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 Difficulty with Nursing Home Staff 
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Joined: Sun Aug 29, 2010 5:46 pm
Posts: 610
Post Difficulty with Nursing Home Staff
On Monday, my mother's doctor changed around her meds, including adding Ativan q 8 h PRN. Before going into the NH, she used to take a different anti-anxiety drug and it helped a lot, so I was hoping to see a change with the Ativan. But all week she has remained weepy, upset about everything, and not improved at all. It is just so hard to see her like this day after day. After another weepy conversation with her this afternoon, I called the charge nurse to ask how much Ativan my mother has had this week, and was surprised to hear she has had just ONE dose!

I asked how it works when the order is PRN, because my mother can barely manage to ask for pain meds, let alone an anti-anxiety drug. She got extremely defensive and said it would be up to the nurse passing meds to administer if she sees the need. I have been at the NH many times when meds are passed, and the nurse spends about 30 seconds in the room. So how is she supposed to observe my mother's emotional state and make that call? In order to avoid a head-on confrontation with the charge nurse, I backed off and said maybe I should discuss this with the doctor. And I did leave word for the doctor this afternoon but have not heard back yet. The nurses don't seem to like it when I call the doctor directly instead of addressing concerns to them, but in this case, I tried and it didn't go anywhere.

Over the past 10 months, I have worked hard to develop a decent working relationship with the nurses because they are my eyes and ears, besides being responsible 24/7 for my mother's wellbeing. Moreover, they all know that I am a lawyer and I don't want them be nervous like I am going to sue the NH if something isn't just right. And I know that I have an assertive personality, so I have been as deferential as possible. However, I am my mother's health care agent and the only family member in town, so I have to address these issues. I'm sure some of you have been in this situation and can tell me the best course of action when I disagree with how my mother's care is being managed, without starting a war with the nursing staff.

Thanks,

Julianne


Fri Dec 03, 2010 2:19 am
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Joined: Sat Jul 19, 2008 10:29 am
Posts: 126
Location: Italy and Toronto (Canada)
Post Re: Difficulty with Nursing Home Staff
We have had exactly the same problems with the nurses and PSW's at my dad's nursing home too. They are extremely defensive and belligerent. My sister and I, like families of all other residents, do our best to look out for the welfare of our LO's and advocate for their needs. And each time, we hit a wall of confrontation and a very antagonistic attitude from the staff.
We started out being extremely nice, courteous, full of compliments and gratitude. At times we have had to get really tough (like the many times their negligence and carelessness caused serious injury to our Dad), and have had to get the directors and administrators involved in our complaints and requests.

My Dad's nursing home is a private one, part of a chain who are even quoted on the stock exchange. But in Canada, all nursing homes (even private ones) are under the supervision of the ministry of Health and there are specific pathways to let our complaints get all the way to the top. I have resisted doing this until now because I have tried to find a collaborative way to solve the many care problems at the home. However, I am very close to taking all my issues (well-documented) to the ministry of health. Every time I threaten to do this, I seem to get more cooperation from the nursing home.

But at the end of the day, it all has to do with the attitude of the staff which in our case is unfortunately defensive and belligerent.

I wish you good luck and if you figure out how to get around all the personality issues of the staff, please let us know.
Shomy.


Fri Dec 03, 2010 5:04 am
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Joined: Wed Dec 30, 2009 1:46 pm
Posts: 3213
Location: WA
Post Re: Difficulty with Nursing Home Staff
To both Julianne and Shomy: It is an unfortunate fact that most nursing home chains--some good, some not--are more concerned about profits than about patient care. It is something I am very concerned about and, if I ever get the time, will do some lobbying for. My husband spent a month in a skilled nursing facility in another state. It was in an impressive building, landscaped grounds, etc. but it seemed to have as many 'managers' as it did caregivers. [NOTE: This is NOT to be confused with the excellent dementia care facility he was in for a few months last year here in WA] The nursing care in that SNF was appalling! If I'd had the time and energy I would have taken a complaint to the state board. At the time, our lives were just too stressful and chaotic. In the US, there are ombudsmen assigned to arbitrate issues with NH staffs. Whether this is true in Canada or not, I cannot say.

I can fully appreciate your concern and frustration. And I totally agree that medications for chronic pain should NOT be ordered 'prn' but should be given on a regular schedule. Maybe you could speak to their doctors about this. And you will probably find that there are no actual physicians visiting the residents but physician's assistants or nurse practitioners. This is not a bad thing, necessarily, but they are sometimes less willing to take assertive action when it is needed. When you speak of 'nurses', are you referring to the nursing assistants who do the direct care? Is there an RN on the staff? How often does he/she see the residents?

Sorry for such a long post. This is a BIG issue that is only going to get bigger. My concern is both general and personal. Hope you can get some issues resolved. It's an ongoing battle, I'm afraid. Don't give up the fight!

_________________
Pat [68] married to Derek [84] for 38 years; husband dx PDD/LBD 2005, probably began 2002 or earlier; late stage and in a SNF as of January 2011. Hospitalized 11/2/2013 and discharged to home Hospice. Passed away at home on 11/9/2013.


Fri Dec 03, 2010 11:10 am
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Joined: Mon Nov 22, 2010 1:24 pm
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Post Re: Difficulty with Nursing Home Staff
I too had the same problems and had a very difficult time addressing them. I brought Mom home. I knew her best and knew how to manage her pain(she lived for many, many years with chronic pain). This PRN stuff or what ever for a dementia patient and a compression fracture is ridiculous! I could go on and on here. It has been a year and half since her passing and I still dont have the energy to address this issue!

Pat, when you are ready to lobby maybe you can guide me as to what to do. I would like to join the cause but dont know how to begin!

Sharon E.


Fri Dec 03, 2010 11:31 am
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Joined: Sat Jul 31, 2010 5:28 pm
Posts: 317
Post Re: Difficulty with Nursing Home Staff
Probably the only way change will ever occur is when families of nursing home patients band together and demand change. Our local newspaper reported a patient who went to the ER from a for-profit nursing home and, on examination, it was found that his penis had rotted off. Apparently it started with a sore that was never addressed. The man died in the hospital. There has been NO further coverage. I woud imagine the lawyers for the nursing home chain filed lots of things to stop the paper from continuing.

But everyone who has a patient in a nursing home knows that rockig the boat invites retaliation against your LO. It is too scary to think of. And the patients often cannot advocate for themselves.

Gotta go...husband has lost his teeth. Panic mode!!!


Fri Dec 03, 2010 12:04 pm
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Joined: Sun Aug 29, 2010 5:46 pm
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Post Re: Difficulty with Nursing Home Staff
Thanks to everyone for your thoughtful replies!

My mother is in a private nursing home that is not part of a chain. I don't have any issues with the care in general. Both the nurses and the aides are very kind and concerned. There are several RNs--in fact, most of the nurses are RNs, the charge nurse of every shift is an RN, and of course the DON is an RN. (Of course, there are aides, too, and some LPNs.) The RNs are very active and almost always when I call the charge nurse to ask something about my mother, she will mention what she observed when she was in my mother's room that day. So I can't say they are inattentive at all.

And my mother sees her actual doctor, who makes rounds at the NH once a month and has gone over there extra times when needed. (I have a good personal relationship with the doctor, which helps.) The doctor did order some of the pain medication to be given on schedule, rather than all of it being PRN, so that my mother doesn't have to ask, and she finally has caught on that she can ask for extra pain meds when she needs them. Ironically, my mother really likes her doctor, and often it is "show time" when the doctor visits, so it is hard for the doctor to see the issues I bring up!

It's more an unspoken attitude that the nurses know what is best and when they are questioned, they seem to take offense as if the family is meddling or something. As I mentioned, they particularly seem to resent it when I go directly to the doctor instead of going through them. I see the point of having them coordinate the care, but not when things aren't being addressed.

My concern is that I don't want to create bad blood with the nursing staff so that we don't have a cooperative or productive relationship. I don't have concerns that the nurses will take it out on my mother. They just aren't like that. But if they start getting uncooperative with me, it will be almost as bad. I can't be there every day and need to trust them to do the right thing.

Thanks,

Julianne


Fri Dec 03, 2010 1:13 pm
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Joined: Fri Jan 15, 2010 9:33 pm
Posts: 3362
Location: Vermont
Post Re: Difficulty with Nursing Home Staff
Since we know our LOs better than any of the staff, our observations, I think, are usually way more accurate than that of staff who come in for a few minutes at a time and observe our LOs. We have to continue to advocate for our LOs who are not capable of advocating for themselves. It is exhausting, frustrating, maddening but is a job we just have to keep doing until we feel satisfied that our LO is getting the best care possible. It took many months to get some meds changed for my dad, and I am glad I perservered, but it was very stressful for me. I finally gave up the fight to get him off the Aricept because I got so exhausted and he was so much more ill that I had other things to deal with about his care and just couldn't continue the Aricept fight any more. But, when things settle down after the funeral I will document what I think were outrageous, harmful or just not helpful things that were done or said, and the proper governing boards in the state will receive notice. Like, the CNP threatening to sue me for endangering my father's life because I asked that he be taken off Aricept and Namenda! I will never be sorry for standing up for what my dad needed as far as better care, changes in meds, etc. It is tough to have to fight sometimes, but you gotta do what you gotta do when our LOs are so vulnerable. Lynn

_________________
Lynn, daughter of 89 year old dad dx with possiblity of LBD, CBD, PSP, FTD, ALS, Vascular Dementia, AD, etc., died Nov. 30, 2010 after living in ALF for 18 months.


Sat Dec 04, 2010 12:15 am
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Joined: Sun Aug 29, 2010 5:46 pm
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Post Re: Difficulty with Nursing Home Staff
I agree, Lynn, it is exhausting, frustrating and maddening! Today I heard back from the doctor. Turns out there is some regulation that prevents my mother from having a standing order to have Ativan on a regular schedule. It can ONLY be PRN, the fear being that otherwise it will be used as a chemical restraint.

So, because the doctor could not change that, instead she called the NH and chewed out the charge nurse, telling her the staff needs to be more observant of my mother's condition and reminding her of why she prescribed Ativan in the first place. Hoo boy, no wonder the same charge nurse was so frosty to my husband and me when we visited the same night. I expect she believes I put the doctor up to it--well, in a sense, I did--and I don't suppose it will do much for my relations with the staff! However, I remind myself that I am not there to be best buddies with the staff but to advocate for my mother.

If my mother was not overall getting wonderful care from a bunch of caring people who have way more patience than I do, I would probably rock the boat, but on this issue I will observe and see how the staff adjusts to being scolded by the doctor.

Julianne


Sat Dec 04, 2010 12:37 am
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Joined: Wed Oct 28, 2009 11:53 am
Posts: 969
Location: Ocala, FL
Post Re: Difficulty with Nursing Home Staff - Lynn
Lynn.... I do hope you will take the time to write all you remember so we can benefit from your experience - not only with nursing home staff but care in general. I've learned a lot from trial and error - but it's so much better to learn from someone who has been on the road ahead of you.

Just tonight, I was thinking about the hint someone gave about placing a towel on Dale's pillow rather than changing the pillowslip often. His head is always sweaty and his pillowslips were hard to clean. It's such a simple suggestion ... but so very helpful. I also make it a habit to offer Dale's pills in small dosage containers I've saved. It's so easy to drop tiny pills when they are in the hand.

Perhaps we could have a list of small 'helpful hints' somewhere here. I don't mean suggestions like remodeling the bathroom... :lol: I know there is a lot of wisdom from the old timers that I could use.

_________________
Leone Carroll (75); wife of Dale (75) who passed away March 23, 2011


Sat Dec 04, 2010 12:49 am
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Joined: Wed Dec 30, 2009 1:46 pm
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Location: WA
Post Re: Difficulty with Nursing Home Staff
Leone, I give Derek his pills in a spoon. It's worked really well for us.

_________________
Pat [68] married to Derek [84] for 38 years; husband dx PDD/LBD 2005, probably began 2002 or earlier; late stage and in a SNF as of January 2011. Hospitalized 11/2/2013 and discharged to home Hospice. Passed away at home on 11/9/2013.


Sat Dec 04, 2010 1:01 am
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Joined: Wed Oct 28, 2009 11:53 am
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Location: Ocala, FL
Post Re: Difficulty with Nursing Home Staff
That's exactly the sort of suggestion I had in mind, Pat. I'll try that.

_________________
Leone Carroll (75); wife of Dale (75) who passed away March 23, 2011


Sat Dec 04, 2010 1:11 am
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Joined: Sat Mar 27, 2010 6:15 am
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Location: USA
Post Re: Difficulty with Nursing Home Staff
Dealing with nursing home staff, nurses, and doctors is exhausting. They want to freely use PRN orders to achieve whatever THEY want for the patient and not necessarily what is best.

Over and Over and Over I have had to get my dad off medications to get him alert after PRN drugs being administered to him. I am his POA and the nursing home calls when they need me to okay something that will have to be paid for but they cannot seem to remember to call me when they decide to change dad's medications and make him nuts.

But I have also found the same situation in hospitals and now he is in a hospital rehab facility while taking a strong antibiotic and blood thinners - I told them over and over - Do not mess with his medications.

He can barely tolerate these really strong long term antibiotics.

HE cannot take narcotic pain killers, allergy medications, many cough medications, sleep aids, etc.. and yet I walk in a few days ago and find my dad (who was doing fairly well after artery surgery) I find him COMPLETELY nuts, fighting, not himself at all.

The nurses are all like.... "what is wrong with your dad?" he was such a nice man.

Well ... they had given him 2 sleep aids and then the next night tried muscle relaxers...
He was already extremely weak from the strong IV antibiotics and also an oral antibiotic for a VRE infection in his foot. (not in is blood stream a local wound infection)

Do they think it is funny to just ignore you when you say and POST in the person room and on his records - he has an extreme sensitivity to these medications and otc medication so ... NO extra crap without calling his POA. Do they think we just make this stuff up?
I ask them to treat him as if he has Lewy Body (although it is very hard to get anyone to diagnosis this)

Each time they give my dad these bad drugs - my dad he loses more function. He recovers somewhat but never all the way. THIS hospital he is in was suppose to be very good and they are horrible and they are all defensive.

After it happens again, and again, and again. You just start to feel like it must be ME and I must be a complete nut to expect them not to drug my dad needlessly. They had no reason for why they did it. He certainly doesn't need sleep aids.. he is barely conscious the way it is. The sleep aids made him nuts and the muscle relaxants have made him more anxious and upset and scared feeling.

My dad has been at this place for a month (for blood clots after artery surgery).
Now they are like "does you dad have dementia"

Well yeah he does off and on ... and if you give him this crap he should not have that definitely triggers a bad spell of dementia. I just hope he recovers from this one too because he is thinking left is right and right is left. He is repeating words over and over.
He is not answering with anything but OKAY OKAY OKAY or on occasion "I don't give a Shxx" whereas a week ago he was hoping to get his leg healed and get walking again.

This is how dangerous these PRN doctor orders are and they are all based on the witless quick snapshot notes that various nurses make and ask the doctor to prescribe crap for.

The nurses walk into the room just as your LO is choking on some spit and coughing and the next thing you know - your LO is taking allergy medications and cough syrup 3 or 4 times a day until they are confused, unbalanced, and urinating in bed. Then new report to the doctor - patient is incontinent....

After what I have witnessed over the past 2 years - , the ignorance, blindness, lack of followup & observations when new medications are prescribed - I fully intend to shoot myself in the head before ever entering the healthcare system. My husband feels the same way (not about shooting me (ha) ) but our talks now center around "holy crap" how could they do this AGAIN? WTH is going on? I, WE, are NEVER going to end up like that.
We never want to be at the mercy of this healthcare system.

Please Lord protect these caregivers and their loved ones. It is so hard.


Sun Dec 05, 2010 2:59 am
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Joined: Fri Jan 15, 2010 9:33 pm
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Location: Vermont
Post Re: Difficulty with Nursing Home Staff
Oh Grace - I do know what you are going through, only our experiences weren't that long-lived as my dad was never hospitalized for very long. But a long time ago I realized that if anyone is in the hospital, it is imperative to have a LO there too as much as humanly possible.
A few years ago my dad had what turned out to be a minor stroke. I took a week off work and spent every day with him, from breakfast till about 9 at night, by his side in the hospital. About the 2nd day he was there a woman came in to give him a neuro. test. He had refused to get hearing aids and his hearing was not great, especially high-pitched voices. This person testing him had a high, squeaky voice, would ask a question once, and then write down my dad's answer, which usually had nothing to do with the question. I stayed out of it for a while, but finally I spoke up and said "please either let me repeat the question for him, since my voice is much more understandable to him, or write your questions on a piece of paper so he knows what you are asking."
Once we got that cleared up, all his answers were correct and she said "Oh, your father doesn't have any memory problems at all." Duh - she thought his memory was totally gone and it was because of his hearing problem at the time, not a memory issue at all. They probably would have put him on memory meds back then, before he ever needed them.
Whenever possible, have a friend or family member with a LO in the hospital - you just don't know what will happen if we are not there observing, asking questions and pointing out things to the staff that they should know about our LOs. It's the only way to navigate the hospital, in my opinion. Lynn

_________________
Lynn, daughter of 89 year old dad dx with possiblity of LBD, CBD, PSP, FTD, ALS, Vascular Dementia, AD, etc., died Nov. 30, 2010 after living in ALF for 18 months.


Sun Dec 05, 2010 9:41 pm
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Joined: Sun Aug 29, 2010 5:46 pm
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Post Re: Difficulty with Nursing Home Staff
Lynn, that is an excellent point. My mother had a minor surgery several years ago and reacted to the anesthesia (in hindsight, one of the first LBD symptoms, though eventually the docs called it "anesthesia dementia" after ruling out everything else, and said it was common in the elderly). So after coming out of recovery and into her med-surg room, she kept trying to get out of bed, pulled out her IVs, etc. I was coming from out of town, so I arrived the morning after the surgery. When I got there, she looked at me intently and whispered, "I have to go to the bathroom!" I asked what they were doing to toilet her, and the aide said they just had those pads under her because she couldn't use the bed pan. I went to the charge nurse and told her that my mother needed to be walked to the bathroom. They did, and she voided some huge amount of urine. The charge nurse was very apologetic and promised they would toilet her every two hours since was unable to communicate with them. And surprise, she stopped trying to get out of bed! The night before, they had even given her Haldol to keep her quiet, for heaven's sake, despite the fact that her neuro status was unclear. (They were still evaluating whether she might have had a stroke after surgery.) So who knows what would have happened if she hadn't had a LO there who could understand her? I ended up taking the rest of the week off of work to stay at the hospital with her.

Julianne


Mon Dec 06, 2010 4:00 am
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Joined: Fri Jan 15, 2010 9:33 pm
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Location: Vermont
Post Re: Difficulty with Nursing Home Staff
Good for you Julianne. I'm glad you could be there for your mom when she needed someone so much.
If your LO is ever in Intensive Care it is even more important to have someone there. The nurses sit and look at computer screens monitoring their patients - I'm sure that's not their idea of caring for critically ill people, but that's how it's done these days. My mom had been in Intensive Care for a couple of days and I was with her almost 24/7. They could not see on their monitors that she had blood runniing out of her nose and mouth. Who knows how long it might have been before they discovered that? When I wasn't there, my cousin was with her, even through the night and we took turns sleeping on the waiting room couch. We both knew how important it was to have a family member with her at all times. Lynn

_________________
Lynn, daughter of 89 year old dad dx with possiblity of LBD, CBD, PSP, FTD, ALS, Vascular Dementia, AD, etc., died Nov. 30, 2010 after living in ALF for 18 months.


Mon Dec 06, 2010 10:59 pm
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