Visited mom in MC and found another resident sleeping on top of her bed

TrumpetSwan · June 7

I visited my mom yesterday in her Memory Care apartment. The door was ajar. I walked inside and saw my mom in her bed under a couple blankets. To my surprise, there was a woman lying across the foot of her bed on top of it face up. Just sleeping there.

I took a photo for evidence. Then went to get the attention of a staff member who followed me to mom's room. She called the woman "Donna", and woke her up, took her hand and led her out of mom's room and to her own room across the hall. There was no evidence of, nor do I suspect, violence or other wrongdoing. My mom woke up only after the woman was walking out and she seemed to have no idea what just happened.

The staff member only said "that is why we want your mom's door closed". However, it apparently was not closed. It made me wonder, is that their only safety protocol for my mom?

On a separate note, a couple months ago another resident pushed my mother which caused her to fall to the floor. She broke a hip that required surgery to repair. Mom is recovering from that. However, she is back in the same living conditions as this resident. The Executive Director informed me that the follow up plan for my mom was that my sister (who is POA) is agreeing to pay extra to have staff keep a closer watch on mom and make sure she keeps distance from that resident.

It just makes me think, nobody is really "looking after" my mom that closely. Especially after she already was victim of one incident causing injury there.

My question is - What do I do about this? Is there an appropriate protocol to report such an incident. Should I be worried, or is this just another example of what happens in MC?

cdgbdr · June 7

You can make a report to the state. That information must be made available to you at admission. Your sister probably received it as POA. Paying extra after being pushed and sustaining a fracture seems wrong to me.

TrumpetSwan · June 7

@cdgbdr Thank you. I felt like reporting it so "someone" but not sure who.

Would that be the state ombudsman for nursing homes? Other?

When my mother was pushed and sustained the hip fracture, I called the ombudsman in the local county. Of course, there was not a live person answering. I left a message. Nobody ever called me back or followed up with me. For some reason, I just get the feeling the "state ombudsman" staff is overwhelmed, not well paid, irritated by taking complaints, and really not interested in doing any diligence.

Thank you.

ladyzetta · June 7

When my DH was in MC at times I would find a lady sleeping on top of his bed. This never bothered me my DH was in his recliner 24/7. This resident never knew where her room was. I prefer the doos to be left open so when the aids do their walk throughs they can see in each room and account for every resident. These residents can also open and close doors. As far as paying them extra to have her watched closer is crazy, they should already be doing that.!

I knew my DH was safe and well cared for, I just had to relax. Hugs Zetta

harshedbuzz · June 7

@TrumpetSwan

Unfortunately, no PWD is going to be watched 24/7. I am so sorry your mom suffered a trauma from being pushed by another resident. Sometimes these things happen out of the blue— a resident shoved me surprisingly hard once when I was walking past her. Staff report that was a one-off for this woman. I would not consider this bedmate situation equivalent to being attacked.

MCFs are often licensed under Assisted Living which requires a lock on the door for safety, but many PWD are beyond managing this themselves. Dad used to leave his door ajar when he left because he couldn't manage the key and open when he was inside for fresh air. This led to randos wandering in and shoppers making off with his stuff. I totally appreciate how upsetting this can be— dad had a couple of folks drop in to nap in his bed which upset him and my aunt had a man disrobe and join her thinking they were married. They never made the connection between closing the door and unwanted visitors because of their poor executive function.

At a certain point, despite the frustration I just accepted that this was inevitable in a congregate living situation. Like the others, I do side eye paying a premium for something as something as nebulus and unverifiable as "a closer watch". Paying a premium for incontinence care or hand-feeding I get, but what is "closer watch"— an hourly check instead of every 2, an aide at arm's reach when she's out of the room or the other resident is present, or something else?

HB

ARIL · June 7

I’d delete the photo. Would you want your mother photographed if she someday mistakes someone else’s room for her own?

That said, it is upsetting and should be rare. In eighteen months with my LO in AL and then MC, I have seen this three times, each a bit different. Once I went to my LO’s room and found someone else in the bed (alone), once my LO went to sleep in the wrong room, and once a new person next door persistently insisted the room was hers, including trying to throw me out—physically—when I was visiting. In all cases the staff were very distressed, but a calm approach did resolve the immediate situation.

In the third case, the staff started locking my LO’s room so the neighbor couldn’t enter (but my LO could always leave the room; it wasn’t locked from that side). Eventually the neighbor needed a geri-psych hospital stay and did not return.

It is perfectly reasonable for you to ask about protocols for managing these situations. It may happen again but should not be common.

Arrowhead · June 7

My wife went through a period where she often fell asleep on other resident's beds. It made no difference if the door was open or closed. Sometimes a room and a bed look the same as any other. Now she’s bedridden and I like to keep her door open so they can look in on her easier. There are a couple of residents who sometimes enter her room and spend time with her, which I think is nice.

There are times when I think the staff could do a better job keeping an eye on the residents, but I think most of the time they do a good job. Sometimes they have to deal with a difficult resident and need to rest afterwards. Remember that they have many people who they need to look out for and can’t keep a constant watch on all of them at once. Plus, they change them, bathe them, do their laundry, prepare meals for them, and sometimes have to feed them. Try to not be too hard on them if something sometimes slips through their fingers.

cdgbdr · June 7

https://alzconnected.org/discussion/comment/244984#Comment_244984

In Ohio it's the Department of Health. The entity in your area that licenses the facility would be there place to start. An ombudsman is helpful but the licensing agency has the most authority.