First day of CNA clinical - Elder abuse?

Nursing Students CNA/MA

Published

Good afternoon everyone. I just need some perspective on what I witnessed today to see if I can expect to see this kind of thing everywhere. I'm not sure if I can handle it. This is going to be kind of long but I really just need to describe my first clinical experience to someone.

I am in my final 2 weeks of my CNA course. I have applied for an RN program for this fall, but I am required to be on the CNA registry to begin. Anywho, today was my first day of my CNA clinical at a LTC facility. I was assigned to an 82 y/o female resident that suffered a CVA three months ago while at an ATF and was moved to LTC. She is a total care patient. She is unable to move very much at all but she does not suffer from dementia whatsoever. When I arrived this morning, I went into her room to wake her for early morning care and to wash my hands. When I turned the sink on, some black crap sputtered out that turned yellow. I went into the employee break room to wash my hands and used foam sanitizer. When I got back into her room, I noticed her emesis basin was on her night stand, and it was really crusty and disgusting. Her toothbrush was inside it and it was totally yellow and had some brown stuff crusted on the bristles. In fact her entire room was pretty nasty. I got out her wash basin and went to fetch her CNA to ask where I could fill it because the water in her room was yellow. The CNA yelled at me to just use the water in the room "de trays are comin out!". Eventually I found clean water to wash her face and hands and perform peri-care. It took me awhile because we had not gone over diaper changing in my CNA labs and I kind of had to wing it. I have one child but obviously changing a full grown adult is a lot different - and while I was performing peri-care she had a major BM. I cleaned that up and did my peri-care all over again to be safe. Naturally this was my first time doing this on a real person and it was taking me a while, and the CNA or my clinical instructor were MIA. So the CNA comes in and yells at me again for being so slow, and starts aggressively pushing this fragile old woman around to put her ted hose and bra and the rest of her clothes. I mean, she was just throwing her around on the bed. I could barely watch. I asked the CNA when I would have a chance to perform oral care because the resident still had her bottom row of teeth with god-knows-what caked between every tooth. She said "we don't do dat! she have dentures!" (she only had top dentures) and just threw the dentures in her lap even though she is completely paralyzed on her left side and her right hand tremored badly.

During this time, all the resident could talk about was that she wanted her red vest that was in her closet. The CNA yelled at her to just wear the clothes she put on her and let it go. I kept moving toward the closet to retreive the vest but the CNA kept turning around saying "Don't get that vest!" like it was such a huge deal. I waited until she left and went into the closet to get a very easy to put on red fleece vest that had the Cornell University logo on it. Her granddaughter was coming to visit today and she attended Cornell. The CNA was ****** when she came back in the room and the resident had the vest on. Why? I have NO IDEA... but the resident was as happy as a pig in ****.

I had reviewed my resident's chart the day before and noticed she had lost 20 lbs since she was transfered to this LTC in November. She is literally skin and bones. So I knew that I really wanted to encourage her eating when I got a chance to feed her breakfast. When the trays came I saw on the card that she had ordered an english muffin, cheese grits and oatmeal. I opened the tray and it was french toast and bacon. I went to find the CNA to tell her she received the wrong meal and the CNA said "that card don't mean nothin!" but the entire time I was trying to encourage the resident to eat she kept talking about the english muffin she wanted and she hated french toast. I felt terrible. I asked her why she's lost so much weight and she said it's because she doesn't like the food there.

After breakfast my resident needed to be moved to her wheelchair because her family was coming to visit a little later. Since she only weighed 107 I asked my instructor if I could use my gait belt instead of a lift (since we were not allowed to operate them just yet, and I wanted some kind of belt practice). With her blessing I went to get my gait belt but when I came back the CNA was in the room putting the resident's shoes on. I said I could handle the transfer to the wheelchair and started to pull out my belt. She said "No, that take too long!" and just heaved her up and into the wheelchair like a sack of potatoes. Mind you this LTC has a no-lifting policy. The resident had asked me if I could wheel her to the nurses' station so she could read the menus, so I asked the CNA where the foot rests to her wheelchair were. She snapped at me that the resident just needed to stay in her room. I repeated my request, "Mrs X would like to read the menus" and she started yelling at me that she just needed to stay out of the way. It was like she didn't like the resident for some reason - plenty of other residents were out of their rooms and just hanging out in the hallways and common areas. Luckily at this time her family showed up a bit early, so I just let them be.

Now would be a good time to mention the overall demenor of this resident. She was obviously a very educated woman, as the entire time I spent with her we discussed our families, education, traveling, literature, good food, politics, her upcoming 63rd wedding anniversary, pretty much everything. At one point before her family came she asked me if I liked poetry, and then recited Walt Whitman's "O Captain, My Captain" from memory. I actually had to turn away so she wouldn't see me tear up because my heart was breaking that such a beautiful soul was stuck inside such a broken body. She seemed so incredibly grateful that I was clumsily providing such basic care. Anyway...

While the family was visiting, I went to join some fellow classmates to assist with their residents. One girl said her resident had a nasty pressure ulcer on her thigh but it was not being taken care of, and she had to clean liquid poo out of the ulcer. One had told me that her resident had such a dry mouth that scales were falling out during her oral care. I told her about what my CNA said about oral care and she looked shocked. I went to my clinical instructor and told her that my CNA said she doesn't perform oral care, and she told me to do it as soon as I could. After the family left I went in to do oral care but then remembered that her toothbrush was disgusting. I threw it out and went to look for a new toothbrush but could not find one. I asked the LPN's at the nurses' station and they sent me on a wild goose chase looking for toothbrushes in every supply closet, but eventually I turned up empty-handed. The charge nurse just sighed, "I'll tell them to order more." I had to try to gunk out the resident's mouth with swabs. I was horrified the crap that came out of her teeth and I didn't even get most of it because I didn't have a toothbrush. At some point during this time the CNA yelled at me for cleaning her mouth and dentures ("she about to eat lunch! we don't clean dentures just put them in the water") but at this point I was so disgusted by how neglected my resident had been I just ignored her. After I performed oral care my resident told me she would like a new diaper. I went to get linens and my CNA of course stopped me to ask what I was doing. I told her I was about to change her diaper and provide care for her and the CNA grew furious and said "She's not that wet!". Of course at this point I had grown so fond of my resident through our conversations that I just didn't care what the CNA had to say whatsoever. And plus, she's my only patient, so who cares if I pay this much attention to her?!

At this point I had to move my resident from her wheelchair to her bed. She looked at me and said "Ok, so you get my legs and can get my head?" like the CNA's just fling her back onto the bed. I was horrified and explained to her I would be using my belt. So I get her back onto the bed and change her diaper, at which point she shows excitement to receive two AM changings, poor thing. She asks me for water so I go to get some. The CNA starts of course yelling at me about getting her water "The lunch trays are coming!" and I ask when, she says in an hour and a half. What? So what? The resident wants some water now. So I ignored her and went to get my resident water and whatever else she requested of me today. Ice? Lotion? Lip balm? Sure. I was having a good time caring for her, talking with her, making her smile, and she needed some extra attention. All the while the CNA is telling me to stop getting her stuff because "she'll run you all day!" and getting very angry that I was just ignoring her ranting. I was documenting all her fluids even though she was not on I&O (I don't know why, she is practically a skeleton, they seem kind of content to let her just circle the drain, which is none of my novice business but at least we could make her happy and comfortable). Her chart indicated she was just to be made comfortable, she was not on any kind of therapies or procedures scheduled or anything. Her only med was ambien.

A few other little things happened but this post is already too long and I think you all get my gist. During clinical I reported my concerns to my clinical instructor and I think she may have spoken to someone at the LTC about it. I'm worried that tomorrow when I go in (I'll be assigned to a different resident/CNA) that I will catch hell from the staff, but I couldn't let this precious angel of a woman be treated so poorly. It got to the point where I prayed she would pass soon so she wouldn't have to bear being stuck inside such a shithole LTC for much longer. Can anyone give me some feedback on this? Is this common for LTCs? Did I do anything wrong? Am I just too green?

I work LTC and I don't care how many residents the CNA has..that lady got poor care. We work short alot of times and some things get missed. Mouth care might be one of them, but it doesn't get missed for days at a time. Inct care gets done and above all...we let the residents be included in their care. If that means they get to pick the clothes they want or meal...so be it. I totally, totally understand the pressure the CNAs are under but this was neglect or abusive in a way.

The transfer tech needs to be what PT/ OT listed. often times it is an order, so go by what is listed.

Specializes in Psych (25 years), Medical (15 years).

stefanyjoy:

I sense the consternation you must be experiencing at this time. You have adequately expressed your concern and have recieved some really good feedback with appropriate critiques and sound reality checks.

Bottomline: You need to do what you believe and feel is the right thing to do. The majority, if not all, of us have experienced similar circumstances and have dealt with them the best we could. No matter what choice you make in dealing with this situation, this process will be a learning experience.

Remember: This current situation is not the whole enchilada- it's only a piece of the pie. You will have world and time to digest this whole pie we call caregiving.

Also be aware of the fact that you can only do what you can do when you are there for the patient. You have no power over what goes on in your absence.

Finally, I'd like to leave you with this quote for you to consider in your decision-making process: "It is better to light a candle than curse the darkness."

You've already begun to show your light. Do with the darkness as you so choose.

May you find peace in your decision.

Dave

This sounds like a horrible facility, not some place I would ever work. The aide you worked with also sounds pretty bad, BUT its hard to judge them without knowing more about the situation from someone who has worked as a CNA and taken care of 7 or more patients/residents during the day for months or years. Some of the things the aide said are simply the harsh reality of being an aide, you only have so much time to spend on one person, so you may have to prioritize or other residents or patients will suffer. There is a HUGE difference between taking care of one person and taking care of 7, or on the evening shift, 10, or on the night shift maybe even 20 people.

People are only willing or able to spend so much to take care of the elderly who need 24/7 care, so facilities have to make do with what they have. Lower income urban areas are probably generally going to have the worst nursing homes. I think nursing homes in remote rural areas tend to offer the best care, because everyone knows everyone. You will often be taking care of your cousin's wifes mother, or your neighbors father, or your former high school teacher etc. so the care tends to be better. Aides also have less places they can work, so getting fired from a job or having a bad reputation as an aide can haunt them. You may only have two nursing homes and one small hospital in the area, with employees at each who have worked at the other facilities, so if you were a crappy aide other potential employers will know it. At least thats my opinion. I've never worked in a big city and never want to.

I wasn't there, so I don't know exactly why that CNA was behaving in that manner. I do know, however, from my own experience that LTC tends to be understaffed, and some of the NA who work there cut corners in order to finish their work.

Many times, the quality of care suffers. That's the reality of long term care. That's why many residents appreciate it when students do our clinicals with them. We don't cut corners, and we make sure to treat them well.

You did right to take care of her the way you did. Maybe it should have been made clear that you were supposed to care for that lady that day instead of the other CNA. I just want you to know that sometimes it is hard to always do what we're taught in school. When you begin work, you'll find that many residents refuse to have oral care. Dentures are very quick to clean. I can really do a decent job in 3 or 4 minutes. :) I can't give any legal advice, though.

Oh my god people. Why are you all so timid about calling abuse ABUSE!!?? When you start out as a CNA student and you notice that everything is not all neat and tidy like it is in your text book and all your co-workers not all kind and happy and competent like you expect, it's quite a shock -- the answer is for the newbie to toughen up just a bit and roll up her sleeves and get to work being the best CNA she can be. Cutting corners here and there is NOT a good practice, but because of the workload of the average CNA it can sometimes become part of the routine to skip oral care once in a great while, or when you're pressed for time just dress the resident without giving him/her a choice of what outfit they want first. The LTC facility that I trained in made a very specific point of showing us videos and discussing at length what constitutes ABUSE and NEGLECT. Continuing education is also a requirement for every CNA at that facility and training about what abuse and neglect really is was also very clear and specific. Treating a person roughly when performing cares is ABUSE. Throwing a post-stroke patient around when transferring them is ABUSE. Preventing a fellow CNA from providing proper care is NEGLECT. Call it what it is, please, and don't be so quick to make excuses for co-workers that hurt people.

Am I over-reacting? Perhaps. Nevertheless, if that were my grandma being treated as described by the OP, I would personally see to it that heads would roll, including the DON if she didn't put a stop to the abuse.

I couldn't even get through the first paragraph; that so shameful and careless.

I would personally see to it that heads would roll, including the DON if she didn't put a stop to the abuse.

Op, you've described my Grandmother's experience to a T. It's just awful. And when LTC is understaffed, no reports are made. Our family told the DON about the unnecessary roughness and the very next day she "just so happened" to have 4 perfect crescent moon nail cuts on her forearm. Her experience haunts me almost daily. All anyone can do in that situation is just pray for a quick passing. It's awful, and it's why I'm studying to be a nurse.

Oh my god people. Why are you all so timid about calling abuse ABUSE!!?? When you start out as a CNA student and you notice that everything is not all neat and tidy like it is in your text book and all your co-workers not all kind and happy and competent like you expect, it's quite a shock -- the answer is for the newbie to toughen up just a bit and roll up her sleeves and get to work being the best CNA she can be. Cutting corners here and there is NOT a good practice, but because of the workload of the average CNA it can sometimes become part of the routine to skip oral care once in a great while, or when you're pressed for time just dress the resident without giving him/her a choice of what outfit they want first. The LTC facility that I trained in made a very specific point of showing us videos and discussing at length what constitutes ABUSE and NEGLECT. Continuing education is also a requirement for every CNA at that facility and training about what abuse and neglect really is was also very clear and specific. Treating a person roughly when performing cares is ABUSE. Throwing a post-stroke patient around when transferring them is ABUSE. Preventing a fellow CNA from providing proper care is NEGLECT. Call it what it is, please, and don't be so b to make excuses for co-workers that hurt people.

Am I over-reacting? Perhaps. Nevertheless, if that were my grandma being treated as described by the OP, I would personally see to it that heads would roll, including the DON if she didn't put a stop to the abuse.

AGREED. Now, it's true that a person has no idea what it's like to care for 10, 15, 20 residents at a time until they have to DO it. And it's true that sometimes, you have to prioritize and skip doing something until later, that you might not be able to change someone every 2 hours like you want to/should, and that corners will be cut, in general. But there is no excuse for some of these things. No matter how short or busy you are, there is no excuse for dehumanizing a resident. Period. These aren't breathing sacks of potatoes we're caring for, they're human beings, and should be treated as such.

Specializes in Emergency & Trauma/Adult ICU.

The difficulty is, that to those not acclimated to the physical reality of caring for physically incapable adults, many things appear upsetting that are not neglect, and not abuse.

Just recently 3 coworkers and I transferred a patient from one stretcher to another. The patient was small, a slider board was used, and the transfer was seamless. But it visibly upset a family member to see the patient, in her words, "manhandled". A lot of hands-on care that we perform automatically can appear to be a huge invasion of personal space, privacy and dignity to laypeople. (and since the OP reports that this was her very first clinical day ... for the moment, I would categorize her as a layperson)

There is a lot of emotion in the OP. And that is why I take the "sack of potatoes" phrase with a large grain of salt. I wasn't there, nor were any of us ANers.

The difficulty is, that to those not acclimated to the physical reality of caring for physically incapable adults, many things appear upsetting that are not neglect, and not abuse.

Just recently 3 coworkers and I transferred a patient from one stretcher to another. The patient was small, a slider board was used, and the transfer was seamless. But it visibly upset a family member to see the patient, in her words, "manhandled". A lot of hands-on care that we perform automatically can appear to be a huge invasion of personal space, privacy and dignity to laypeople. (and since the OP reports that this was her very first clinical day ... for the moment, I would categorizer her as a layperson)

There is a lot of emotion in the OP. And that is why I take the "sack of potatoes" phrase with a large grain of salt. I wasn't there, nor were any of us ANers.

I understand your point; there may be a 'gray area' in what is considered abuse and some things can be a matter of opinion about what abuse really is, that's why I thinking training about the subject is really important. In my opinion, tossing a 107 lb malnourished little lady around like an inanimate object is clearly abuse. I think that the OP being very 'emotional' about her experience shows that she has a good heart and will make a compassionate, caring nurse -- the kind I'd want taking care of me or my family. The fact that she 'mocked' the broken English of the CNA from hell doesn't make her points any less valid, Ms. Fuzzy -- you ought to know that CNA work is a refining fire and can bring out the very best in us...and for some, the very worst. stefanyjoy did the right thing at every turn and should be lifted up and validated, not torn down by a fellow CNA. I can tell by the way she writes she's very intelligent.

Specializes in Emergency & Trauma/Adult ICU.

The OP did what she had the luxury of time to do, including time to reflect on innumerable details of her experience.

I agree that sometimes, what we have to do can seem like being mean to outside people. For example, many of the residents I care for have severe cerebral palsy and many of them are very constricted, so dressing them is difficult. As such, we've had new people concerned that we are "too rough" when we dress them...until they do it a few times and realize that pulling that arm through the sleeve is the only way it's going into it.

Similarly, as only a handful of our residents can walk, stand, bear weight, etc. most of them are lifted. That's another thing that throws people off, picking up a resident and putting them in bed sometimes comes off as "tossing them around", even when it's not done in a rough fashion. So I do understand that perception is a lot different.

HOWEVER, the things that concern me most are the verbal things - like the aide telling the OP that they don't brush teeth, and that letting her choose her clothing was a big deal. It's the neglect. I have been working more consistently short staffed in the last 3 months than I have in my adult life, having between 17-21 fully physically dependent nonverbal residents an evening to care for, so I definitely do understand the time constraints. However, regardless of short staffing, we have to provide at least the most basic care - bathing, oral care, and incontinence care.

And by the OP's account, it sounds like this is not being done at this facility...and considering that no one there knew where to find a toothbrush and the water was dirty, it seems like this is not a one time thing.

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