St. ATM

Watching the news today, there was a barrage of ads touting how wonderful some nursing homes are.  Some bragged how 'profits aren't important, their residents are' and some flaunted five star ratings.  Ha. Ha. Truth be known, Medicare five star ratings are seriously flawed and may mask some serious deficiencies.  It's been found that the five star rating relies too heavily on self-reporting by the nursing homes, omitting much negative information reported by state inspectors.  Now isn't that the foxes guarding the chicken coups? 

The star ratings are supposed to give nursing homes an incentive to improve, when in reality, most have found ways to game the system. Nursing homes know when inspectors are in their area,they notify each other and add more staff, clean up areas that they normally neglect, and sharply cut staff once inspectors are gone and go back to their sloppy ways, until the next year.  Moral of the story: do not rely on this bogus five star rating system for nursing homes.

Those who say: 'profits are not our big concern' well of course that bottom line is of big concern.  How do you think staff gets paid?  How do you think administrators make those big bucks?  By not being concerned about profit?  Oh, please. Traditional nursing homes, based on the Medical model are the pits to live in. The Medical model is set up for staff convenience only.  If huge profits are not a big concern, do you think corporations would even own them?  Hardly.  This is a billion dollar industry, owners of nursing homes aren't rich by accident.  

Traditional nursing homes need big changes.  They may have five star ratings like some Grand Hotel, and admittedly, they do charge the elderly like it is an expensive hotel, but without all the nice services one would expect at a hotel where one pays in excess of at least $1500 per week just for room and board, but they are not a nice hotel by any means.

Traditional nursing homes will never change until, you, you, and I, demand our loved ones actually get what they pay huge money for.  So all of them are the Nursing Homes of the ATM. 

Why doesn't someone do something?

I hear, quite often: "Why doesn't somebody do something?"  Americans seem to have forgotten they are someone.  Too often people sit back, waiting for someone to step up and 'do something.'  It's a good thing that people like Martin Luther King didn't wait for someone to do something.  He, as did many great names in history, realized they were somebody and they did do something.  Have I driven this point home yet?

I see 'celebrities' (using the term loosely here) like Perez Hilton, getting a lot of looks on their blogs because fashion, stupid famous actors and the like, seem to be foremost in people's thought.  Way too much so. Young people think they will be young forever, never grow old and nothing like old age happens to them.  Ha Ha!

When it comes to nursing homes, too many loved ones will say 'why doesn't somebody do something?'  The loved ones are somebody, they pay the bills at the nursing home, making them very important somebodies.  I used to hear many complaints as a Social Services Director, about how the nursing homes were run.  Sometimes they were families just wanting special treatment for their loved one, but the complaints were always genuinely true.  Why shouldn't all residents get special treatment anyway?  After all, they pay enough to certainly warrant special treatment.

What can loved ones do to help change the traditional nursing home environment?  

1)  They can get to know other families who have loved ones living there.  Once they get to know others, they can get together once a month and draw up, write things down, take notes and present the Administrator with their concerns.  Remember, as loved ones, you can make a difference, safety in numbers.

2)  Request small steps in making the nursing home a culture change place.  Where to start?  Well ask why the damned nursing station cannot be moved to an office and not placed in the middle of each wing.  

3) Ask why all the rooms cannot be private rooms so your loved ones do not need to undress in front of a stranger all the time.  Nursing homes can charge just a bit more and still make a good buck.  Do you invite strangers into your room to undress in front of them?  Probably not.

4) Ask why a choice of meals cannot be offered to your loved ones.  When the dietitian decides, the meals are bland and unappetizing.  Cannot imagine why your loved one refuses to eat.

These are just simple starters.  The private room one is big because everyone should have access to the window, not just the person lucky enough to have a window bed.  The removing of the nursing station immediately removes the obstacle people have to try to maneuver in wheel chairs and with canes.  Since the nursing stations are usually off limits to people, it immediately establishes the staff, not the paying customer, is in charge.  People living there pay the bills, not the staff.  Why should staff call the shots?

I hope this blog gets through to people who feel frustrated by traditional nursing homes.  Remember, it does not have to be that way.

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Social Work in a nursing home

 

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Social Work in a nursing home can get tricky at times.    Many, many times, even the Administrator gets confused as to what is right and what is legal.  

For instance, one place I worked had a man living there who was a flaming alcoholic.  He would periodically decide to leave, go on a drinking binge with his old cronies and simply walked out of the nursing home to do so.  He was prescribed medications to curb his alcohol craving, but sometimes the cravings proved to be too great and he wanted a few drinks.

One evening, just before dinner, he walked out of the place.  One of the nurses noticed him missing and came to my office.  The next thing I knew, the Administrator was in my office, demanding I 'call the police' to have him brought back.  I tried to explain to the Administrator that since the guy was coherent, which meant he knew exactly what he was doing, the police would not drag him back, kicking and screaming.  Sometimes you have to explain that nursing homes are not prisons.  Some staff members think all residents have to adhere to all rules, like a jail, not so.  Now a nursing home can, and sometimes will, kick out a problem resident, but they cannot just kick them to the streets without making arrangements for their safety.

The Administrator didn't like that I refused to call police to drag him back.  She picked up the phone in my office, called them and then hung up a few seconds later.  I asked her what the police said.  Her reply: "They said what you just told me."  Uh Huh.  The best they could do was a well being check, not much more.

I would get told, often, by other staff that: "So and so cannot call a cab to go shopping, go home or for other reasons."  I beg to differ.  I'm telling you that they can do that.  The nursing home is supposed to be their home, not a prison by a long shot.  

If anyone does go home, AMA, against medical advice, Medicare can cut them off for services for a time and all you can really do is call Adult Protective Services to check on their well being.  Not much more if that elderly person is coherent and knows what they are doing.  

When a nursing home tries to act like a resident does not have the same rights they have in their own house or apartment, you must explain to staff that they do retain those rights, like it or not. 

Social work in a nursing home

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 Nursing home Social Work does not come without its challenges.  Simply because the nursing home population is so diverse, many people come with their own unique sets of problems.  Some of them that I encountered are as follows:

A)  We had a lady, very sweet and docile, the docile part proved to be a problem.  She had a sister who was mentally ill and, unfortunately, was also her POA (Power of Attorney).  This fact posed problems because: 1) Many times nurses and even doctors, do not understand how these forms should work.  They think a POA has free reign over making decisions for the person involved.  I'm here to tell you, they do not.  In fact a POA is only good if the person for whom it is intended is unable to comprehend simple instructions: i.e. in a coma, has severe dementia, had a stroke and is not coherent.  Remember this as a Social Worker.  That sister thought she could make any decisions she pleased even though the resident was as alert as you and I.

B)  Many times adult children, not wishing to lose their beloved parent, will have their loved one, or in the POA case, the adult child, will sign a resuscitate form instead of a do not resuscitate or DNR.  A resident is allowed to sign whichever one they choose.  But always bear in mind that they also think if a loved one is resuscitated, the person will be good as new.  No, as we grow older there is a big chance we can end up in a vegetative state, or even have to have tubes, wires and the whole 9 yards, which is usually not how most of us care to exist.  Plus, as we grow older, the resuscitation act itself, can break brittle bones, causing even more problems.

C)  One of the most difficult residents to deal with is the person who absolutely doesn't want to be in the nursing home.  Traditional nursing homes are not appealing to very many people.  I can see their point.  Convincing the person they should be there because they are unable to care for themselves is very difficult.  You probably can see why.

D)  Nursing homes that place two to a room is another difficult area.  The room mate the facility chooses may not be compatible with the person already there.  I had one lady who was determined that no room mate was acceptable.  She wanted the room to herself and so she would turn up the air conditioning in winter and turn up the heat in the crushing heat of summer.  She would always never allow her room mate to open a window for fresh air either.  My Administrator told me I needed to have the (I want my own room lady) sent out for psych evaluations.  Basically the woman was being mean on purpose and there is no cure for 'bitch.'  I did not see the lady as a bitch, she just acted bitchy to room mates.  I fully understood her position and in a Culture Change nursing home, with one person to a room, this sort of conflict could be avoided easily enough.

I'm hoping this true information will assist new Social Workers in knowing some of the problems they can face in traditional nursing homes.  I do not believe in blowing smoke up your asses.  You deserve the truth.  All the more reason as a Social Worker, to become an agent of change, encouraging traditional nursing homes to become Culture Change ones.  They are better for workers and those living there.

Thanks for reading.

 

Social Work in a nursing home

 

What does a day as a Social Worker in a nursing home look like?  I did not say typical day because there is no such thing as a typical one.  Each day is unique in itself.

First thing in the morning, all nursing homes have a morning meeting.  This is with the department heads, all of them, so the administrator has an idea what each department will be doing that day.  It also gives the administrator a chance to tell any department if they want something looked into or done.  Literally, each department head, when it's their turn, says what they will be doing.  Mostly I found it a time for nurses to ask if Social Services could change someone's room, for whatever reason, or if a resident requested a change.  Many times nurses expected us to convince a resident to change rooms or accept a room mate.   Whenever we got a new resident, the facility didn't place people together who might be compatible, they just looked for an empty bed.  As you can imagine, many residents were not happy over that situation.  This is one reason NO nursing home should have two people to a room.  Someone doesn't get a window and probably no access to the existing windows.  Many times you will face irate relatives who do not want their loved one's room changed, or who does not like the room mate.

Changing a room is not just a simple task either, you have to get a permission paper signed by either the resident or the responsible person, which is not always easy.  Then you have to place a copy of the paper in the chart and chart the reason why.  Even with the new electronic paperwork, it still has to be filed someplece and charted.

An example of charting:  Resident requested a room change due to:  then you fill in the blank.  I always charted what resident said or did, or what their responsible person said or did.  Mostly state examiners only care how the resident views things.

A behavior example:  Resident is distraught and complained about (fill in blank) or resident got into a shouting match with room mate, or hit another resident.  The hitting is where it can get complicated.  You Must check on the one who got hit, plus the hitter.  Maybe the hitter has dementia and didn't know better, or just has a bad temper.  You absolutely have to follow up, talk to the hitter, then check on the one who got hit.  You have to write what you did, and will do, to prevent anymore incidents.  Usually the nursing home's solution is to drug the hitter.

As a Social Worker you absolutely have to know when a resident's psychotropic medication is changed.  This can get tricky if the nurse asks for a change and does not bother to tell you about it.  This can happen in the middle of the night, without your knowledge.  You should be sure you have a form and request a nurse Always makes it out whenever there is a change.  Good luck on that one.  But if you do not know and do not chart it, believe me, You will be held responsible for not knowing, nurses usually toss you under the bus.

You have to know, because once a powerful psychotropic med is started, then You have to  ask, that nurses request the doctor to reduce it until gradually, the resident is off the med.  Then you have to chart if the resident is doing fine without it or not.  If not, you must have the doctor write why the person has to have the meds.  Crazy, isn't it?  Yup, it is.  Then You have to describe how resident acted without the sometimes needed, medication.  

I'm going to Warn you, in a Medical Model nursing home, staff feels it is easier to medicate a difficult person than it is to try other alternatives.  There usually Are other alternatives, but they take team work and cooperation from other departments. 

I don't tell you this stuff to scare you off.  But I think every Social Worker deserves to go in with eyes wide open.

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Social Work in a nursing home

Some days will be like this

Social Work in a nursing home can be fun, rewarding and very stressful, all in one day sometimes.  The paperwork and what you do, after the MDS's are done (Minimum Data Set is time sensitive and has to be completed in a timely fashion and must come first) what you do otherwise is dependent on your employer and maybe state examiners.  I say state examiners because once in a while, if they dig, dig, dig, an examiner will give you a list of 'residents in need of a psych evaluation, on paper, and results placed in the person's chart, within 10 days of the state's request.  Who are the residents in need of this evaluation paperwork?  Pretty much it will be residents who have come in and who 'have depression but have no dementia' diagnosis.  It is a given, by state examiners, that people with dementia have depression.  This psych eval is required to be sure other residents are safe from the person suffering depression. (You'll learn once you are hired).

Is it All like this? No, but often it is.

A good piece of advice to those Social Workers seeking employment in a nursing home is this: If, during an interview, the person tells you that you will be doing marketing as well, RUN, and run as fast as you can in the other direction.  Why?  Well the interviewer may as well say: "Frankly, our owners are so cheap they refuse to hire a marketer, so you get to do two, or more jobs here.  The reason for this?  "Well the owners and CEO insist in pulling down a 6 figure income while you run around, frazzled, making them rich by not paying a marketer."  Simple as that.

A decent marketer is supposed to be out of the office 85% of the time, drumming up business.  How in hell can you do your Social Work paperwork, be available to residents and families and take care of setting up home care and your usual paperwork and be out of your office that much?  Impossible!  

Marketing consists of: Hanging out at hospitals like a vulture, talking to older people who will be discharged and convincing them to come to your nursing home.  It's a highly competitive business with stock holders, owners and administrators pushing you to keep the building at 95% capacity. (Fill those beds with asses.) 

Unless you are a glutton for punishment, do not take that mush responsibility on.  I guarantee you one job or the other will suffer, not to mention your jangled nerves and sanity.  You must look out for your own health and well being because I assure you no one else will. 

Do not let rich companies make you juggle a 100 tasks.

Some nursing homes want Social Workers to also do, in addition to marketing; admissions.  Do not do this one either.  Because many admissions will not be until 5PM when most hospitals get around to discharging patients from their facility.  Unless you relish 12 to 14 hour days, admitting a resident; then steer clear of this extra job as well.  If you have a family and wish to see them, do not accept this extra job.  Many nights you won't see home until 10 or 11PM when your day already started at 8 or 9AM.  

Do not take on the job of discharges either.  When any resident is discharged from therapy (Medicare only pays for 100 hospital and therapy days per year), the discharge person is supposed to send a letter, or hand a letter, to the family member and/or resident who is responsible. The letter must be signed so no one can say: "My loved one was supposed to get more therapy and didn't get it."  When that signed letter (a copy of it) is placed in the resident's chart, then your ass and the facility's ass is covered.  Otherwise you can all be in trouble for not notifying the family and/or resident of this change.  This requires you to always be in touch with the therapy department, which can be difficult at best.  There is a web site where you can download this form, print it out and make copies of it.  You have to use the official form for your state. 

I hope these blogs are of help to those new Social Workers who seek employment in a nursing home.  The more you know, going into it, the better for you.  

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Is your family prepared?

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With so many Boomers growing older, it is becoming a big concern about what a family should do in case Mom, Dad, Grandma, Grandpa or anyone in your life who is elderly, may need more help with activities of daily living.  

Many people will, out of necessity, choose a nursing home if the person needs round the clock care.  Yes, many will feel pangs of guilt when having to choose this route.  Unfortunately we, as human beings, are great at living in a state called, denial.  Having said this, far too many, probably most, people never consider checking out nursing homes or alternative care, until it is absolutely necessary. It can and usually does, get sprung on families more often than you might think.

For instance, I have seen quite a few elderly people break a bone, end up in the hospital and then have to enter a nursing home while undergoing therapy.  Hospitals, in this modern era, have a habit of not keeping the elderly patient more than a few days, so it is highly possible your elderly loved one can, and will be sent to a nursing home to recuperate much sooner than you think.

Countless numbers of those elderly patients will enter a nursing home for therapy, plan on going home, then discover that the therapists recommend they stay, never to return home.  It is usually either for safety reasons, or the person is too frail to care for themselves, they may be forgetful and not able to discern things like placing a tea kettle on a stove, using a burner to cook and often times, forgetting to turn the burner off.  Or maybe staying alone, especially nights, that person may not be able to leave their home in case of any kind of emergency.  Nearly every time the elderly person who planned to go home was told it wasn't recommended, they and their families were thoroughly stunned and unprepared for that kind of news.  Are you prepared?

Remember too, you have options if this happens to you and your loved one.  Before you get old, even though you might think you will always be young and vibrant, it is important to think and appoint, a medical proxy and a power of attorney before you need one.  In both cases, pick someone you can trust with your life, literally.  Be sure to have medical decisions you want to have happen in case you are unable to talk or sign papers, in writing, have them notarized be sure you and the person you choose, each have a copy as well as a lawyer.  Being incapacitated can happen at any age not only to the elderly.  

I also want to stress that the people you place in charge do not have to be a family member.  You can choose a friend if you trust them more.  Be very choosy because I have seen POA's run off with bank accounts, make decisions that the unconscious person might not have agreed to and I've seen POA's seize property, only to see the elderly person recover and find out they were stripped of everything.  One poor lady's niece was given POA powers then cleaned out the lady's checking account and then left the state. While you might say: "That could never happen to me."  Be assured that lady was saying the very same thing in my office.   

Hopefully you will be prepared for such things.  Remember, it's never too early to plan ahead. 

Nursing home diaries

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The Administrator decided today to have the Activity Director try and bring in Culture Change.  I suggested Culture Change, but she wasn't listening, as usual. I get the picture, this Administrator is not truly interested in real Culture Change, she is trying to use it as nothing more than a marketing gimmick.  This pisses me off so badly.  I want to kick her in her big fat butt!

Culture Change is when the entire nursing home works together, with the Administrator, who is the only one with the authority to usher in real changes.  The rest of us are simply peons.  

Real change is getting rid of those damned nursing stations.  They can be placed in offices, not in the center of the residents' home.  I do not have one of those stations in my living room, I trust you do not either.  Medicines should be administered individually, not to everyone at meal times.  When the Administrator asked how that could happen, I told her about a wonderful invention called a medicine cabinet, just like we all have at home.  When she asked about keeping others out of the medicine cabinets, I reminded her of another wonderful invention, called a padlock.  Wow, that's a no brainer.

Make every room a one person only room so each person can have more personal items and can look out the windows whenever possible.  Nursing homes would not lose money, they can charge a bit more per room, surveys show families would gladly pay a bit more for a pleasant living space.  

Small groups can be permanently assigned to the same group of seniors every single shift, whenever possible.  Studies show that smaller groups of permanent aides cuts down on seniors' stress levels and thus cuts down on the use of psychotropic medications.  OK, I know pharmacies have a nice little racket going on forcing medications on seniors, kind of like the racket for drug testing welfare recipients.  Get over it pharmaceutical companies.  

Invite the aides for each resident to the care plan meeting because they know more about the resident they are assigned to than the damned nurses do.  Nursing homes are set up for the convenience of staff, not as a nice home for the paying customers. 

This is just a start.  But it's a good one.  No having to build whole new buildings or anything, just shuffle things around in the ones they already have.  

This can all be done, it is doable.  If you have a loved one in a nursing home, talk to other family members, press the facility for Culture Change, any Culture Change is better than none.  

There are many other changes they can do, I will list those on another blog.  But these are a good start.