Resident Centered Care

We moved our nurses station out of the middle of the lobby into a enclosed room so visitors can't see it when they first walk in.

I'm a student and I've been doing a practicum in a really wonderful LTC facility that bases its philosophy in part on the Eden Alternative. A few things that really stood out for me:

- as has been mentioned previously, residents are allowed to wake and eat on their own time. For most people this is between 0800 and 0900, so it's not as demanding in terms of shifts in the dining room as one might expect. For the few that like to wake early or sleep in, it seems to significantly enhance comfort, and makes the dining room overall less chaotic

- instead of a set menu, residents in the dining room are offered a selection of food choices in steam trays that rotates through the dining room on a cart. There is a fruit and beverage cart that makes rounds as well... I think the moving bev cart is a great idea because I've often found those items on carts in the first place! For many residents, visual choice is easier to comprehend than a list of options, and people are not forced to eat overly large portions or foods they don't enjoy. I have found so far that residents are more likely to choose beverages other than or in addition to coffee/tea if they see the choices. The fruit is display with a cutting board, so that people can choose just a little fruit instead of "the whole thing"... for some tiny ladies this is more appropriate and ensures that they actually have some fruit

- residents have a locked glass display case outside their rooms to display photos, precious objects, medals, etc... i think this is wonderful because one is reminded immediately that there is a complex person behind every door, one who is very unique... I've seen variations of this with a photo display on doors as well. Many people have photos of themselves as young adults which is really fascinating...

- instead of storing small pieces of medical equipment or supplies in obvious places in resident's rooms, things are placed in cupboards or left on the linen carts. For example, briefs/incontinence pads etc. are not stored in one's bathroom in an obvious way, but are left on the linen carts. Night shift will put out pads/briefs for the resident for the day on the bedside table @ their last round of checks for the am shift to use for the resident before breakfast. People who change their own briefs have them in small cupboards usually brought in by family.

- staff are encouraged to contribute to the home-like environment through their unique talents. One person plays the piano for the residents if they have some downtime (and since the staffing ratio is very appropriate given the residents needs, this is certainly possible). Others have contributed artwork, people bring in fruit + flowers from gardens etc. etc...

- there is a "men's club" and a "ladies club" once a week for residents to socialize in common area... the men who are allowed get a small glass of beer!

It sounds lovely. Two things struck me: people change their own briefs? If they can do that, perhaps they could be on a toileting program and get rid of the brief all together (unless they are one of those women who has had kids and will never stop dribbling). The other....the MEN get a glass of beer?? What about the women? I've told my kids that if I ever have to live at a facility, they need to make sure of 4 things: not more than 3 meds a day, no diet restrictions, wireless computer access. and a BIG glass of wine (or two) every night if I want it!!

lol I think the ladies can have beer if they'd like! I've not seen the ladies club get together yet while I'm on, but I assume there might be an option? There are a few ladies that have a glass of vino with dinner which I think is lovely

It is odd about the folks that change their own briefs isn't it? I recall one E. European gentleman in particular (97 y/o!) still mobile w/walker and will toilet himself throughout the day... but still wears briefs and requires assistance w/am care (he's rather wobbly upon waking, though we try to get him vertical in stages). Ideally he is not to toilet himself, but he is fiercely independent to the best of his ability and he's quite annoyed if he's prompted to use the toilet or if someone follow him! (To quote "I am an old man, not a baby" was his reply to one of the aides...)

It would be interesting to find out about the folks that do seem to have the briefs available as a choice. I've noticed in my limited experience in LTC that there are many odd things that go on in the facilities I've been at... (one bizarre and sad example... one of the nurses @ another facility told me that on her wing a resident is given prozac in her coffee w/o her knowledge! The family (one of whom has decision-making power for the resident) consented and the rationale is that it keeps her quiet!)

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I agree mermaid that I'm going to need some special TLC if I'm ever at a facility... I'm looking forward to seeing how LTC will evolve in the next 10-20 years, as I suspect people who are beginning to enter older adulthood will NOT put up with many of the practices still in place! (I could NOT imagine my father w/o wireless internet...)

I was going to start a thread about this but see there is already one here.

We are going through culture change.

We have a resident with a cat who must be kept in her room so as not to disturb the resident facility cat. Every time she opens the door the cat runs out and then we have a ten minute hunt for the cat. We also can go in there and she's put toothpaste in the cats food (very confused woman) Toothpaste is very toxic to cats - I'm sure the cat probably didn't touch it. Nobody really assessed this womans ability to care for the cat so we thought we would care for the cat. However, we can go in there and put fresh food and water out for the cat, then half an hour later find the water all over the bathroom floor along with dry cat food - fall risk anyone? I think about two nursing hours in one shift, (mine and CNA's) were spent on this cat.

We have a man from another unit with MRSA in his urine. He's incontinent and peeing all over any furniture he sits on. It's his right, apparently, but not anyone elses right to not have MRSA infested couches. If the CNA's ask if they can change his pants he screams and refuses. This is his right. We (nursing not housekeeping) are meant to follow him around with a bottle of spray. I'll bet in a couple of months there will be some inservice about infection control and how it's all spread by nasty nurses who don't watch their hands.

We have a wanderer. They are not to be told to stay on the unit or wait for an aide to walk with them. No, it's their right to get lost - and she does.

It's everyones right to have a shower every day if they so choose. Well, if that's the case, how about hiring a shower aide. No, no budget for that.

A couple of residents have their own dogs that visit. How many times am I interrupted to be told there is a dog running around the halls? This dog is not on my unit and it really should be the responsibility of the family member that brings it in. Some people don't like dogs.

We already had in place carpeting, plants, facility pets, good menu choice, one to one activities, outings, rooms painted different colors, nap times when needed/wanted, no 5am get ups. People can have alcohol if they had an MD's order. Diabetics can go on an all you can eat fest.

What I see happening is that some residents rights seem to be superceding those of the other residents. Society has rules outside the nursing home - ie, keep your dog on a leash, if you are in an apartment your neighbor can call the cops on you if you have loud music blaring. These rules are now falling by the wayside and I cannot be policewoman in this zoo.

Are we being backed up by management with any concerns? No, it will be all our fault if the diabetic has a BS of 500 or the lady with the cat slips and falls, or the dog bites someone or we didn't have time to give someone a shower at 10pm shift change and the wandering lady ends up at the bottom of a lake.

She shouldn't have been allowed to bring her cat - that was a silly policy decision. In Australia we have a policy that any pet must have certification as a "companion animal" to be allowed in. This is quite an onerous process so people don't tend to bother. She needs to be prepared by her family to relinquish the care of this cat to a family member (who can bring the cat in in a carry box for closed-door visits).
More policy nonsense and a too literal reading of what Eden means. Eden doesn not mean anarchic lack of control over cleanliness. If he is incontinent why is he not wearing incontinence pads? If he refuses, then he must be refused permission to sit on seats that do not have a plastic cover. - His choice. Screaming refusal entitles him to a plastic covered chair - and a gentle reminder from the CNA that she/he is trying to help, there is no reason for him to be rude (is he demented?)
Rubbish. Suggest you negotiate a behaviour control regime with him and his family. He agrees to do x,y,z in return for a,b,c and if he breaks the contract, there are consequences d,e,f. If he is demented, get his PoA to sign the contract on his behalf.
For goodness' sake - this is so ridiculous it's funny. OK - fine - "Madam Mgr, I will be able to nurse total minus x patients while you maintain this regime due to time constraints". They need to adapt Eden - let's face it - he's not in his own home. Do you think he'd get away with peeing on his nephew's or granddaughter's couch?
adapt Eden - is your mgmt more stupid or inexperienced than usual? By allowing her to wander unrestricted aren't you threatening your license through neglecting your duty of care? Refuse to allow it on your shift - lock the outside doors. In Australia she would be reassessed and reassigned to a locked unit. In our nursing home there is a security electronic key pad on every door that leads to the street (tho not the garden) and everyone, including visitors, uses the key pad. Stops the wanderers.
They should only be having a shower every day by prior negotiation. End of story. Unless they want to hire their own private assistant and pay them for 4 hours for taking a 30minshower/dress (no-one does). We give 2nd daily showers (with some exceptions), otherwise it's a sponge refresher job. The way you are describing this either a) you are being deliberately negative and exaggerating or b) your mgmt/change team haven't understood Eden and c) don't understand that they need to introduce these changes slowly.
Only if they are freshly CLEAN, on a lead and under supervision by family member at all times or OUT. Again - would they behave like this at a relative's house? I don't think so.
Misreading of Eden and neglect of duty of care.
Of course - that's human nature - and they will unless someone takes control and sets some limits. Talk about Lord of the Flies!!!
Well you'd better get yourself on the change cttee and insist on some changes that will protect your license, then. Don't give up - get a grip. You'll find that if you can take charge of this process with your fellow floor workers and mgmt is prepared to back up your very sensible suggestions that Eden can be a lot of fun and your load can be reduced a bit - a happy resident is easier to look after.

Good luck

Thanks for the reply Trish.

I must admit, these are all the problem residents we have in a building of 100.

The MRSA pt is meant to be wearing inc. briefs, however as he's also ambulatory he takes them off when they get wet himself - then refuses care from the nursing staff. However, I think the careplanning for this resident was ridiculous, done by a member of staff that did not know him very well. He is not on my unit. However, he sits on my unit and watches TV.

The wanderer is an issue mainly because the family thinks she isn't one and doesn't want to put her on a locked unit. She so far has got as far as the front desk/grounds where a member of staff has always spotted her. She is wearing a wanderguard, but there are a lot of exits she can use where nobody can hear the alarm. Our policies have become very reactionary, I know once someone finds her in a dangerous situation they will give the family no choice but to put her on the locked unit. However, they are not taking any of the nursing staff at their word when they say she is a danger to herself.

The cat apparently was the fault of an admissions person. It's the first time it has been done. One of the dog visitors is fine, however the other dog visitor (not on my unit) is an idiot.

We have had some management changes and with it came this idiocy.

StNeotser I see that you are in the position of having to cope with a fractured mgmt process. However, at 100 residents the facility may still be small enough for individuals to make a difference. If you love the place then you do have practical change options (as of course you realise) so maybe your post was out of frustration and needing to vent?

I feel for you - I recently gave up on my place - moving from 70 to 140 beds - construction about finished. Mgmt couldn't manage itself out of a wet paper bag. I was burning myself out, badly. I still visit my sweeties every week, but I could no longer continue to work for morons whose response to my valid and excellent suggestions was to ignore them completely. You ignore me? Fine, I'm outta there. I didn't do the amount of study and gain the miles I've gained to be prepared to tolerate that.

Look after yourself first StNeoster - so you can continue to do good work for your charges.
Good luck.