We arrived at the locked front doors of the SNF in New Jersey at 12:30 AM Friday night/Saturday morning. We had left the hospital in Pennsylvania five hours before, following my sister- and brother-in-law who were in a medical transport van. We got there before they did. I had called ahead to alert them of our unavoidable arrival time and was assured that, “We’ll be waiting for you.”
Of course, the front door was locked. We rang the doorbell and waited. After about 5 minutes, a staff person appeared, looked at us, and held up a finger suggesting we wait, and she walked away. After another 10 minutes, another person appeared with the first person and, with great animation, they tried to unlock and open the front door. “Is this a sign?” I asked myself.
After decades in the long-term care sector as an operations and marketing executive and consultant, I have accumulated some self-confidence about data, issues, and topics related to my domains of experience. Nothing prepared me for the experience of being a consumer.
There wasn’t any data I could find about the percentage of SNF admissions after hours or on weekends. However, I was able to find data from the NHS that shows that the “hazard ratio” for patients admitted during periods of lower staffing is significantly greater. Amen to that.
The rest of our 26-day experience as loving, engaged, and caring family members for two of the best human beings that ever walked the earth was even more enlightening. My wife’s sister and her husband died in that SNF within 10 days of each other.
Most of our experiences were bad (The New Jersey Ombudsman’s office is in my phone history), some of them were dangerously bad (NJ Board of Nursing and NJ DPH are also in my phone history), and a few slices were wonderful. My purpose here isn’t to excoriate that SNF, the bad actors, or the Hospice, but to share with you one (very experienced) consumer’s point of view and to make some actionable recommendations.
After about 10 minutes (that seemed like 20), the two staff members figured out the problem and unlocked the doors and my sister-in-law, pushed by one transport driver, and my brother-in-law, pushed by the other, along with my wife and I entered the facility. We were led to the “short term” wing. There was a large central room, off which two corridors extended. The tables in this center room were pushed aside and the linoleum floor was piled with trash and litter. An aide sat at one of the tables eating as though half asleep; she didn’t look up as the six of us trundled by.
Broken windows
There is controversial theory about perceived safety and crime, which suggests that the more derelict the neighborhood, the less safe the residents feel, and the more crime is committed there. The so-called “broken windows” theory has been widely challenged, but there’s no doubt that damaged, dirty, and decrepit interiors in nursing centers create a negative impression. After having visited over 2,500 nursing homes in my career, I was ready for duct tape. The level of capital improvement in SNFs has been hampered by many factors, not the least of which is that nursing homes cannot (generally) qualify for further debt since they’re already heavily leveraged, and they’re unable to service the types of loans which other real estate-based operations (like hotels) use for refurbishment and updates.
The site of the trash, and the lack of any positive greeting was deeply dispiriting.
Recommendation
Pick up the trash! Andrea (the names have been changed), the administrator at this nursing home in NJ, should take a cue from Mike Dukakis. The last time I saw the Governor and presidential candidate in Brookline (where I lived for a while), he bent over and picked up a McDonald’s cup and threw it in the trash. Andrea walked by a lot of trash while I was there.
Who’s running the asylum?
The staff: “Have you asked Shirley? I think Shirley does that. Shirley knows where the humidifiers are. I’ll ask Shirley when she’s back from break.”
The administrator: “Anything you need, just let me know.”
No, Andrea. I’m going straight to Shirley.
There are a few people who really run your SNF operations, and it’s not you, the administrator. Each unit has one person who knows where the bodies are buried. No one crosses Shirley. I watched Shirley “dress down” not only aggressive patients but doctors and other staff; it wasn’t rude or rough, although it was very confrontational.
Recommendation
Find out who your key people are and support them any way you can. Acknowledge them and their work in ways that resonate.
Find a way to get Shirley to start picking up the trash, and I promise you, within 5 days you won’t see a speck. (All of you reading this know who Shirley is and are intimidated to ask her. But if you do, and this works, please tell me.)
Plugging holes isn’t delivering care
Just because the shift is covered, it’s often not enough.
My interaction with an agency nurse. Jessica, my niece, called from the center one evening to say: “We don’t know why, but Nurse Betty won’t give Alice (my sister-in-law) the morphine.
Me: “Did she offer a reason?”
Jessica: “She doesn’t want to wake her up.”
Me: “Does the nurse know that she’s on hospice and that IF she wakes up, it’s because she hasn’t had her medication?
Flummoxed silence. Then I get Nurse Betty on the phone, who explains: “I really don’t think it’s nice to wake people up for medication. They need sleep.”
Me: “While I agree about sleep, Alice is a terminal cancer patient on hospice, with breakthrough pain, and if she arouses, it will be because of pain. And are you aware that failure to administer a medication on time is a medication error for the SNF [this would be the third such error in two days], and if you refuse to follow the doctor’s orders, that’s a reportable offense to the licensing board?”
Nurse Betty: “It’s just not what I do.”
Me: “Are you an agency nurse?”
Betty: “Yes.”
Tough pill to swallow: Medication errors
During the 21 days I was at my relatives’ bedside, I personally witnessed 11 reportable medication errors, and I am certain that more occurred. None of the errors I witnessed were recorded or reported. None, zero, niente. My conclusion is that wrong-time, wrong-dose, wrong-medication errors are happening all over the place, and they are not being reported. You cannot manage what you are not measuring.
The computer system at the nursing home was relatively new (a reputable, respected software), and most of the nurses struggled with it (although not Shirley). The system was down for almost an entire shift one night, so no meds were passed. Really. (OK, make that 16 errors.)
My observation about medication administration in nursing homes is that accuracy will not improve until the errors are counted, and counting will only happen when nurses are no longer punished for reporting errors. That’s never going to happen in this punitive, “gotcha” culture. Shit rolls downhill; when there’s a med error, Andrea gets in trouble, then Barbara the DNS gets in trouble, and then she has to talk to Shirley, and we know how that’s going to go.
Weekends are a nightmare
We stayed overnight a few times because of my sister-in-law’s condition, and what we didn’t see was care. Medications weren’t administered, call lights were unanswered, and patients weren’t being taken care of while aides napped. Staffing gaps and cultural issues are really apparent on the weekends.
Recommendation
Value your family members. Active, engaged, and present family members of residents know very well what’s going on with their relatives, so listen to them carefully. Some staff members were incredibly responsive to our needs, our suggestions, and our observations. Others treated us like we were idiots who didn’t know what we were talking about, and that they knew better. It was insulting, offensive, and just added to the stress of an already very challenging situation.
If you don’t have an active volunteer corps, perhaps you should consider developing one. It might be very illuminating to attempt to recruit family members for a “citizen” corps to help. If you hit obstacles, ask yourself and your team, “Why?”
My bet is that Shirley knows the answer.
You can read the full article here, starting on page 4.