“I wish I’d brought a tape recorder,” sighed Tony. “Since I turned seventy-eight, my memory isn’t what it used to be. I had no idea there was so much to learn before I move my mother into a nursing home.”
Relocation of any kind takes planning, time, and perseverance. The following are additional points of information needed prior to the actual move-in date. Under standing the challenge of the new environment will help ease the process.
1. The Best Times to Admit: Not at Night, Not on a Weekend
“I’ve never lived through anything like it,” began an exasperated Ryan. His uncle Stephen had been released from the hospital to a nursing home after being diagnosed with a brain tumor. “I waited at that hospital for twelve hours on Friday! The doctor didn’t write the discharge order until three in the afternoon. Then, a nurse explained that we’d still have to wait for the ambulance because the company was backlogged. What time do you think we finally arrived?” Before I could answer, he exclaimed, “Ten-thirty at night! By then, uncle Stephen was in pain, but they couldn’t give him any medication without contacting the nursing home doctor assigned to him. The new guy didn’t return the nursing home’s call until Saturday morning. To make matters worse, my uncle needed a special air mattress for delicate skin, and no one could deliver one until Monday. There was no one in administration to help us figure out these problems. Poor uncle Stephen has suffered needlessly for three days. Stella, help me get him out of there!”
Every new arrival at a nursing home should be made to feel welcome, special, and secure. However, there seems to be a complete disregard for timing and for the comfort of the patient when a hospital discharges to a long-term care facility. No nursing home is equipped to carry out a proper admission after six P.M. It is unlikely an administrator will be there to help you through the process. The director of nurses will not be present to assess your parent’s medical and emotional needs. On admission, the attending physician is required to verify the patient’s medical orders, but after six in the evening, he will have to be paged. Until he has verified the prescription orders, the pharmacy will be unable to deliver the medications.
There is an art to the admission process. After thirty-seven years of nursing home experience, I can testify that admitting a resident at night, on weekends, or on holidays is a setup for disaster, and I actively discourage it. My policy frequently flies in the face of discharge planners at local hospitals, but the primary concern should be the welfare and comfort of the residents.
If questions arise during the relocation process—and they will—the people best qualified to answer them are usually available Monday through Friday. Of course, a nursing home should run smoothly on Saturdays and Sundays, but the admission process is special, and it requires the expertise of the administrator and the director of nurses. When they are involved, they can defuse the anxiety and worries of the family, making the admission smoother and easier for everyone. Even a Friday-morning admission does not give the resident and the family time to become oriented to what is initially a foreign environment. Nor does it give the nursing staff time to create and implement an individualized plan of care, which is critical for the comfort and security of the resident.
If the resident is being admitted from home or from assisted living, your best chance for a successful admission will be late morning or early afternoon between Monday and Thursday. This is because the day shift has the flexibility to focus on welcoming a new resident and family. Inquire about the facility’s admission protocol. If a welcoming staff member is not part of their admission process, ask if someone can come out to the car or ambulance and welcome your parent. If you arrive around three in the afternoon, bear in mind this is the time when the staff is sharing pertinent information from one shift to the next and they are not available to be actively involved in an admission for about half an hour. During the three to eleven P.M. shift, the “welcomers” will no longer be on duty. The smaller staff will be stretched to give your parent the attention she deserves.
Once your parent’s plan of care is in place, there is still a learning curve for the resident, the family, and the staff. The first few hours and days are the most critical. When is the best time to admit? Not at night. Not on a weekend. Preferably, not even at shift change.
2. The Attending Physician
For nursing homes, individual states require that the attending physician see the resident within a certain number of days following admission. In California, for example, the resident must be seen within seventy-two hours and then monthly thereafter. The facility itself will receive a “deficiency” from government inspectors if the physician does not visit in a timely manner. Ask your parent’s attending physician if he can commit to visiting your parent every month in the nursing home. In my experience, the majority of attending physicians are unable to make the commitment. If your parent’s doctor cannot do so, ask the facility if they have someone to recommend. Be sure to ask the following questions about the new doctor:
3. The Podiatrist
With age, toenails become thick, striated, and brittle, which makes trimming a challenge. Skin surrounding the nail bed is easily bruised or nicked. Because most of the elderly are prone to poor blood circulation, these injuries to the feet can take a long time to heal. For diabetics, even a small sore can become painful and lead to infection.
Every facility has a contract with a podiatrist, and an appointment with your parent is covered by Medicare every sixty days. Be sure your parent is on the list to be assessed by this physician. HMO recipients can only be seen by the HMO-approved podiatrist, who is unlikely to make nursing home visits. Because of this, HMO families frequently choose to pay privately for the facility’s podiatrist.
4. Dental Care
Every nursing home has a contract with a local dentist for routine and emergency care. Again, be sure your parent is on the list for an evaluation shortly after admission and approximately every six months thereafter. Dental care is not a Medicare-covered service.
5. The Use of Restraints
The use of restraints, whether physical or chemical, is an emotionally charged subject with families as well as with health-care providers. Since each facility will have its own philosophy, ask for a clear explanation.
Physical Restraints. It is not uncommon for families to say, “We’ll take the risk of Mom falling—there’s no way we want her restrained.” To restrain or not should be the family’s decision. Facilities are not allowed to arbitrarily restrain a resident for staff convenience. Before use of a restraint is implemented, an interdisciplinary team must assess safety issues. For example, they may find your parent to be at high risk for falls due to unsteady gait, impaired vision, or diminished judgment. If they recommend a safety belt or “lap buddy,” a doctor’s order is required as well as the permission of the resident or family. The family will be asked to sign a form acknowledging that they are aware of the recommendation and that they accept or decline the decision. If they decline, the use of a restraint cannot be ordered. If you feel a restraint is no longer necessary, ask the staff to reassess its use.
Chemical Restraints. Much has been written about the overuse of antianxiety medications, antidepressants, tranquilizers, and psychotropic medications. Admonitions not to “drug your parent,” and warnings that “drugs will change your parent’s personality” frequently prevent families from considering the benefits of chemical intervention. Nonetheless, if your parent exhibits agitated behavior or physical outbursts, her life is far from peaceful. It can be inhumane not to use chemical restraints if in fact they can reduce the anger, fear, depression, paranoia, or agitation that a resident is experiencing.
Since dosage and duration of use differs from person to person, standard medical practice is to “start slow and start low.” An evaluation by a geriatric psychiatrist or a physician experienced in caring for the elderly should precede the use of any chemical restraint.
Alan, Dan, and Gina. “I don’t have a problem using psychotropic medication for Dad,” explained Dan, about his eighty-nine-year-old father, Alan. “Dad believed my mother was having an affair with the local pharmacist. Every time she went to the drugstore, Dad became angry. When his doctor recommended an antianxiety medication, my sister Gina flatly refused to consider ‘mind-altering medications,’ as she refers to them. She insisted, ‘He’s not crazy, Danny. He just gets a little mixed up sometimes.’ But Dad’s fantasy got worse. Even though Mom was standing right there in the room, he would lament that she was in New York with the pharmacist for the weekend. He didn’t recognize her and refused to believe anything we said. Dad was miserable, and all my sister could say was, ‘Try to reason with him. This will pass.’
“One morning at five A.M., Mom called me in tears,” Dan continued. ‘Your father is convinced there are roaches coming out of the bathtub, and he’s trying to kill them with bug spray. Danny, there are no roaches and I can’t get him back in bed!’
“The next day, I accompanied Mom and Dad to a geriatric psychiatrist recommended by his doctor. The psychiatrist ordered lab tests and an MRI and started Dad on a small dose of an antidepressant along with an antianxiety medication. ‘Your sister will not be happy,’ Mom murmured as we drove home.
“When the doctor asked us how Dad was doing a week later, Mom replied that the imaginary bugs were still frightening him. The doctor increased the medication. During the next week,” Dan went on, “Dad’s behavior began to improve. Even Gina admitted that life was more peaceful. The bugs disappeared, and Dad’s episodes of unpredictable anger decreased.”
“I really gave Dan a hard time,” Gina later confessed. “Psychotropic drugs are such a hot-button subject. I should have listened more and given directions less. These medications have been a lifesaver for all of us.”
6. The Diaper Policy
Approximately 60 percent of residents in long-term-care facilities are incontinent of urine. Each resident should be checked every two hours by the nursing staff, and changed as needed. This schedule should be in effect twenty-four hours a day.
Disposable diapers are available that supposedly need to be changed only every twelve hours; however, the discomfort level, loss of dignity, and risk of infection make these diapers unacceptable. Review with the administrator the diaper system used in the facility.
7. Catheters Use
A catheter is a sterile tube that is inserted through the urethra into the bladder and which drains urine into a plastic container. This device should be used only for specific physiological problems such as enlarged prostate, cancer of the bladder, or urinary retention. Catheters can be a great benefit when necessary but are high risk for infection. In addition, they can be uncomfortable, become clogged, and cause pain. Should your parent be admitted from the hospital with a catheter, ask the director of nurses if it is still necessary and how soon it can be removed. A catheter should never be used merely because the resident is incontinent, bedridden, or confined to a wheelchair.
8. Visiting Hours
Every facility posts visiting hours—typically ten A.M. to seven P.M. If your family has special needs, how flexible are the hours? Even though Bernadette has a difficult commute to downtown Los Angeles, she runs in every morning at seven for a quick visit to see her one-hundred-year-old mother. She says, “I know she doesn’t know I’m here, but I know I’m here.” Can the facility you are considering accommodate you? If your parent is critically ill, you should be allowed to visit twenty-four hours a day.
9. The Beauty Shop System
If the facility has a beauty shop on the premises, you will find it is a very busy place. The beautician and manicurist may be employees of the facility or independent contractors. Ask the administrator if they are paid at the time of the visit, or if the charge is added to the monthly bill. How is tipping handled? Are standing appointments recommended, or should you schedule as needed? Will staff members see that your parent arrives on time? Asking these questions ahead of time can eliminate misunderstandings in the future.
10. The Resident’s Wardrobe
Provide clothing that your parent currently prefers to wear during the day at home. Be mindful that it will be washed in hotter water than you would use at home, so permanent press is best. Clothing that requires dry cleaning is not advisable. Garments with snaps fare better than those with zippers or buttons. In the nursing home, sweats are by far the most comfortable to wear and the easiest to get on and off. Your parent should have at least ten days’ worth of clothing.
Will the facility be responsible for marking your parent’s name on clothing? Look over the wardrobe from time to time to see if it needs remarking. The laundry pen may say “indelible,” but when the name fades after many washes in hot water, items will end up in the wrong closet.
11. The Laundry System
Are you allowed to do your parent’s laundry if you choose? How often should you pick it up? Who will provide the hamper? If your parent is incontinent of bowel and bladder, allow the facility to be responsible for all laundry. Soiled clothing placed in a hamper can cause offensive odors to permeate the area. It must be removed from the room as soon as the resident is changed.
In institutional laundries, there will be misplaced clothing and errors in sorting. While small items such as socks and underwear are difficult to keep track of, a cooperative staff will make an effort to hunt down a missing article of clothing by searching the resident’s room. (If you discover that laundry is your main concern, you are probably in a good facility!)
12. The Tipping Policy
Some books recommend tipping the staff. I disagree. When families notice a particular nurse’s aide who develops a relationship with their parent, it is normal to want to thank this person with a monetary gift. Most likely they believe tipping guarantees that the nurse’s aide will keep a closer eye on their parent. However, an attitude may develop on the part of those who are not given a tip and feelings may be hurt, which was certainly not your intention. Families tend to tip only the staff they see. Many of the people who care for your parent are behind the scenes: the late-night shift, the dietary staff, housekeepers, and maintenance personnel.
I am frequently asked how to show appreciation to the staff. Several years ago, we established an Employee Christmas Fund. Donations are collected from the families and then divided equally among the entire staff. If you want to express thanks during the year, cookies, popcorn, or pizza for each shift will always be enjoyed.
If there is a no-tipping policy, respect it. Think before you put a staff member in an awkward position. Our staff knows accepting a tip is grounds for dismissal.
13. Leaving Cash with Your Parent
For many residents, having their own money represents freedom and independence. They may leave money on the table not because they need it, but because they like to know it is there.
Suzanne gave her mother $50 which soon turned up missing. By the time we found it in the tip of her mother’s shoe, relationships of trust had been sorely tested. Suzanne temporarily lost faith in the staff, and the staff felt uncomfortable even though no accusations had been made. When I asked Suzanne why she had given her mother so much cash, she replied, “Mom begged me for it. I know I should have used common sense.”
If your parent has experienced memory loss, do not leave money in her room. Petty cash can be placed in the administration office and used as needed. This prevents putting staff in a position where they may be tempted or unjustly suspected. I encourage residents to keep no more than $10. Even then, keep in mind, it may be misplaced.
14. Ordering Medications
If you understand the facility policy on ordering prescriptions before your parent arrives, it will be one less thing to worry about on admission day. Letting the facility order the medications will be easier. In accordance with state laws, you have the right to continue to use your current pharmacy to supply your parent’s prescriptions, but you will be responsible to meet your state’s pharmaceutical regulations. The rules can be confusing. For example, in California, any medication we receive must be labeled with the specific patient’s name, the doctor’s name, the number of pills dispensed, the name and strength of the medication, the expiration date, and exact directions. Since state laws vary, ask the facility you choose to explain the regulations.
If you decide to supply prescriptions yourself, find out who is responsible for ordering and reordering medications at the facility. On a weekly basis, ask this person, “Does Dad need any of his prescriptions refilled?” Planning ahead to refill prescriptions on time is essential. I recommend having at least a five-day supply on hand in case of emergency. By federal law, each medicine ordered for your parent must be in the facility’s medication cart at all times. If you use a mail-order pharmacy, it can take ten days for delivery. Families get busy. They order the medications but forget to pick them up. Or they go on vacation. Since it is not uncommon for residents to require ten to fifteen different medications, keeping the facility stocked with each one can prove overwhelming to the individual family member.
In some states, emergency medications, such as antibiotics or drugs used to treat severe pain, nausea, diarrhea, and agitation, must be available within one hour of the time ordered. This is a difficult rule for most people to comply with. Families who supply routine medications themselves often direct the facility to take care of emergency requirements.
If you supply over-the-counter medications, you must deliver them in unopened, original containers. Products such as Milk of Magnesia, Tylenol, multivitamins, calcium, or Fleet’s enemas are more costly if the nursing home orders them for you because there is a delivery charge from the pharmacy. You can purchase them less expensively at bulk-price stores. However, state and federal regulations for nursing homes are again exceptionally strict. If the doctor orders Tylenol for pain, and you bring in Extra-Strength Tylenol, the facility can only accept it if they call the doctor and receive a new order specifying “extra-strength.” If the doctor prescribes a multivitamin, and you bring in a multivitamin with minerals, again, a new order is required. These rules are frustrating for everybody, so familiarize yourself with them to eliminate surprises.
15. Hearing Aids and Dentures: Now You See ’Em…Now
You Don’t
Placed and removed 365 days a year, hearing aids and dentures seem to have a life of their own. Frequently the front office gets a call from the kitchen, saying, “There’s a denture on a tray. Who’s missing one?” Hearing aids fall on the floor and get crushed. Dentures are placed in a Kleenex box “for safekeeping,” only to have the box thrown away. One resident parked her hearing aid in the toe of her shoe. We have found these items in the trash can, in candy boxes, floating in the toilet, and in neighboring residents’ pockets.
If your parent is unable to remove a hearing aid and place it in the case, trust me, it will get lost. Left in during sleep, it may fall into the bedding, get bundled up, and sent out with the laundry. Often, residents take out their hearing aids because they pick up background noise, such as several people talking at once. If your parent has dementia and removes her hearing aid, we recommend you return it to the nurses’ station when your visit is over. I am aware that the initial response to this plan is, “But my mother should be able to hear all the time!” I agree. However, hearing aids are expensive and caregiving requires flexibility. Keeping hearing aids and batteries at the nurses’ station means they will be available when needed. Some families have successfully used an Amplified Listener, a little black box that hangs around the neck. Worn with earphones, it amplifies sound and functions as a hearing aid. It is available from Radio Shack.
Lost dentures are so common in nursing homes that you should ask the dentist to have your parent’s name engraved on them. For some residents with dementia, it may not be realistic to wear them all day long.
Missing hearing aids and dentures are a frequent cause of misunderstanding between families and care facilities. Talk to the staff and come up with a workable solution.
16. Developing a Cooperative Game Plan
Since caregiving facilities are most successful when families and staff work as a team, devise a game plan for special needs. If your mother is unable to turn on the TV to watch Wheel of Fortune, designate a family member to call the nurses’ station every night and remind them to turn it on for her. In time, you will discover that the staff is anticipating your call and has already turned on the TV. One woman asked that her father fall asleep every night listening to his favorite classical radio station. A clock radio was our solution.
Because of staff rotation, employees’ days off, and new nurse’s aides, some requests are difficult to handle on a daily basis. Misunderstandings happen easily and can lead to tension between family and staff. In extreme cases, I have seen staff avoid certain family members whose demands were unrealistic. A goal of good communication is understanding what is practical; the art of good communication is negotiation and flexibility. Be sure to address requests or complaints to the right person. Do not take a problem to a nurse’s aide or a housekeeper. Check with administration so that they can direct you to the best person to handle your request.
Good Questions Lead to Good Decisions. Finding the right facility for your parent is not always easy. As you visit facilities, use the inquiry process (see Chapter 15) to ask pointed questions, and evaluate the manner in which they are answered. The education you receive, added to your own intuitive sense of how the facility feels to you, will prepare you to make a decision with a sense of control and confidence.
You cannot plan for every eventuality when admitting your parent to a nursing home or an assisted-living facility. There will always be unexpected details and decisions. How the staff responds to your concerns with workable solutions sets the tone for a successful family/staff partnership. Meanwhile, the more you know and plan ahead, the more comfortable you will be making the transition.