Trying to Organize the Nursing Assistants Time

2-15-2012

Nursing homes have a bad rap. Sometimes it’s even deserved. You’ll get the occasional lazy nursing assistant and nurses who don’t care if the aids are doing their job. I think that’s terrible.

The first time I ran into problems with a group of aids, I worked night shift. The aids spent the night partying down in the break room, screaming with laughter. More than one call light came on from people complaining about the noise. A couple of times during the shift, they’d head out and spend 15-30 minutes on the floor, changing a few resident’s bedding and diapers, the last run spent making sure that everybody looked good for day shift.

Once I felt comfortable with the authority, I started to gradually steer the aids back to actually working. First I decreed that that rounds should be made every two hours, 10:00, 12, 02 and 04, which I had been taught at a place that got near perfect inspections. They argued. Their ringleader, “Suzy” stated that the next round should start two hours after the previous round ENDED. I told her that each person should be checked and changed every two hours and if the round takes an hour and if they waited two hours after that, it would be three hours before said resident would be changed and the aids weren’t being paid to sit around for two hours it would be neglect.

They ran to the Director of Nursing Services (DNS) and asked if they had to do rounds every two hours. She said yes, they did.

Next, I required them to turn people in bed each round who couldn’t turn on their own. I explained that this was important for preventing bedsores. I routinely ran down the halls making notes on how each resident was positioned so I could see if they were turned after the next round.

The aids ran to the DNS to complain they were being required to turn the residents. The DNS said that they were supposed to.

One by one they quit except for the ringleader, Suzy. She educated the new aids about how mean I was and how they had the right to sit around all night. Resentment continued. Screams of laughter continued to come from the break room, complaints were made by residents so I asked them to please talk a little softer, that residents were complaining.

They ran to the DNS and complained that I’d told them they couldn’t talk. At all. Despite the ridiculousness of this, (how can they do the job without talking?) I was written up as a concession to their constant complaints.

Eventually, the troublemakers quit and I had my crew, most of whom were faithful. They were an odd bunch that I called the misfits. If the work gets done, I don’t mind personality problems and do quite good balancing complaints of that nature. I have rarely ever had a patient develop full-blown bedsores where I worked the night shift, at least new ones that weren’t there when I started.

I worked one other place where the aids did much the same thing on evening shift. I guess previous nurses had tried to roust them before and were fired for being so hard on those poor, poor mistreated nurses aids. I was told to be kind since they’d had such a hard time, but when I tried to get them to use their time wisely, get vitals done and pass water at the beginning of the shift when it was slow, they acted like I was crazy. I answered lights while they had their Koffee-Klatches down the hall. After being asked repeatedly to do some work, they started to hide out in patient rooms to yak. I’d track them down and break them up, but the attitude continued. Again there was an instigator, reminding the others that I had no right to tell them what to do. Word got around that I was “mean”.

There came two new patients, both in the same room and both with looney-toone daughters. One daughter was vile, spitting filth and angry at all times, always finding fault. The other talked in the royal third person and kept cornering me to put her mom on the bedpan. I could have said “not my job”, a lot of nurses would have, but I could tell she was going to be difficult and tried hard to please. In the end, she wrote a long list of complaints about me, most of which concerned about how mean I was to the aids though she’d only seen one interaction of a minute or so and I’d been perfectly nice. I lost that round with the nurse’s aids.

Most groups of aids I’ve worked with are trying their best by their residents. They get fond of the patients and I’ve seen a few bring something special to eat for a resident who’s not eating. At one facility, the nursing assistants were just great, responsive to the residents and for the most part, working efficiently. But I noticed one problem…. the man they put to bed last wanted to be first. “Frank” finished his dinner quickly and would slowly make his way to his room. He could just make it to a standing position, but then would get stuck, unable to turn around and lay on the bed. Because he was so unsteady, he had a chair alarm that sounded when he tried to stand and a staff member would rush and urge Frank to sit down, we’d get to him soon.

I noticed, however, that the aids were being rather rigid in their bedtime routine. They would start at the end of one hall and go room to room, working their way down the hall around the corner to the end of the next. Frank was last by that system. An aid would come running when Frank set off his alarm and tell him he had to wait. Half the time, I was stuck doing the running. It made no sense to me to waste all that time running so I started laying him down on top of his bed while he waited for his aid, which irritated them into at least putting Frank to bed first.

But this got me to thinking about organizing bedtime routines and so I mandated the following: The first residents to lay down would be the loud and demanding ones, including Frank who kept setting off his alarm. The next group would be those who were tired and hurting followed by the ones who didn’t care when they lay down. This would not be a static setup, residents would move to another place in the line up when needed. I told the aids that I knew it didn’t seem fair that the noisy residents were placed first, but many of them also were ones who hurt a lot. Plus, keeping the floor quiet was less stressful on everyone, including the residents. I received more than one compliment from visitors stating that this was quietest nursing home they’d visited.

Working in a long term care facility is not easy, but sometimes thinking outside the box helps… ;-)

Assaults in Nursing Homes

1-7-12

When someone mentions assaults in nursing homes, one thinks of staff attacking a poor, helpless resident. Maybe it’s pinching an annoying woman or giving a kick to bad-mouthed man. What most people don’t realize is that staff are more often hurt by residents than the other way around.

I’ve worked in nursing homes for almost 20 years and I’ve rarely seen staff deliberately harm patients (at least physically), but I’ve seen residents get frustrated and try to hurt their caretaker. All of them, of course, have dementia to a severe degree, which doesn’t make it hurt less. Most of the time, they are too weak to do much harm. The favorite action seems to be to grab the arm and twist. That usually doesn’t hurt. If they twist enough, all you have to do is lean in the direction of the twist to reduce torque on the arm. Sometimes they take both hands and twist your arm in different directions, like wringing a dishrag. That can be tougher on you, but even if it’s enough to hurt, it’s a simple thing to reach over and pry a thumb loose and the rest of the hand comes off. It doesn’t harm or even hurt the resident when you do that. The worst is when they grab your hair and pull. You can count on losing air with that. One resident seemed to like to grab the hand, separate out the pinky and twist it. One aid got her finger broken with that. They usually do these things when upset at having wet clothes changed or to get up to go to dinner. Usually they don’t believe they’re wet or that it’s time for dinner, etc.

My worst assault with a resident was a man who still had some strength and could walk and get around. I was coming back from the dining room to get something from the nurse’s station when I found “Chuck” pushing “Tom” around in his chair. Tom was a double amputee and was already frightened of Chuck who was his roommate. Chuck got an angry look over his face when Tom yelled in fear and brought up his right hand to do a kind of karate chop on Tom’s left neck. By then I’d broken into a run and as I arrived I put my body in front of Chuck, between him and Tom’s wheelchair. I’ve found that in talking to an agitated resident, it’s best to look right in their eyes, so I kept my eyes on Chuck’s face and started talking as I gently pushed Tom’s chair away. After I was sure Chuck wasn’t going to immediately punch me or something, I stepped back a bit and glanced around to see if Tom was severely injured. He was wheeling himself away, so I turned back to Chuck and tried to coax him back to his room.

Chuck had problems keeping his blood oxygen up, but refused to keep his oxygen on, couldn’t remember to keep it with him. When his oxygen levels dropped, he frequently got combative and agitated and generally improved when his oxygen tubing was replaced. That’s why I tried to get him to his room. I didn’t want to leave him alone and no one else was around except residents returning from lunch. About halfway there, he stopped and grabbed my right arm and twisted it to my right. His grip was stronger than any I had experienced and I couldn’t break his grip my usual ways so I had to lean right to lessen the torque and keep him from breaking my arm. I kept trying to loosen his fingers when he suddenly grabbed a big bunch of hair and pulled. I then grabbed that hand to keep him from pulling it out and then was stuck for something to do. I’d worked a lot of night shifts so it was second nature to me to remain quiet no matter what since usually there was a way out. But now I was stuck. So I deliberately started to yell for help, trying not to sound like a resident with a habit of always screaming that was there. After a couple of yells, he turned loose of me and stepped back looking confused, like, ‘Why is she screaming?’. An aid came along and helped me get him to his room and put oxygen on him.

My hair fell out as I tried to fix it up and left a bald spot on my left top forward part of my head. Chuck was sent out to the hospital and from there to somewhere else for difficult people with dementia, which surprised me. The last place I’d worked kept everybody regardless of what they did except one who tried to assault the administrator. HE got sent out!

Most of the time agitatable dementia patients can be treated with anti-psychotic meds or antidepressants. Since in the early part of the twentieth century when patients were routinely sedated for the convenience of the staff, state laws have forbidden such things. Many inspectors of nursing homes get down on use of these meds, but I hardly think preventing assaults is a convenience. Also, an agitated person is clearly not happy, but fearful and confused. Assaults are a result of the delusional resident fearing harm. I’ve seen patients go from getting angry all the time to cheerful and start to participate in social activities. How can that be bad for them? Today’s medications are much less sedating than those available in the forties and fifties.

I totally agree that abuse of the elderly is unacceptable and people who do this deserve what they get. I once found a mute resident left in her bed during dinner while her aid was in the dining room feeding people, clearly not going to get this woman up for dinner. I also remembered that this resident was missing from dinner the night before. “Mary” was helpless, unable to complain and I was very angry. I immediately went to the supervisor to complain and the aid was fired. I don’t know if her license was suspended, I hope it was. In most places, there is usually someone who cares about the resident and who will stand up for them.

Medicine: Code or No Code?

March 23, 2011

As a nurse in primary geriatric care, you see a lot of death. Not everyone entering a nursing home expects to die there. Some come for extended surgical care, sometimes followed up with physical therapy, then they go home. However many are those who, in the progression of life, have reached the point where a lot of care is needed and is unlikely to recover to the point of being able to live independently again.
Upon entering a long-term care facility (LTC), it is required that a decision be made as to how much and how far life saving efforts are to be made in the event that the heart stops or an illness develops that look to be fatal. There are several scenarios and levels at which a different level of care can be chosen. For example, the patient or his representative can mark yes to antibiotics, but no to CPR if heart stoppage is imminent. The gray area that would require a representative to make a decision is if an illness, such as pneumonia, strikes at the patient’s weakest and an antibiotic might save them or you can let nature take it’s course. Death comes from many causes, usually at the patient’s weakest. It might be infection. It may be the gut shutting down, making eating and drinking difficult and frequently the patient refuses to eat or drink. One can force-feed such a person, but there are issues of patient’s right to refuse food. Also, if there is abdominal discomfort, it could be considered cruel to force food in such a situation. In many cases, food refusal is a signal of early descent in the process of death. “Gracie” was 90-year-old woman, wheel chair bound with complete dementia. Gradually she ate less and less, drooling the food out. Concerned with her loss of weight and dehydration, Gracie was sent to the hospital where she was burnished with IV fluids with glucose to up her energy level. However, Gracie didn’t eat or drink any better when she came back. She had just decided it was her time at a basic level. It wasn’t long before she passed on.
On rare occasions, there will be a person designated a full code. “Henry” was one such; a contradiction in character, he attempted suicide regularly while fearing natural death. Most, however, are designated full code by a family member who can’t bear to think of Mom dying or perhaps from some level of guilt.
Family member reactions vary widely. One never knows what seethes under the sympathetic face of a loving wife or child. My most memorable patient death was a genial old gentleman named “Steven”. He always had a smile as he tootled around the facility in his electric wheelchair. He had a faithful wife, “Sylvia”, who volunteered at the home and sat with him at most meals. Most everyone thought they were a loving couple.
Then came the day when he collapsed as he was being put to bed for a nap. He was a heavy guy and with difficulty the aids got him on his bed and summoned me. I always bring my stethoscope when being told someone was fading or gasping. I first noticed a definite line between gray and his normal color and it was sinking fast. There was no heartbeat though there was raspy breathing. I told the aid to start chest compressions and went to check on his code status. ….. There was none in the chart!! Sylvia had not returned them and no one had noticed. She had gone home to rest, so I called and asked if she wanted a pull out the stops life saving, CPR, heart shocks etc. After recovering her breath, she said absolutely not. No. “Don’t you dare send him to the hospital, I’ll make you pay the bill if you do.”
It was stunning. Everyone had thought they were a loving couple. Not that he likely could have been saved. The heart attack had been massive. But that wasn’t all. Sylvia stated there would be no funeral. She was going to have him cremated and dump his ashes in the garden. Her tone of voice suggested it was going to be the garbage can.
What could have happened in their lives to lead to this? Some men mellow, as they get older. Some are different with their wives and kids than they are with other people. Steven had been a popular patient and I was in deep doo-doo for “letting” him die. It was impossible to convince some people that you have to do as the next of kin wanted, even if they were convinced he’d have wanted a full code. Even if he’d had a signed paper demanding extreme life saving methods, his wife had the right to reverse it. However I had no way of knowing any of it and had to do as Sylvia asked. Maybe he’d marked full code on the papers and she deliberately held onto them until it was too late. Who knows?
I was fired shortly after and I believe that it was because of this. The supervisor responsible for terminating me was one who held Steven’s death against me. In many ways, LTC residents and staff become close and it becomes part of politics.