Are we over-reacting?

[RainMom]

My mother lives in a free standing locked dementia unit. Essentially like an ALF, but residents are able to continue living there even after they become more total care.

Over the past yr as my mom has progressed into the end stages of her disease, she has required more assistance as expected. However, we have had to complain more & more for basic care to be done. Ex: bringing her to the dining room with feces on her hands/fingers, feces on the toilet seat/commode handles/shower seat, not putting lotion on her following her bath, etc. (things I know the average LTC would be sure to take care of & anyone with common sense would do).

Things in general have improved regarding her hygiene needs. However, we discovered a few weeks ago that at night, they do not put pajama bottoms on her, just a diaper. My sister questioned the manager who indicated that she should not have been left that way, but kind of blew it off as a fluke occurrence.

Turns out, when my sister stopped by yesterday evening at 6:30, mom was ready for bed, again with no pants. She was told by the aide that it makes it easier for 3rd shift & that's how they do it with everyone. It should be noted that mom has lost 35 or so lbs the past yr & might be about 115 soaking wet. She's always cold & they left her with no pants or socks, just a light blanket over her legs (she sleeps in a recliner).

Are we over-reacting? I know when I did an evening CNA clinical, the immobile pts often were left open to air & then changed thru the night as needed; we do the same on the floor. But mom is still ambulatory (at this point); they are changing her brief/diaper while she is in the recliner. (It didn't help that 2 male residents wandered in & out while mom was only partially dressed.)

We hate to feel like we're complaining about something almost every month, but this costs mom over $1000 per week. She deserves to be clean & dressed.

My sister is thinking of going above the facility's manager, complaining to the regional director. Thoughts?

[Phledd]

No, that is not an unreasonable request. Seems odd that the manager wouldn't insist on that being honored. I wonder if it could be a communication problem. Do the 2nd & 3rd shift charge nurses know about it? Maybe you could speak with the director of nursing....if you haven't done so already. Explain how important it is to your mother and to your own peace of mind, and ask him/her to ensure that everyone is on board with it. Also, have a chit chat with the charge nurses. Then they can/should make sure the aides follow through with it.

(Why would they prefer to change briefs in the recliner, rather than doing it with the residents standing up? Seems cumbersome.)

[RainMom]

No, that is not an unreasonable request.

(Why would they prefer to change briefs in the recliner, rather than doing it with the residents standing up? Seems cumbersome.)

Thanks; it just feels like we're having to ask for basic things to be done & it starts to feel like we're complaining all the time.

My impression is that for most of the CNAs, this is their first job & they have no experience in LTC. Once when I was changing mom's brief in the bathroom, one tried to show me a "trick" for putting on the brief. (They have no idea I'm a nurse.) The trick was to weave the brief up thru the pantleg. It truly made no sense; mom is ambulatory & can lift her legs/feet to dress! I'm sure my facial expression was "You're some kind of stupid".

I'll be over there tomorrow & see if we can establish an understanding.

[ttt4271]

That is actually a great trick, it avoids the need to remove a resident's shoes and pants in order to change a soiled pull-up. Assuming your mom is changed frequently enough that her pants don't need to be changed it is quite efficient.

The other thought I had is, why not get your mom nighties to wear? That would avoid the dignity issue of her being only half covered. Pants are much more difficult to change in bed and often dementia patients get upset with staff waking and changing them. Also if you want them to get a good nights sleep the less time the resident is disrupted for changing the more likely they'll fall back asleep. If you haven't been speaking to the director of nursing go to her with your concerns, then the administrator, then if still not satisfied go to the regional director. Give them a chance to fix things first.

[RainMom]

That is actually a great trick, it avoids the need to remove a resident's shoes and pants in order to change a soiled pull-up. Assuming your mom is changed frequently enough that her pants don't need to be changed it is quite efficient.

Her pants/shoes were already off. And with mom being perfectly capable of lifting her feet/legs up to assist, it definitely didn't save time. Partly I think the aide wasn't doing her own trick right for one thing. She put the pants on first & then weaved the brief up thru the pantleg without actually putting it over one leg, so she ended up just taking the legs back out of the pants to put on the brief.

I like the idea about a nightgown. That may be a good solution, especially if we get them fairly long. Thanks for the comments.

[middleagednurse]

I have worked in 3 SNFS. Your concerns are not unreasonable. Why can't she sleep in a bed? Can they at least put some warm sox on her? And going to the dining room with feces on her hands is inexcusable. Talk (politely) to everyone, the CNAs, the nurses, the DON, the big bosses.

[CrunchRN, ADN, RN]

Request what you think is best for your mom.

[RainMom]

She started sleeping in her recliner several yrs ago while still at home, prior to dx. She has severe kyphosis now & it physically hurts to try to lay down.

The hygiene issue has been much improved now over the past several weeks, once we started complaining. Getting her on a bowel regimen also helped I believe.

I spoke with the nurse on duty today & requested that mom be fully clothed during the night, at least at this point when she's still capable of geting up to the BR. Spoke with my sister too about trying nighties which may be a good compromise.

[tyvin, BSN, RN]

IMO she shouldn't be in an assisted living. She no longer needs assistance, she needs total care. If she can't clean herself up than she can't take care of herself. It sounds like the ALF is overstepping it's bounds by keeping patients that obviously qualify for LTC.

[canigraduate]

It is standard practice not to put pants on incontinent residents at night in a lot of facilities. It's hard on the residents with dementia to have "strangers" take their clothes off at night. You risk more injury if a resident fights and kicks while taking off pants.

When I worked LTC, we aides didn't really have time to inspect everybody before dinner, although we tried to get everyone to wash their hands.

If your Mom stays cold, a better solution may be warm socks and a flannel nightgown with a thick throw. I had a few residents who slept in a recliner and blankets are unwieldy and slip off. Throws can be tucked in better.

[NotAllWhoWandeRN, ASN, RN]

The LTC/SAR where I spent my first year as a nurse was not a good place, but it had a locked Alzheimer's unit (still walking & talking, but mental and behavioral issues, and maybe 1/3 were incontinent), which was actually the one unit where the patients got good care. But I worked briefly at a specialty "memory care facility" that was a living nightmare.

If you're not able to get your mom's care up to scratch (where it should be without having to address so many issues repeatedly) don't be afraid to look for a better facility. If basic care isn't being looked after now, it may only get worse as she loses more function.

Maybe buy her a thick warm blanket or two and instruct staff to cover with that when she sleeps? I'm cold natured and I dread the day I have a medical problem and find out just how thin those hospital blankets really are.

Edited to add: You are not overreacting. I think you know that, but it's ok to need some affirmation that you're doing the right thing now and then.

[ktwlpn, LPN]

She belongs in LTC with staff who are trained to care for her.Is this a 'for profit'? When her funds are depleted watch how fast they can " no longer provide her care"...Most of your concerns are spot on with places like this,they are not regulatedlike LTC ,the staff often are clueless.However you need to accept her cognitive decline,if she is incontinent at night she should not be wearing pajamas or clothing.Access for incontinent care needs to be fast and comfortable for HER.You really don't want the staff to wrestle her every two hours through the night,likely causing upset and injury.I am betting the heat is turned up as well.You can provide leg warmers for her.I don't like to see the unit walking around in nightgown at 4pm,I would put a stop to that for my mother.She should be undressed when she is going to bed,not hours prior.