take out so-and-so's bathroom trash before she goes to bed. No one can stand the stench".

My final favorite things to see in the shift reports are about our residents who hide the stuff they don't like. Don't think that TED hose (tight socks for diabetics) are comfortable? Hide them. Dislike your dentures? Stash them somewhere weird. I love seeing "Housekeeping found TED hose under bed. Told resident if he keeps hiding them his daughters will have his doctor prescribe another pair at his expense. States he doesn't care and will never wear them. TED hose missing again". And "upper dentures found wedged in easy chair cushions. Removed and cleaned, put in soaking cup with polident. AM shift, please encourage resident to wear them tomorrow".

Shift report logs = comedy gold, don't you think?

Crossing the line

The other day, in between shifts, I stopped at a fast food restaurant for a rice and bean burrito. Tasty! Since the home I was headed to doesn't have any toilets without "hats" in them to collect urine, I figured I'd better use the bathroom there. I walked in and was hit with that cloying, suffocating smell, and instead of thinking "Oh gross, jeez!" like a normal person, I thought "Oh! It smells just like Mrs. So-and-So's bathroom! Does someone in here have an ostomy bag?". Then I saw that one of the stalls had an out of order sign on it and probably something ungodly was in there.

That's when I knew I'd crossed the line and would never have a normal sense of what is and isn't disgusting again. I think it's inevitable when you spend your days toileting, changing, bathing and all around dealing with sick and elderly people.

It takes something really beyond the pale to get to me anymore, and if something does manage to grab my attention through sheer revulsion on my part, it's probably making me laugh at the same time.

So in no particular order, here's the short list of things I still get grossed out by. It's not for the squeamish!

1. Changing a brief or doing peri-care on a male who has a "#3" in there. If you're not familiar with this term, use your imagination. It's not a #1 or #2, although the presence of either or both of these increases the horror exponentially. Nope, a #3 is the other thing that can exit the urethra. Yep. Ew.

2. Poop on the shower floor. Something about the wet plopping sound and the way the steam just turns it into a vaporizer of fecality that will have you longing for Vicks or anything strong and mentholated to coat your nasal passages in. And the cleanup is a real bastard.

3. The smell of old, stale urine, especially if the urinator has a UTI or has been drinking alcohol. You wouldn't think it could possibly smell as strongly as poop, but it sure can.

4. The smell of blood mixed with any of the preceding three ickies. Adding in the smell of blood to any of those is the only thing that currently makes me gag and dry heave immediately.

What about you all, which of these is the grossest to you? If anyone says "none" and means it, you deserve a bronzed section of intestine to show what a strong stomach you have.

See, it stuff like this that makes healthcare workers into a subculture. No one else wants to hear about this junk, let alone thinks it's as funny as we do!

Paternalism

I've written here before about dignity being a hot topic among those in the eldercare field. This month, I've been thinking a lot about rights and paternalism. We're working with adults, and they generally retain the rights all adults have: to vote, to make financial decisions, where to live, etc. A few of our residents have court-appointed guardians (family members) because they weren't able to handle those rights anymore. But for the most part, you can't really tell your parents or grandparents what to do unless they're so confused they don't notice you're doing it. We use words like "encourage" and "persuade" and "offer" a lot when talking about getting our residents to bathe, eat, take their meds, etc. Because that's all we really can do. It's easy to think of old people as overgrown children (especially because bald, toothless, and diapered describes babies just as well as very old people). But they're not children, and don't want to be talked to like they are. Usually that makes sense to me, and there aren't many rights that I want to take from the people I care for. The "right" that I have the most difficulty with at my facility, though, is the right to get drunk.

The idea of an elderly alcoholic is a little weird and off putting, probably because you either had one in your family, or because you think old people are unintelligible and clumsy enough sober. I wonder if we know fewer elderly alcoholics because the WWII generation tends to hide it more, or because alcoholics usually die younger?

At any rate, the fancy-shmancy AL facility I work at has a bar, and has a handful of alcoholic residents. This adds up to a lot of falls and a lot of belligerence for staff to handle. We're constantly speculating as to why the bartenders serve as many drinks per resident as they do, but my instinct tells me that they probably want to avoid the ugly scene that happens when you cut a drunk off, so they cave.

This weekend, I had a run-in with one of my drunken "frequent fliers/fallers". While he was still sober before dinner, I took him outside to smoke. Residents who smoke have to turn over their matches, lighters and cigarettes to nursing staff, and we store them where we keep the meds. If they want to go out to smoke, a lucky aide (sarcasm here - I'm a nonsmoker) gets their things and escorts them out, then takes the person inside again and puts their things away. This is because not only is it state law that you cannot smoke in a public building (including bars, even) but we've got a lot of oxygen tanks throughout the building for people who need them to breathe, and those are combustible.

Smoking and drinking go hand in hand, and the last thing we want is our drunk residents trying to smoke in their apartments, setting themselves on fire, and having their oxygen tanks fuel that fire. A lot of people could die that way.

So despite my general non-paternalistic approach, you can probably see why, when Mr.Perma-Rugburn (from drunken falls) whipped out his own lighter, I reached over and snatched it out of his hand. I've learned from past experience that he won't hand them over when asked or told. He was pissed. I was pissed. I labeled it with his name and room number, and stuck it in my supply bag to store with the rest of his smoking paraphernalia in the nurse's station.

And then another employee from a different department spoke up, "But I'm the one that bought it for him". Picture Pollyanna with steam coming out of her ears and red as a tomato. This jackass, also an adult, went and bought lighters for someone who could easily incinerate this building and all the people in it?!?!? I glared and shook my head at this employee, wishing desperately that there weren't uninvolved residents around who don't need to hear me chewing out someone they know and trust.

So what to do now? The next day I put out an APB for that employee, hoping to catch him as he went off shift, but he was too fast for me. Bah.

Later that evening, I was thinking maybe I was overreacting and should pull the stick out and calm down. Until I got a page and went in to see Mr. Rugburn sprawled on his floor once again, drunk as could be, furniture scattered everywhere, insisting that a very pregnant employee should be helping him up and slurring all the while.

This dude, plus the one who is buying lighters and cigarettes for him?

They need a little paternalism. Or a LOT.