Care plan meeting tomorrow

M1

Finally have our meeting scheduled for tomorrow.  I have spent the weekend preparing a list of questions and issues to address.  Outcome will probably determine whether I leave her where she is or start looking for a different facility (though the very idea just exhausts me).

She is still pretty independent in her ADL's, and I think (and will ask) that she's likely the most highly functioning resident they have right now.  I'm sure that has advantages and disadvantages.  I think the disadvantages are that her hands-on care needs, being relatively low, may get overlooked, and that she doesn't get enough mental stimulation.  She is also such an intense personality (used to giving directions and getting her own way) that I have a suspicion she is being allowed to refuse housekeeping services, etc. when she shouldn't.  For example:  what triggered me to pick up on the toiletries problem was an email saying they should all be locked away.  I delivered a bunch of supplies on a Friday, and because she's not tolerating my presence, they said they would take them up.  Well, ten days later they were still sitting in the bag on the floor of her room (not in the locked closet where they're supposed to be), and she refused to let me put them away.  Is it not someone's job there to be sure these things are done?  That's one of my questions.

I also have a sneaking suspicion the same thing is happening with other things--like changing her sheets.  There is a little stain where she spilled some Coke or coffee on her fitted sheet, up near the pillow--and it hasn't budged in six weeks.  I suspect she's refusing housekeeping when they come, and that shouldn't be allowed to happen.  I'm about to find out....

Joe C.

M1, I hope you can find a resolution for all these issues. I would agree that the staff should be finding some work around if she is refusing some services. A simple thing like the staff scheduling an activity or a walk outside while house keeping swoops in does not sound like a big ask. Good luck.

Lills

I wish you all the best tomorrow.  

I can't believe they haven't changed her sheets in 6 weeks.  If she won't allow them to do this...how about changing them when she's not in the room, duh.  

My DH was in a TCU after his appendix rupture.  One morning, I arrived at my usual 8:00 a.m. and found that he had had a BM and 'it' was everywhere.  When I (nicely) asked if someone could change him, one of the CNAs told me that she asked him earlier if he wanted to get changed and he said no.  I was stunned and blurted out, "He has dementia".  Poor DH.  I took my DH home a day early.  Clearly, the ones who dealt with my DH didn't have dementia training.  I could give so many, many more examples!  I was so relieved to get him home!  I wrote a letter to the director of the TCU who called me to apologize.  She said that ALL staff would be required to take a course on dementia.  It was a start.

Again, good luck. 

toolbeltexpert

M1 my wife had a fitted sheet for the four weeks she was in a snf, I took pictures. The day she left the cna admitted that it hadn't been done.

Ed1937

M1, I hope you can get some answers that seem like a breakthrough for you. Hoping you can get that place straightened out instead of having to move her. Keep us posted.

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M1

Very good suggestion Victoria.  Asking what their issues were is definitely on my list, but leading with that is a very good idea.  Thanks---

Jo C.

Hope the meeting brings good results and SO hope it is a multidisciplinary conference with each department represented; that is the way it is supposed to be done.

Victoria's idea to start the meeting is really a very good one; after you ask, "What sorts of issues have you had in caring for her" . . . .  can be followed through with, "What approach or interventions did you use to deal with that problem" . . . and then; "What were the results of your interventions?"  Lastly would be, "Is there any way in which I could be helpful with this?"   Be sure each person around the meeting table gives their input and see what pops up.  Sometimes only one person seems to do the talking or the staff that is present appear fearful to speak as the "leader" is in power.  If that happens, you can mention that you wish to hear from each person present and go around the table to get further input. 

If a plan is being put together to deal with issues, then ask if each point is put into a written plan of care AND if it will be discussed at report at each change of shift with ALL staff on ALL shifts so there is follow through so there are no lapses which would then diminish results.

M1, I can only imagine how heavy this must all feel; you haven't had peace of mind in all these seven months she has been in care.  (Not to leave out the issues with prior to that.)

Have to say, I would wonder even about the question of overall ability for continuity of care on all shifts and even being able to format adequate care approaches and most of all; common sense follow through.  I do wonder specifically just how they are addressing meeting the challenges of her behaviors - that is a big one - do they actually have a plan that is met by all staff to assist or deal with your LO?  Is your Partner even on the best unit to meet her needs?  (Is this unit by the way specifically for persons with dementia?)

Sheets not changed in six weeks; even with a drink stain readily seen by staff, and not putting supplies away leaving them on the floor in the room?   So . . . if she makes refusals while she is present; it is absolutely basic common sense to perform such duties while she is out of the room at an activity.   Makes absolutely no sense in any way that it has not been done.  (All of this at the cost of $100,000 soon to be reached.)  Not acceptable.

So much that has been missed during these seven months; the terrible lack in communications is a definite issue.  That they give the relatively inexperienced activity person who has not been trained or educated for such interactions the job of communicating issues or giving report to you is another concern that could be addressed. The issue of items you were unaware that you were  supposed to provide and no notification of a lapse was provided to you in seven months,there are no excuses for that.  Toilet paper not supplied and to be provided by you!  My oh my.  Another issue is lack of TP in the bathroom and lack of cleanliness.

 I said it before and once again,  staff performance and staff performance expectations with concrete results comes from the top on down.   Perhaps the DON or whoever is at the top of the chain of leadership for staff has not had the experience or capability to manage staff and issues.  For a near $100,000 cost near to this point, not acceptable. 

What in the world happens and what items are left unmet that you are not aware of?  May want to ask about anything that is an issue that has not been brought up.  Wonder just what their continuous approach is to the behavior challenges that are present - what are their specific care plans to deal with that issue on all shifts so there is continuity.

NOTE:  May also want to know if they have a Family Council that meets at intervals. If so, that would be a good place to attend a meeting or several to pick up information and even what other issues have been and how they are being addressed.  By law, Family Councils must be permitted and the facility must provide a room at no charge for said meetings and staff may not attend any of the meetings.  The Council can communicate problem issues or make suggestions for improvements in writing.  Anyone can start a Council, it requires nothing special.

May this meeting bring positive results that will make a difference.

J.

Jeff86

Will be thinking about you today, M1, and hoping you get satisfactory responses.   Failing that, that you get clarity about the need to make a change (ugh, I know).  

Good luck.  You’re thoughtful, caring, and well prepared.  You got this.

Kibbee

M1, It is so disheartening to hear of what is happening at your partner’s care facility, and that others on this board have experienced similar problems at their LOs placement as well.  I hope your Care Plan meeting brings answers, and some assurance of resolution going forward.

Victoria and Jo C, your advice on how to approach the meeting and proceed through it is excellent.  At this time my DH is at home but I will file your advice away in case I ever have to place him and subsequently deal with facility administrators and staff.  

And yes, quality of care is absolutely driven from the top.  Administrators are paid their big salaries (compared to staff) because they are responsible for overseeing all quality of care issues and directing any needed improvement actions.  A facility should have written guidelines / goals in place for quality, safety, etc.  Each goal should be measurable and be monitored on a consistent schedule via report-outs by the department heads responsible for each goal.  There should be an at-glance dashboard in place to show progress and performance against goal achievement.  Any goal not on track should have an improvement action plan in place.  There should also be “stretch goals”, whose aim is continuous improvement and growth.  I don’t know if these goals and action plans would be available for family members to review, but in my opinion they should be.

Jo C.

Thinking of you . . .

J.

M1

Thanks you guys.

The meeting was okay in some ways, but did confirm my suspicions:  They are not giving close oversight to her personal care needs, and she has been allowed to refuse things--including having her sheets changed--for God knows how long (at least six weeks, by my reckoning).  This apparently does not get checked on or reported.  It will now, or we will be moving.

I have a call in to the head of the facility now; she was not in the meeting, it was the young activities director, whom I know well, and the deputy director of nursing.  The fact that neither of them was aware of this until I pointed it out---that visible coffee stain on the fitted sheet has proved quite useful--speaks to a big process issue.  I think they have been hit by staffing issues, as most places have--but still.  I asked to be given a specific oversight plan, and we'll see what they come up with.  I know my partner can be a forceful personality, who can probably intimidate their care associates if/when she says no; but she must not be the only one. And since she is likely their most functional resident, i think the tendency has been to assume that she could slide by on her own.  Wrong.

On the more positive side, it is clear to me that they love my partner and care about her wellbeing, and they had some good ideas about increasing her engagement and how to proceed with visits with me in group settings.  So I am not ready to throw in the towel yet.  but we''ll see how the director responds.

Comes back to what I said previously:  heaven help any residents whose families can't be there.  If I hadn't caught these things, who knows?  And I still wonder, what am I missing still?

White Crane

M1, I hope it goes well.

Ed1937

I'm glad you got at least some temporary satisfaction. I'm praying that they come up with a plan that will take of the problems, and actually be implemented round the clock. She's lucky to have you advocating for her. Maybe you'll be able to get better rest when things are said and done.

jfkoc

thanks for the update....

Jo C.

Been thinking of you so much; thank you for letting us know how it went.  It is at least a start and with any luck and consistent buy-in by all staff, and adequate oversight by the managers and/pr the directors, perhaps things will improve.
 

Found it interesting in that the young, fairly inexperienced Activity Director was the one cosen to run the meeting who is also the one who makes contact with families when there are issues to be discussed.   My goodness; a default person who is hung out there with not only her department responsibility, but also the overall interactions with families with updates and problem issues as well as putting together a plan of care for an entire set of needs when that is not her area of education or expertise.  Wow.

 You are a marvelous advocate and know what to look for, so you are on top of things and are so right; if you had not been able to make visits, heaven only knows what may have been missed..

 Here's hoping this makes a difference.  Your monitoring will be able to assess outcomes very well and you are no shrinking violet, so my guess is they may well be more careful.

 J.

M1

The director answered by email but has yet to call me, we'll see.

I would love to get some answers about WHY this happened--I think it's important for their process for THEM to figure out why it happened as the first order of business to prevent it.  I doubt I'll get completely transparent answers, because it's obvious that its a SNAFU of major proportions and someone will be embarrassed.  Someone maybe should lose their job.  More important is that I get a written, actionable remedial plan of how this will be addressed from here forward.  That's what will determine whether I pursue a move or not.  

Why would anyone, ever, give someone on a memory care unit a CHOICE or an opportunity to refuse whether their sheets get changed????   Or that they shower, or that their bathroom gets cleaned, or any of that???  And is there not a care log of some sort, where these things are checked off when done?    It beggars the imagination.  

In retrospect, I'm grateful for the coffee stain on her fitted sheet, because I know more or less when in happened:  in September, when I was managing to visit regularly for a few weeks, and before my granddaughter made me sick.  I noticed it then, and it was still there this morning.  So you do the math:  six weeks, minimum.  Likely longer than that.

Gig Harbor

M1 if your wife eats in the dining room someone can step in and change her sheets and clean her room. I would make a coffee stain on her new sheet where it is not readily visible and see how long it stays there. I used to sneak into my husbands room and check things when he was eating and after a few complaints things are much better. Ask them to seat her at a table where she can’t see you if you come in. I actually used to straighten out my husbands dresser drawers but now they seem to be doing that. I think they will shape up because if you move her they will lose that money until they can fill that room and since they seem to like her they may not want to lose her. When I worked in an ER I was often floored by how messy some of the staff were. I wondered what their houses looked like.

M1

Gig, I think because she is still pretty verbally intact, they have been grossly overestimating her ability to take care of herself and have just left her to it.  But she can't, really, and now I have to wonder if part of her difficulty settling is that her needs really aren't being met, and she can't really verbalize it, but she knows it at some level.  it will be interesting to see, IF we can correct what's been going on, that she becomes more content.  Time will tell.  

The more I've thought about it today, the more aggravated I am.  I am not sure which way to move, yet, everything will depend on what happens in the next few weeks.  TBD.

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M1

I did get a call back from the director and the director of nursing this morning.  They are in the process of writing up a plan for remedial action, we'll see when I see it.  But in the meantime, the DON went up and reassured me that everything has been put away....but revealed yet another problem:  as my partner persists in packing up her room, they have lost track of most of her stuff.  For example, I had supplied her with two sets of sheets and towels when she moved in, a new bedspread and blanket, etc. etc. etc:  all now missing.  Labelled with her name, but God knows where they are.  They said she would put stuff in the hallway outside of her room door--so heaven only knows.  

I told them to put anything that is not in direct use in the locked closet, period, and we'll see if the promised increased oversight keeps this from recurring.   I don't think there is any other way to control it.  The loss of a few linens will not break me, but really, I don't know what the hell they have been doing.  Meanwhile, they are planning a group outing next week; IF she will agree to go (remains to be seen), I will go in while she's gone and do a repeat inventory, to see what I need to refurnish.  Sigh.

Victoria, you had asked about the inspection reports, yes, I have looked at them, and no infractions reported.  But the last onsite inspection was November 2019 (pre covid).   Budgeting for oversight is not a strong point around here.

Gig Harbor

On her linens and mattress pad write her name on a very visible spot so if they end up in another room the person making the bed will realize if they are in the wrong room.

dayn2nite2

I don't have high hopes for this place, unfortunately.

Just the fact that in all this time it never occurred to them to change sheets or clean her room when she is out of it speaks to the mentality here, and at this point they're appeasing you.  If it turns into something you can accept, great.  If not, you tried.

JJAz

M1,

You're doing a great job!!  Keep on it and watch closely.  But don't fuss over missing items.  That is the bane of any LTC facility, even some of the best.  Make a habit of searching your nearby Goodwill store for used quality items (clothing, bedding, etc) so that when they disappear it won't be so annoying.  For my Dad, I wrote his name on the outside of his clothing and bedding in large letters (back of his shirt, up-and-down his pants leg, top of his moccasins, etc.  After that, they stopped disappearing and it didn't bother him a bit.

jfkoc

Red Sharpie worked for us.

M1

Yes, everything was marked with sharpies and labels.  Appears that she was giving things away to other residents because she told them she was "going to Texas."  Including the coat hangers in her closet.    But why did staff let that happen?   I think because they wanted to avoid confrontation with her (see below).

I am going in tomorrow afternoon--they are taking her out on her first outing, ever, so i am going in while they are out and re-inventorying everything.  At least I'll know what needs to be replaced.  I didn't take anything that was irreplaceable.

I know, day2nite, I'm not sure of the outcome here yet either.  There was apparently a huge reaming out of the staff today by the DON, as well as a huge hissy fit by my partner when they (finally) changed her sheets and put stuff away.    She apparently actually pushed two staff members that she's most fond of.  We'll just have to see how the dust settles.  They owe me:  if she's going to misbehave, they've brought it on themselves by not addressing these things from the getgo.  

Brighter note:  I went for a music hour this afternoon and it worked to do a group activity.  This normally wouldn't be her thing, and she was reportedly in a terrible mood because of the earlier events--but they told her I had bought tickets for it, and being so conscientious about money (which she is or used to be)--that worked, she agreed to sit with me, and by the end of it she was holding my hand and crying, telling my how much she'd missed me.  "I just want to be with you," she said.  I teared up, too.  This is so, so hard.

Will be interesting to see how the outing goes and what the inventory reveals.  But maybe there's a way forward with the group activities as a background for visits.

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Elshack

My DH has been in memory care since Aug 17th. He is mild mannered. He fell 2x within 4 days there and had to go to the ER and have stitches. The main problem with his care is his diarrhea caused by Crohn's disease. I supply the Depends. I do his wash ( clothing not sheets ) as they were washing his dark pull on slacks with his white tee shirts and white sox and everything ended up to be grey. I live in the independent living bldg next to the memory care so I visit everyday and eat lunch with him most days.

Even though the aides are very nice I have to be on the ball re: many issues. One day I brought home his clothing and lo and behold his slacks were filled with poop. I took a photo of it and sent it to the director of the memory care and also a lady who is in charge of admissions etc. Now I heard they reamed everybody out and said if it happened again they all would be written up! I don't know what it is but I too have had his towels missing and other clothing. They do supply TP and I pay $5200.00 for  large private room. I bring his electric razor with pre shave and after shave every other day and I shave him. They are very good about showering him every 2 days. 

I wish you well in trying to have your issues addressed. I can only imagine the stress you have been under. I really hope you don't have to move her. I have so many signs in my DH's room re: to put in his teeth, put in his hearing aid etc. They managed to lose his new $ 1800 hearing aid several weeks ago so he is operating with 1 hearing aid.

White Crane

M1,  I'm sorry this is so hard for you...and for her but she is blessed to have you advocating for her.  You are doing a wonderful job of getting the answers you need and making the facility aware of their oversights in her care.  You and she continue to be in my prayers.

Ed1937

M1, nobody should have to go through what you have in order to get things done the way people should rightfully expect them to be done. I'm sorry you had to do that, but at least you are seeing some positive results. I just wonder if that will carry over to the other residents. In service training, like Victoria mentioned, would probably have a wider effect.

I'm glad meeting her at activities is working for you. But it sure is hard to hear them say things like she did, even though they are actually positives that we can look back to and welcome them in the future. 

You might not want to replace everything that seems to be missing yet. It will probably show up if it has her name on it. Even if it does show up, that might happen again. These are the things that happen probably in every facility. Just give it a little time to reappear.

You have been doing a top notch job, but I think you might need to get a little rest. You are a doctor, and I'm sure you understand what stress can do. We want to keep you around for a while, and out of a hospital bed.

You and she are still both in everyone's prayers and good wishes. 

dayn2nite2

Elshack wrote:

Even though the aides are very nice I have to be on the ball re: many issues. One day I brought home his clothing and lo and behold his slacks were filled with poop. I took a photo of it and sent it to the director of the memory care and also a lady who is in charge of admissions etc. Now I heard they reamed everybody out and said if it happened again they all would be written up! 

I have so many signs in my DH's room re: to put in his teeth, put in his hearing aid etc. They managed to lose his new $ 1800 hearing aid several weeks ago so he is operating with 1 hearing aid.

Unless you want everyone avoiding his room so they can avoid the write-up, the next time something like this happens, please wait until the next day and address it with the aides directly and not their superiors.  Just as there are many things you can pick your battles about, there are different methods of getting an effective outcome when failures like this occur.

I made sure I had an excellent relationship with the aides taking care of my LO daily and a more professional relationship with the DON/administrative staff.  Because I didn't have a terroristic method of addressing issues (top-down) and came to them face-to-face with a respectful, collaborative approach, they also felt comfortable enough to let me know when they were seeing new or exaggerated behaviors or other issues.  I'm not saying you need to shower these people with gifts and praise every day, but definitely giving them a chance to fix things before reporting to their bosses and treating them like the important members of the care team (as they are) goes far.

Regarding the hearing aids, if they lose the other one, don't replace it unless you are a very wealthy person who can buy multiple pairs of hearing aids.  It happens with things like hearing aids and eyeglasses.

M1 unfortunately was a trigger for behaviors and has had to send others to visit, which is why we're only finding out about the ongoing issues now.  In this case, it is certainly more appropriate to go to DON and administration, because the issues seem to be pervasive and "standard operating procedure" and that needs to change.