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?

Video 3 and 4 here, from the series.

How often do we see our residents acting out? A lot. Do we ever wonder if it’s the drugs they are taking? Perhaps we should.

Ramona Lamascola thought she was losing her 88-year-old mother to dementia. Instead, she was losing her to overmedication.

Last fall her mother, Theresa Lamascola, of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor — the younger Ms. Lamascola’s own physician — who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.

Theresa Lamascola was moved to a nursing home to get these problems under control. But things only got worse. “My mother was screaming and out of it, drooling on herself and twitching,” said Ms. Lamascola, a pediatric nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.

“I knew the drugs were doing this to her,” her daughter said. “I told him to stop the medications and stay away from Mom.”

Not until yet another doctor took Mrs. Lamascola off the drugs did she begin to improve.

At work, we should ask the nurses if our residents are taking any new meds; if they are, we should ask if there are specific or not-so-specific side effects WE should know of, and report. So many times older people are drugged up and we think this is WHO the person is…I once worked with a woman who was DX with dementia- but she wasn’t demented. It was her meds. It took months to figure things out, but she ended up being discharged from the nursing home. If it weren’t for the excellent nurses who were very aware of drug interactions and side effects, the poor lady most surely would have died in the facility.

I found these videos at YouTube and thought it would be a good resource. I’m including them here in two posts…

Transfer Techniques p.1 of 4

Video Two from the series.

Transfer Techniques p.2 of 4

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.

A what?

Thanatology
The study of death and dying, especially in their psychological and social aspects.

I have never heard of this profession until I received an email from a woman who does this for a living. And I am amazed.

From Donalyn’s web site:

Dr. Donalyn Gross, PhD., LCSW, CMP, Thanatologist
D. Gross, PhD., LCSW, CMP, Thanatologist, has worked with the terminally ill and their loved ones for over thirty years. She has worked in hospitals, correctional systems, been a hospice volunteer director, has taught college courses in death and dying, and gives workshops on death and dying issues.

Donalyn created a program called Good Endings.

At her web site, Donalyn offers training materials for nursing home staff who work with people who are dying- so this encompasses all nurses and CNA’s of course:

GOOD ENDINGS-Caring for the Dying Resident-A Guide Twelve page booklet dealing with the end of life issues for those in the nursing home and health care agency field. Provides strategies and insights for caregivers. It includes Five Stages of dying, Problems Associated With a Terminal Diagnosis, How We Can Help The Dying, Physical Signs of Active Dying, and After A Death. $2.00 each booklet plus s/h.

We have written here many times how CNA’s are not prepared to deal with the emotional aspects of the death process. We even lack good training when it comes to Hospice practices in all honesty. I think any education on this matter is worthy of having on hand. Donalyn sells booklets which can be shared with staff and perhaps an in service can be developed based on her program. She offers on site training for nursing homes located in the North East region of the US.

Additionally she offers CD’s with her own music, which she uses harps as a means to relax people who are in the process of dying. She authored an article on this topic at Long Term Care Living recently.

Be sure to check this out. The booklets alone would make an excellent addition to Staff Develop book resources.

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.

Provider Magazine, a long term care trade publication, has an excellent article up about how CNA documenting can be streamlined and made much more efficient and, productive. In less time.

Read on (PDF File)

A new pressure ulcer reduction program—known as On-Time Quality Improvement for Long Term Care(On-Time)—was developed by the Agency for Health Care Research and Quality (AHRQ) with support from the California Health Care Foundation in an effort to close the gap between staff knowledge and staff practice.
[...]
Since certified nurse assistants (CNAs) spend the most time with residents, they are frequently the first to notice subtle health status changes; however, their observations often never reach the team members who are formulating care plans. In addition, nurses are sometimes reluctant to use CNA
documentation because it may not accurately reflect resident health status and is often incomplete.

More:

There are three key components of the On-Time program:
*Assessing current CNA documentation, streamlining CNA documentation, incorporating best practice elements into daily charting, and consolidating CNA documentation into one form;

*Establishing audit and feedback processes to confirm CNA information completeness and accuracy;

*Integrating weekly reports that identify at-risk residents into care planning processes and structures.

Sometimes I wonder about ALL the documenting we do- is it helpful, is it really necessary and, who reads it? Where does it all go? AND how much of the paperwork is geared towards making someone’s else’s job easier? Hmm.

Implementing The Program
Successful implementation of the On- Time model entails the following three steps.
Step One: Streamline and standardize CNA documentation to capture relevant information. The heart of the On-Time program lies in the daily care documentation conducted by CNAs. Prototypes of the CNA documentation form and the On-Time reports are the starting point for implementing the program.
During the first stage of the initiative, documentation forms currently used by CNAs are reviewed; cross-referenced against regulatory requirements, facility care protocols, and best practice elements; and compared to the On-Time CNA form prototype.
[...]
The result of this process is the development of a new CNA form designed to include best practice elements and to eliminate both redundancy and documentation of unessential items.

READ the entire article HERE; this is a PDF file and it’s very worth printing and saving. Any efforts to reduce the amounts of paperwork is worth looking into. CNA’s and nurses spend astronomical amounts of time writing, checking, noting and reading many forms, sheets, records, logs..much of it is inefficient and wasteful.

The National Association of Health Care Assistants- NAHCA- used to have a magazine for CNA’s called “CNA TODAY”- it ceased publication a couple years ago. NOW, they introduce a new magazine for ALL direct care workers in the nursing field, titled, “MY CAREGIVER”.

From the MY CAREGIVER web site:

My Caregiver is a quarterly magazine published by the Academy of Certified Health Professionals (ACHP) for and about health care assistants and their role in long term care. It is a special magazine, a publication virtually every person in the long term care industry will want to read.

With a circulation of 10,000, we reach nursing assistants, Directors of Nursing, facility Administrators, nursing home residents, and their families, product manufacturers, policy makers, and other health care associations.

The first issue of My Caregiver debuted March 2008. It evolved from the original CNA Today magazine to focus on health care assistants from diverse settings in long term care. The original magazine, CNA Today, launched June 2001 and was unveiled at the NAGNA National Convention.

Now My Caregiver will prove to be a remarkable resource for information on long term care for all who perform the role or duties of a nursing assistant, regardless of title.

The magazine is published quarterly and costs $15.00/year for non NAHCA members; $10.00/year for members.

NAHCA’s main web site is HERE.

A nursing home in New York City cut off health benefits to it’s staff over last summer, and they have been on strike since February.

After three wearying months of walking the picket line, 220 nursing home workers at the Kingsbridge Heights Rehabilitation and Care Center in the west Bronx have had plenty of time to sharpen their message.

“Health care workers like us should have health care coverage,” said Jacqueline Simono, who has worked for 10 years at the six-story, 400-bed nursing home.

In August, the nursing home stopped paying the workers’ health insurance premiums, and as a result, their coverage was cut off. That, the workers say, was the main reason they went on strike on Feb. 20.

The workers, members of 1199 S.E.I.U. United Healthcare Workers East, say they are expecting the National Labor Relations Board to give them some good news soon to help end the strike.

Sadly, those on strike are not earning any income and I cannot imagine how they are making ends meet right now. The costs of health care benefits is skyrocketing for everyone- not just health care workers. We’re seeing more and more businesses from every sector dropping coverages or increasing premiums.

Reading the rest of this article, it isn’t clear what’s really going on here. One thing: If these staff belong to a union, it is the unions’ job to make sure benefits are part of any bargaining plan. Somehow, somewhere, someone let the ball drop here.

I did a little digging into this situation and found a couple articles worth mention.

From a May 7th article:

NEW YORK–About 5,000 members of 1199SEIU from across the Northeast rallied May 3 to support 220 strikers at the Kingsbridge Heights Nursing Home, whose owner, Helen Sieger, has refused for six years to sign a contract with SEIU or pay into the 1199 health benefits fund.

The overwhelmingly immigrant strikers entered the rally at Fort Independence Park in a boisterous show of force, calling on a broad spectrum of militant national labor traditions.
[...]
Bartosz and Tomas, two strikers from Poland, described Helen Sieger’s anti-labor practices: “We have no sick days. We have no health benefits. We are required to arrive at 10:30, but are only paid from 11:00 on. Though we should finish at 7:00, we often have to work later, also without pay.”
[...]
A number of federal, state and city politicians and union officials spoke at the rally, including SEIU President Andy Stern and Sen. Charles Schumer. Barack Obama spoke through a recorded message. SEIU members from Albany and Rochester, N.Y., turned out, along with others from Massachusetts, New Jersey and the Washington-Baltimore area.

The rally highlighted the role that immigrants play in organized labor. A win for the Kingsbridge workers will be a victory for both the immigrant rights and labor movements.

There were not 5000 people at any rally for this. That is a gross exaggeration. Using militant strike methods wins few friends in these causes; however, asking politicians to speak on the behalf of those on strike is admirable.

The fact that many of those on strike are immigrants leads me to ask the tough question: Are they legally entitled to work in the US? Are these people just doing another job Americans won’t do? I wonder how many American CNA’s worked for this facility?

Finally, I ask this: If there is a strong union here, HOW do we explain such bad working “conditions” that include no sick days, not being paid for actual times worked, and so on? In many places of employment, meal breaks are not paid time. So, employees are expected to be on premises for 8 1/2 hours- eight of which are paid and the other that is not. And exactly how much longer were they made to stay over 7:00? A few minutes or hours? If minutes, then this issue is moot. If hours, then there is a serious problem. The devil is in the details, and we’re not getting those.

I also found the latest survey information for this facility. As usual, it doesn’t provide a clear picture of the facility, but all in all it isn’t THAT BAD. I have no doubt this place is a dungeon to work in; I also have little reason to believe the management gives one hoot about the workers. But my instincts tell me we’re not being given ALL the facts.

I ask people to be skeptical on these articles because the lack of detail can make a huge difference. A unionized nursing home should NOT have these issues. A union that has failed it’s members, however, might encourage a strike just to blow smoke in the air around it’s own failings and obscure the truth.