Wheelchairs. It seems like they are everywhere we go within the walls of so many nursing homes. Many believe they are a needed, if not required, piece of equipment. For some residents, the wheelchair is their ticket to independence. For most though, it’s a one way street to declines in almost every aspect of life. How many residents do we see slumped over in these chairs, belted in, reclined or otherwise forced to stay in them? Do we see the connection between wheelchair use and physical decline?

I can attest to this over dependence on wheelchairs. It starts out innocently enough- the aides are working short (again) and meals are being served. Time is short. Residents walk slowly. It’s easier to just pop them into a wheelchair and push them to the dining room. Or to the bathroom. Or to the activity room…and so on. Soon, the resident begins losing their confidence and desire to walk themselves. Perhaps they’ve had a fall and we are nervous to let them walk again…whatever, it’s insidious and sneaky- this overuse of chairs.

Provider Magazine has an excellent article (PDF) about wheelchair use, or more like, abuse. The article stresses that nursing home culture includes having so many residents sitting in these chairs that it’s almost expected. The article highlights one facility that decided to end the abuse, and how the residents have benefited. The Administrator started this process and walks readers through the steps she took to go “wheelchair free”…

WHEN FOREST AT DUKE, A continuing care retirement community in Durham, N.C., began planning its renovation and expansion, Leslie Jarema, administrator and director of health services, seized the opportunity to dramatically reduce wheelchair use in the community. “My many years in nursing home environments convinced me that wheelchairs created the discomfort that resulted in many negative outcomes and behaviors of residents,” says Jarema.

She has a tough policy:

Jarema instituted a new policy that limits the use of wheelchairs to two purposes: to enable a resident to be independent in ambulation or to transport a resident from point A to point B.

So, even the common “Walk-to-Dine” programs aren’t acceptable here, it seems. This isn’t a bad thing.

And what happened?

For the residents of Forest at Duke, the outcome of the wheelchair policy was nothing but positive, Jarema says. Dignity, comfort, improved skin condition, and residents’ range of motion were improved. “But there are some less obvious, more subtle outcomes,” she says. For example, the feel of the home became quieter, calmer, and more visually appealing. “The new program has totally eliminated the residents who typically sit around the nursing station crying out in discomfort.”

Jarema admits that the new policy meant more work for staff, who at first put up some resistance. “Even families and some residents resisted the initiative,” she says. “But one
must be committed and convinced that this change is for the better. Perseverance, persistence, and patience go a long way in achieving this highest level of functioning for our residents by getting them out of wheelchairs.”

A few reasons to re-consider the over-use of wheelchairs:

Over the years, the image of someone who resides in a nursing facility has become synonymous with an elderly person seated in a wheelchair. According to a study in the Journal of Rehabilitation Research and Development, wheelchairs provided to the elderly are often the wrong size, are in poor repair, are unsafe, and have fixed armrests and foot rests—factors that could lead to “poor posture, pain and discomfort, decreased sitting tolerance and function, decreased mobility, and pressure ulcers.” The authors conclude that psychological factors associated with “inadequate or inappropriate mobility devices” include loss of self-esteem, depression, diminished quality of life, and social isolation.

Does your facility abuse the use of wheelchairs? Are residents transported and then kept in the chairs as a means of convenience? Do you think it could be better to go to a policy such as highlighted in the article? What steps can CNA’s take to prevent this dependence upon wheelchairs? And who is more dependent: The resident or the CNA?

The latest word from CMS on helping consumers decide which nursing homes are good: Star ratings.

June 18 (Bloomberg) — Nursing homes, like luxury hotels in travel guides, will soon get star ratings for quality and safety, according to Medicare, the federal health insurance program for the elderly and disabled.

Medicare’s new ranking system will help people choose the best nursing homes for relatives and push operators to do better, said Kerry Weems, the program’s acting administrator, on a conference call with reporters today.
[…]
“The public is hungry for information and this is an easy way to evaluate quality,” Weems said. “The new `five-star’ rating system will provide a composite view of the quality and safety information.”

All I can say is they should have CNA’s be part of this rating system. As in, asking CNA’s to actually rate the facilities based on the special insight and insider info they have. Bet most nursing homes would get two, maybe three stars at most if the aides were doing the rating.

I have seen a disturbing trend of late. Quietly, medical and nursing facilities have been laying off staff in higher numbers. Not just housekeepers and janitors either; but nurses and CNA’s. In my state, a couple weeks ago a highly rated hospital closed down a unit and laid off 23 nurses and aides. Another facility was going to trim down a nursing unit by 15 beds, and would have laid off about 20 LNA’s and several nurses; the facility changed it’s mind on this, for now.

What’s going on? Did we ever think CNA jobs would be targeted for lay offs? Times are getting tough.

Cape Cod Hospital has notified an employees’ union it intends to eliminate about 17 full-time positions, including jobs held by cleaning staff, shuttle bus drivers, nursing assistants and food service workers.

The hospital is looking to save $800,000 through a combination of layoffs and not filling currently vacant positions, said David Reilly, spokesman for Cape Cod Healthcare Inc., the parent company of Cape Cod and Falmouth hospitals.

The job loss affects only Cape Cod Hospital, which is feeling the brunt of a multimillion-dollar revenue decline.

The 16.9 positions are “full-time equivalents,” meaning each is the equivalent of a 40-hour-a-week job. But the job loss could actually affect more than 17 individuals, since several of the jobs are shared by part-timers.

Revenue is the income a facility receives to pay for it’s operating costs. Much of this money comes from the federal government and state government, as well as from insurance payments. But, because these sources are not increasing their rates of reimbursement to the facilities, we have a shortfall.

Don’t assume belonging to a union will save CNA jobs:

‘The entire health system is feeling the pressure,” said Jerry Fishbein, vice president of 1199 SEIU, United Healthcare Workers East, whose union represents the workers whose jobs will be eliminated.

As required by collective bargaining stipulations, the hospital gave the SEIU a “30-day notice” of its intent to lay off the employees.

The next step is for the union to meet with hospital officials to see if they can whittle down the list, said Fishbein, whose union has 1,200 members at Cape Cod Hospital. “At the end of the day, there will undoubtedly be some layoffs. We certainly think the numbers should come down. It’s process of negotiation.”

This process might save one job, or position. It’s not comforting to know this process, negotiation, is all the unions can offer us when we face a job loss.

Last month, Cape Cod Healthcare CEO Steve Abbott announced that the organization had suffered a $17.6 million revenue loss in seven months.

The company responded by laying off 11 employees, mainly in mid-management and clerical positions, requiring a dozen senior executives to take a 10 percent pay cut and asking employees to consider early retirement.

The cut backs weren’t enough. So now they take it to the next level.

“Cutting back on the nursing assistants is a big problem for us,” said Stephanie Francis of the Massachusetts Nurses Association.

The two nursing assistant jobs scheduled to be eliminated could require nurses to pick up the slack and spread themselves thinner among patients, she said. Such a move would be in direct opposition to the Patient Safety Act being proposed on Beacon Hill, which requires a certain ratio of nurses to patients, Francis said.

Well usually the nurses whine when it’s THEIR job on the line; they complain when they are replaced with the less skilled, lower educated unlicensed assistive personnel (as we’re known as); they cite patient care problems when there are more of US then them. Since UAP don’t fall under Nurse s scope of practice rules, this claim is disingenuous at best. BUT, at least she’s sticking up for the aides in this case.

Abbott, who is retiring this summer, has blamed some of the hospital’s financial woes on the rise of off-site, privately run surgical centers and on an independent physician association, Physicians of Cape Cod, that he says is making fewer referrals to Cape Cod and Falmouth hospitals and their affiliated laboratories and services.

By sending patients to private organizations for procedures that receive lucrative reimbursements, the physicians in the I.P.A. are forcing the nonprofit hospitals to absorb more and more of the cost of serving the community, Abbott said.

More disingenuous stuff here. First off, remember this is Cape Cod. Kennedy country. John Kerry country. Where the rich live and house up for the summers. These people will not utilize the services of a public hospital no matter what. Cape Cod is full of private facilities that offer services at far cheaper rates than the public hospitals, believe it or not. Private sector doesn’t always mean more costs. The people who reside in this area do have a right to pick and chose where they will receive their health care, surgeries and the like. I do know these private facilities offer jobs to nurses and CNA’s and pay them better.

Do we take away this choice in the name of saving jobs? I think not.

What is certain is times are changing. More and more medical and nursing facilities are going to be forced to make cutbacks; this will result in patient care being put in jeopardy in many situations. I would expect to read more and more similar articles in the next decade or so, too. The trend is only just beginning. Brace yourselves.

Residents with dementia: Who are WE to decide who they have relationships with? This is a thought provoking article.

Bob’s family was horrified at the idea that his relationship with Dorothy might have become sexual. At his age, they wouldn’t have thought it possible. But when Bob’s son walked in and saw his dad’s 82-year-old girlfriend performing oral sex on his 95-year-old father last December, incredulity turned into full-blown panic. “I didn’t know where this was going to end,” said the manager of the assisted-living facility where Bob and Dorothy lived. “It was pretty volatile.”

Because both Bob and Dorothy suffer from dementia, the son assumed that his father didn’t fully understand what was going on. And his sputtering cell phone call reporting the scene he’d happened upon would have been funny, the manager said, if the consequences hadn’t been so serious. “He was going, ‘She had her mouth on my dad’s penis! And it’s not even clean!’ ” Bob’s son became determined to keep the two apart and asked the facility’s staff to ensure that they were never left alone together.

After that, Dorothy stopped eating. She lost 21 pounds, was treated for depression, and was hospitalized for dehydration. When Bob was finally moved out of the facility in January, she sat in the window for weeks waiting for him.

People with dementia should have rights too. But until we loosen up a little, they won’t.

Frances Shani Parker used to be a school principal. Then she became a hospice volunteer and has written about her experiences in nursing homes. I received a copy of her book and it is excellent. I recommend it to anyone who works in a hospice setting, and for all CNA’s as well. I will venture to ask that DON’s and Administrators have a look too. Sometimes people in higher places at nursing homes forget some of Frances’ important lessons.

You can purchase her book HERE.

Also, Frances has a blog HERE.

We write of Culture Change often here, and for a reason. It simply makes sense to adopt to this newer model of caregiving. And, it saves many cents, too! McKnights LTC News has the scoop right here:

Nursing homes that have adopted aspects of the culture change movement, or at least strive to, are more likely to see benefits in resident satisfaction, staff retention, higher occupancy rates and improved operational costs, according to a recently released survey of directors of nursing.

In the report, which was conducted by The Commonwealth Fund, nursing homes were broken into three groups: culture change adopters (31%), culture change strivers (25%) and traditional nursing homes (43%). Of the adopters, 60% reported improvements in operational costs compared with 31% of traditional nursing homes. Additionally, staff absenteeism decreased in half of the homes that adopted culture change, according to the report. Roughly a third of traditional nursing homes reported any such similar decrease in absenteeism. Culture change is a movement emphasizing resident-centered care in nursing homes.

From California:

LOS ANGELES, April 11 /PRNewswire-USNewswire/ — The California Nurses Association/National Nurses Association today condemned the Service Employees International Union for targeting CNA/NNOC leaders and members with threats and intimidation, stalking them at home and in patient care units at hospitals.

In a statement today, CNA/NNOC — the nation’s largest RN union — demanded SEIU International President Andrew Stern “immediately renounce the actions of SEIU staff and cease and desist these despicable attacks against anyone who speaks out against his pro-corporate agenda.”

“SEIU’s behavior, sending swarms of staff to threaten women in their homes, is especially disgraceful, and another illustration of their contempt for a predominantly female profession that they treat as chattel in so much of their activity, including trying to force RNs into his union,” said CNA/NNOC Executive Director Rose Ann DeMoro.

Roving bands of SEIU staff, four or five at a time, arrived on the doorsteps of at least two CNA/NNOC female Board members in Southern California Thursday, with video cameras to film their abusive exploits.

Is this what we pay dues for?

“Union membership is about collective democracy. Nurses decide they need a union and then choose the union of their choice,” Cuaresma said. “We will continue to give voice on behalf of our patients and we will never be intimidated in our struggle to defend our ratios and our hard-won benefits. Stern should rethink his strategy — he will not intimidate me or the CNA.”

Thursday’s attacks on CNA/NNOC Board members are the latest escalation by the Service Employees Union which has in internal conversations bragged about its intent to “destroy” CNA/NNOC for challenging SEIU’s practices which the RNs say compromise patient safety, erode RN standards and professional practice, and undermine workplace and union democracy.

Also on Thursday, CNA/NNOC obtained a letter from an SEIU staffer who resigned in disgust with the behavior of SEIU International and quoted a top SEIU official bragging of plans “targeting ten to fifteen C.N.A. bargaining units.”

SEIU’s corporate partnerships compromise patient safety

Perhaps the most egregious behavior of SEIU International, says CNA/NNOC are its deals with corporate hospitals and nursing homes, sacrificing patient safety for agreements to help it recruit more SEIU members.

For example, SEIU has signed pacts with nursing home operators in California and Washington state agreeing to lobby for the nursing home chains. Under the 2003 California deal, SEIU agreed to oppose legislation requiring nursing homes to provide enough staff to keep patients safe and healthy, and to not report health care violations to state regulators except when required by law.

Five years later, according to a report cited in the Los Angeles Times this week, despite increased state funding for nursing homes, the direct result of SEIU lobbying, nursing homes are spending less in California on direct patient care, and reports of patient mistreatment have shot up 38%.

Similarly, in partnership with hospital corporations, SEIU lobbied in California against the RN-to-patient minimum ratio law, and worked to erode the law after it was enacted.

Unions should work for the people who pay them to represent them. Not against them. Clearly the SEIU has held the hands of nursing home industry leaders, who have goals that are not in favor of good patient care. We might think unions are a good thing, but we should be careful consumers (that would be me and you!) when it comes to what a union really offers, AND how it operates behind closed doors.

I found an article about nursing homes and restraint use.

WASHINGTON (AP) - The use of physical restraints on nursing home patients declined nearly 40 percent nationally in recent years as the federal government, states and the nursing home industry placed greater emphasis on eliminating what once was a common practice.

Overall, about 5.9 percent of 1.5 million long-term patients were physically restrained repeatedly in 2006. That’s a drop from 9.7 percent in 2002.

Read the rest of this entry »

I wonder where this money goes?

DES MOINES, Iowa (AP) — A state program is under scrutiny for paying bonuses to some of Iowa’s worst nursing homes.

The program boosts the amount of Medicaid money homes collect for resident care if they score well on certain accountability measures.

However, Iowa Senator Charles Grassley is taking a closer look at the program after a report from The Des Moines Register showed bonus payments are going to 16 Iowa nursing homes that faced large fines last year for the abuse or neglect of seniors.

Grassley wants the federal Centers for Medicaid and Medicare Services, which approved the Iowa bonus program, to provide some explanation for the bonuses.

The program pays about $8 million a year to more than 400 Iowa nursing homes.

One thing is for sure- the money isn’t reaching the pay checks of the CNA’s. Keep your eye on this Senator Grassley.

National Nursing Assistant Week is coming up. The original idea behind this week was to honor those CNA’s who have chosen this work as a career. It now includes all nursing assistants, with June 12th being specially designated for CAREER nursing assistants.

The annual observance of Career Nursing Assistants’ Day and Nursing Assistants’ Week began in Ohio in 1977 as the Ten Year Club, and expanded nationwide by request in 1985. Since that time, this popular nursing assistant recognition program has grown to include thousands of facilities and organizations joining together each year to recognize and honor nursing assistants in long-term care services.
The title, Career Nursing Assistant © was developed by the Nursing Assistants’ Representatives’ Committee of NE Ohio in 1977. Today’s nursing assistant is proud to be designated as a Career Nursing Assistant, and the terminology is now in common usage to identify the experienced nursing assistant.

Nursing Assistant Week should be cause for positive reflections of the work CNA’s do. Too often, we are looked down upon. Too often, we’re an after-thought and our input is rarely asked for. We’re the most supervised group in the medical/nursing setting yet we are expected to deliver most of the hands on care, at dirt wages. Others have high expectations of us- not for our skills and education, but for our warm bodies and names on a schedule. More emphasis is placed upon our attendance than our skills; our pay reflects society’s overall disrespect of elderly and disabled people.

The Best Way to Honor CNA’s for National Nursing Assistant Week
Spread the celebration over time…Are we only to be recognized one week a year? How hard is it to recognize our good work and value all the time? Asking for our ideas and input isn’t difficult. Saying “Thank You” every so often isn’t hard, either. Both of these ideas cost nothing in terms of money; but would be considered priceless to most CNA’s.

One thing I hear all the time, from management, is how much these week long “events” cost; the strain on the budget…well, honoring the aides doesn’t have to cost a penny. At the National Network of Career Nursing Assistants’ web site, there are many things that management can do, that might require the expenditure of a stamp or two.

Ask your local newspaper to write a story about your NA who has the most years of service

Plan a group project to submit to the National Nursing Assistant Authors Club

Invite your local congress man or mayor to discuss NA related issues with a group of NAs.

Collaborate with the Ombudsmen or other local groups to plan an Award or Recognition Program.

…these are just a few ideas.

Also consider:

Ask your residents to provide insights about how important the CNA is to THEM.

Ask resident families to provide stories that reflect the caring and wisdom of CNA’s employed at your facility

Ask your CNA Mentors to write up their Best Practices; desktop publishing can produce a neat little book.

Ask your CNA’s to develop an in service or other presentation, to be given during NCNA week; provide them with the time and tools to do so; better yet, form a CNA Excellence Committee (or some aptly named group) that develops in services/presentations all year long. Collaborate with other local facilities- to share and inform. Think about the possibilities.

…these ideas are what MAGNET hospitals call Best Practices- and there designed to attract and keep the best nurses.

When people are involved in their work, and feel their opinion counts, they will give feedback and participate. If you’ve had problems with attendance or attitude at these celebrations, blame yourselves. Once a year isn’t enough. It’s doesn’t feel real, or honest. It’s a slap in the face. Many aides compare it to the dreaded survey illness that infects nursing homes once a year…all’s crazy and phoney for a week than life goes back to normal.

So, what about the actual EVENT? The CELEBRATION?
Here’s where these things get testy. It’s NEVER a good thing to SHARE the celebration of the work of CNA’s, with Nurses, or Housekeepers, or Dietary Staff. Each group is a very valuable part of the big picture. Each contributes it’s own important set of skills and work. Each deserves their own time to be honored. To lump everyone into one big party, once a year, is not only disrespectful of the employees, it’s disrespectful of their work.

NCNA WEEK is 7 days long for a reason. Seven days are listed with events for each day…as a guideline.

No one expects a nursing home to spend seven days celebrating. Hardly..what is expected is a concentrated effort to truly honor ALL the CNA’s employed- on all shifts including third shift and weekends. This might mean coming into the facility at midnight, or on a Sunday afternoon.

When planned ahead of time, seven days will not be necessary. When planning a major event where we want to include as many CNA’s as possible it would help to get creative with the schedule. Nothing stinks more than not being able to go to the one event designated for the aide- when he or she cannot leave the unit to attend.

A facility I worked at filled up three DAYS with events to honor the CNAs: One day was scheduled to target third shift aides; the next day was for second shift and weekenders and the third day was for day shift. Aides from ALL shifts did their own schedules to ensure coverage of the units…so, it did mean some slight overtime for more than a handful. But it was worth it. Attendance for these events was close to 100%- the only aides who didn’t show up were those on vacations.

As for “gifts” or tokens, one creative facility grew houseplants for the staff…the residents, with the activity folks, planted and grew little African violets and Spider plants. Another facility had the residents hand paint little plaques “awards”; and yet another facility utilized the local community with discounted and free coupons for pizza, groceries and gas. There’s plenty of opportunities in the local community- management just needs to seek them out.

Specific items for CNA Week are available, of course, and when possible, should be purchased. The NNCNA web site has a store, that has lapel pins, T shirts and little TIPS booklets designed just for this event.

This post was written for the management of nursing homes…I will have another post for the CNA’s on THEIR part in this.