Our Elderly population needs support when in rehabilitation centers and in nursing homes. Any person, who spends a great deal of time visiting a loved one at centers of this type, likely will witness similar occurrences as the ones described below. The scenarios that follow were compiled from many visits, during 13 days, 14 days, and 28 days (for a total of 55 days) to three different rehabilitation centers during a time span of just over one year. They are descriptions of some of the actual observations made or circumstances experienced. Important website links are included at the end of this post for your information and convenience.
First location (during a 13-day stay):
- Surroundings of general uncleanliness: a) Dirty bathroom tiled walls – showing dried out drips and stains of unidentifiable material. b) Filthy patient room windows give the impression of not having been cleaned in a very, very long time. c) Small, live roaches at the microwave and counter top of the mini lounge area used by employees and visitors.
- Deferred maintenance: Flooded bathroom floor due to a leak at the base of the toilet. Said bathroom is for use by up to four patients. When brought to the attention of staff, at least some had awareness of the problem. However, when a maintenance technician comes to address the needed repair, he states he was unaware there was an issue. Obviously, at best, this is a communication breakdown, and at worst, this presents a fall risk to a Senior.
- Having to choose between freedom from a soiled diaper or freedom from patient room seclusion seems unjust: See details: Wheelchair-ridden Senior announces having a bowel movement. The time of day is several hours before the typical 4-6 p.m. time frame that patients, who are unable to ambulate by themselves, are transferred back to bed for the night. The Elder’s relative speaks to a staff member about changing out the soiled diaper. The staff member informs the relative that once the Senior is transferred to the bed for diaper changing purposes, the general practice is to leave the patient in bed for the rest of the day until the following day. This practice hardly seems fair or humane. The decision to make is obvious – get the patient away from the soiled diaper as soon as possible to avoid possible skin sores or infection! However, is it not better to find a way to make sure the Senior has the opportunity to go back out of the room again instead of contributing to patient loneliness and isolation?
Second location during a 14-day stay:
- Breakdown in communication between staff members having direct, hands-on, patient-care duties: It seems that documentation of food and liquid intake as well as urine and bowel movement output is required during a typical work shift. However, somehow, this information is not always appropriately used. Documenting is only useful and effective if each party directly responsible for the health and welfare of a patient is knowledgeable of such information before administering any intended care.
Details of breakdown of communication between nursing staff and CNA (certified nursing assistant) staff: Patient is having three days of runny diarrhea. At 9:00 p.m. a nurse nearly administers a stool softener to the patient before being stopped by the Senior’s relative. The nurse states that she appreciates this type of information from communication with patients’ relatives. The nurse explains that she usually works in a different area of the establishment.
Questions that immediately come to mind:
a) Why has this nurse not read documentation concerning the patient’s bowel output before administering medication?
b) Was documentation even made by the CNA(s)?
c) What could be the possible outcome if this practice continues uninterrupted on an elderly person who is unable to communicate appropriately due to cognitive impairment?
- Under-staffing? Perhaps?: See details: CNA (certified nursing assistant) mentions relief in knowing that a patient’s relative is present, and that the relative will be feeding the patient. The CNA explains that out of a total of 10 patients under her care during her current work shift, 6 of them require assistance with feeding. Side note of interest: Over a period of just over one year, throughout which observations were made of practices in three different centers for rehabilitation, and for a combined number of 55 days, only once was a nurse observed helping out a CNA with a task that is typically done by CNAs.
Questions that may come to mind:
a) Since 60% of the CNA’s (certified nursing assistant) patient work load for the work shift above-referenced consists of patients unable to feed themselves, why can’t efficient arrangements be made for temporary help with feeding?
b) What could be the potential outcome if anyone else is unavailable to help for whatever reason? Since out of 10 patients in this scenario, 6 of them need help with feeding, the first patient, maybe even the second patient, will have a hot meal. The rest of them, more than likely, will eat room temperature meals at best.
Something to keep in mind – The staff from the kitchen who is responsible for bringing the meal carts to each floor must also pick up the meal carts afterwards. This staff must maintain a rhythm and pace within their shift in order to get their job done. Knowing that the kitchen staff will need to pick up the meal carts within a reasonable amount of time, all patients needing assistance with feeding will need to be fed as quickly as reasonably possible. The problem is, that many times, some impaired patients cannot be rush-fed. These Seniors eat, but it takes some of them more time than expected.
c) If one CNA shift has a ten-patient to one-CNA ratio, with 60% of those patients needing feeding assistance, and if no other CNA can help out, why can’t a nurse or other floating staff member be on standby to temporarily help?
d) Would this make for a better meal-time experience for our Elderly population in need?
e) Is it reasonable to imagine these same patients who require help with feeding probably are the same ones in need of help with changing out of soiled diapers?
f) Can the CNA in the above example provide “optimal” patient care to each patient during her work shift if she’s in charge of spoon-feeding 6 out of 10 patients, changing soiled diapers, documenting food and liquid intake, documenting urine and bowel movement output – all before shift-end?
g) How about the morning shift CNAs who are also responsible for bathing patients? Remember: Some patients cannot be rush-fed. In addition to that, some may also be less than cooperative due to no fault of their own because of their health condition.
h) Is it possible that situations like the ones described above may contribute to less-than-optimal quality of life experiences for our Senior loved ones?
i) Can these episodes become a contributing factor to infections and to dangerous skin sores from sitting in soiled diapers too long, malnutrition, as well as other undesirable outcomes?
Third location (during a 28-day stay):
- Ah, to the good old days – when going to the restroom was easy to do! – a comfort taken for granted until it’s gone! It’s very common to see and hear patients expressing the need to go to the restroom and becoming upset with delays in receiving assistance. Some need assistance with ambulating to the toilet or assistance with changing out of soiled diapers. Obsessive attention to this need could go a long way towards the assurance of optimal quality of care, quality of life, and simple bliss and comfort!
- Therapy for those with compromised mental cognition: With patients with compromised mental cognition, the need for constant supervision and reminders of physical-therapy-exercise expectations is of vital importance. These patients may stop doing the exercise unless the therapist is by his/her side reminding him/her of what is expected. Even with less than ideal mental cognition, if a patient can be physically rehabilitated back to being able to walk again, the patient’s circulation and general well-being can benefit. However, physical therapists commonly work on more than one patient at a time in the physical therapy department.
In this case, a possible solution may be to use a piece of equipment that automatically moves the limb or limbs for the patient in order to accomplish the desired movement. This allows the freedom of time for the therapist to assist another patient in the physical therapy department without sacrificing productive therapy for the patient with mental cognitive challenges. However, if that piece of equipment is present, but not in working condition, and the therapist is unable to offer individual, undivided attention to the mentally challenged patient, will that patient receive optimal rehabilitation services?
Many times the only reason a person is in a rehabilitative center is for the sole purpose of physical therapy. Observations made confirmed that physical therapy sessions are not lengthy to begin with and are usually given only once per day. If on top of that, there cannot be undivided attention for each patient since the therapist typically has more than one person at the same time to tend to, then positive results from rehabilitation efforts most likely will be hindered. Obsessive attention to adjustments, as needed, for all physical therapy patients to have the opportunity to prosper is not only expected, but is morally and compassionately the right thing to do. Perhaps, as common practice, the physical therapy department staff and the psychiatric physician should consult to find the best way to address this shortcoming.
In conclusion, the main take-away points intended from sharing this post with you are the following:
- These places may comply with the laws of the State regarding minimum staffing requirements, but at the same time, minimal compliance may not be enough to provide optimal service and care for your loved ones and someday, possibly, even for you.
- If you have a loved one who is cognitively challenged and in one of these places, the importance that you be present at meal times, or to have some other trusted friend or relative there in your place, cannot be over emphasized.
- It is not surprising to imagine that if these circumstances occur in places of temporary stay for rehabilitation purposes, the same may be occurring at permanent/continuous residency places such as nursing homes.
I urge all those who can, to be advocates for our Seniors in rehabilitation centers and in nursing homes. Some of them can no longer help themselves. They can really use our eyes, ears, attention, awareness, and voices. There’s no need to be shy or embarrassed about asking questions and showing that you are involved and attentive. However, keep in mind that civility, tact, and professionalism can co-exist with your will to do the job. You may find that more may be accomplished with honey than with vinegar and still be very, if not more, effective.
Sending all the best intentions your way!
Helpful Links:
https://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/
https://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/Index_LTCU.shtml
https://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Long_Term_Care/Nursing_Homes.shtml
https://www.flrules.org/gateway/ChapterHome.asp?Chapter=59A-4
On the top left of the screen, click on the word-document labeled 59A-4 to the right of the phrase “View Chapter”. This will download the whole Chapter (see lower-left of your computer screen to find the download). A good way to begin the research from here is to scroll down to 59A-4.165, Nursing Home Guide.
Consistent with Section 400.191 F.S., the Nursing Home Guide is published quarterly to help people compare and evaluate nursing home facilities.
http://www.floridahealthfinder.gov/LandingPages/NursingHomeGuide.aspx
Click on “Health Care Resources for Consumers”; then click on “Consumer Guides”.
https://www.floridahealthfinder.gov/reports-guides/NursingHomesFL.aspx#_Alternatives_to_Nursing
https://www.floridahealthfinder.gov/CompareCare/SelectLocationFacilities.aspx
https://www.floridahealthfinder.gov/CompareCare/CompareFacilities.aspx
http://www.floridahealthfinder.gov/Comparecare/MethodologyNH.aspx
Helpful Phone Number: (850) 412-4303 – Long Term Care Services Unit. Call for more information regarding skilled nursing facilities and nursing homes.
DISCLOSURE: Any information provided on and throughout this post including, but not limited to, information furnished on resource web links are provided for your convenience and general knowledge, is not warranted or guaranteed, and is not intended to be legal, health, medical, or professional advice. All information presented herein is subject to errors, omissions, and changes without notice. We urge you to seek the advice of qualified professionals for the most accurate information and before taking any action.
