Whee! The People

**VivaLasViejas**, ASN, RN

"Marla, Ruby just took off again," was the greeting from the med aide as I arrived at work @0745 Thursday morning. "Karen's with her, walking up the hill, but she's refusing to come back."

I ran to the window and saw a ponytailed caregiver in bright scrubs trotting beside an elderly lady whose walking speed belied her age and the arterial ulcers on her legs. My heart sank: this was the second elopement for Ruby, whose dementia had taken a quantum leap forward in the past two months and rendered the once-cheerful 90-year-old utterly paranoid, delusional.......and with absolutely NO safety awareness.

Her first attempt to leave the facility on her own had thankfully been aborted by a passerby who had seen her walking briskly up our driveway, and he persuaded her to come back to the building. In assisted living facilities without a memory care unit, a person with dementia who elopes from the community is considered high risk for move-out, as we aren't set up to provide 1:1 staffing to keep a wanderer safe. The executive director and I had already had several lengthy discussions about memory care with her guardian, a daughter who was far more concerned with her high-powered executive job than her mother's declining condition; now that Ruby had done it again, moving her to a secure facility where she couldn't wander into a busy street or become lost was no longer optional.

Unfortunately, the ED happened to be out of town for a family wedding, leaving yours truly in charge. (I've already let him know that he is never, ever, EVER to take more than a single day off again.....he just laughed at me.) With some coaching from our corporate powers, I drew up the 14-day involuntary move-out notice and began to do some legwork to help Ruby's daughter (hereafter known as DD) find a suitable placement; in the meantime, the telephone and my right ear became one as I called staff members to try to cover 1:1 care at least through the weekend. Ruby was not going to get out and be run over by a bus on MY watch---no way, nohow.

By the time 1700 rolled around, I'd found two available memory care beds, faxed all of Ruby's information to their admissions people, and agreed on times for them to come and assess her for placement. Then it was time to have the come-to-Jesus talk with DD, who'd given me the OK to share Ruby's chart with the memory-care places but still did not appear to understand the gravity of the situation (even after I handed her the involuntary move-out papers). I suggested to her that this move didn't have to be permanent; that it could even buy her the time she needed to find the right setting for her Mom; our only concern was for Mom's safety, and unfortunately the dementia had progressed too far for us to be able to meet her needs. After an hour and a half of using every form of persuasion I knew---plus a few more I invented for the occasion---to help her understand, she not only agreed to the move, but stated she'd go see both facilities in the morning, choose one, and move Ruby the very next afternoon.

Having been in this business awhile, I've developed a fair amount of instinct, and it was telling me I'd better have a Plan B lined up. Next morning, representatives from the two memory-care facilities were in the building assessing Ruby (who had taken off yet again earlier that day, companion in tow, and headed "out to the restaurant") and putting together plans to transfer her when DD called, frantic: "I can't possibly move her in 24 hours, it's not fair for you to expect me to move her this soon, you're going to have to have someone watch her until I can pull it all together." I gently reminded her that she had a 14-day notice, that I had never said "Get her out of here by sundown tomorrow", and that she herself had said she would get it done, but she wasn't hearing me and continued to rant.

Of course. It's Murphy's Law: nothing is EVER easy......at least, not when your administrator's out of the building and all hell is breaking loose.

Luckily, Plan B---hiring a home-health agency to provide 24-hr. supervision---was not only one of my better ideas, it also calmed DD right down, and better yet, put the responsibility for Ruby's new care needs squarely on her shoulders. And, after calling a couple of agencies and finding out what they charged for this, I figured it just might motivate her to find an appropriate care setting a bit sooner.

I should mention that in the midst of all this, several of the other residents and families were also in need of attention---one who needed a catheter removed, a family member who wanted to harangue someone about her mother's laundry for the eighth time that week, still another family member who was upset and complained to the office manager because I didn't have time to come up and look at his dad's dandruff just then.

The admissions coordinator from the home-health agency came out to meet with Ruby, DD, and me at 1300 on Friday. I had our own staff covering the 1:1 until 1900 that evening; beyond that, however, it was going to be me if this didn't work out. My staff was already fried from chasing Ruby all over the campus, and I didn't relish the prospect of staying at the facility all weekend to keep an eye on her. However, I wasn't about to let DD know that this was even an option, and she signed the authorization and paid the $1500 deposit without turning a hair........although I didn't take a full breath until a copy of the documentation was in my hand and I was assured that services would begin at 1800 that evening.

No sooner did everyone leave than Ruby herself stormed down to my office and shook her finger in my face, yelling "I WILL NOT have anyone in my room but me, EVER!!! Do you understand that?" I'd never seen her so angry; even in her rapidly advancing dementia, she had never been combative, but for a moment or two I tensed, fully expecting a punch in the nose at any second. Instead, she balled her fists and continued to yell: "You can't make me stay here! I don't want anyone in my room, I am going to come and go as I please, and there's nothing you can do about it."

Now, anyone who's ever worked with dementia patients knows you can't argue or reason with them, because it's the disease talking. It's hard for me to take a tough-love stance with them, having been brought up to defer to my elders in most things, but this is one time when being direct becomes necessary. "I'm sorry, Ruby, but that decision has been made already," I said, firmly but kindly. "It's okay if you don't like it, but you're going to have a companion for a while and I'm afraid you don't get to vote on this one."

She didn't like it, but she didn't argue with me either, only stomped out of my office and down the hall, much like the four-year-old child she was once again becoming. Seeing her go like that made me sad.........Ruby was one of the very first residents I bonded with when I started working at this community, and even until a couple of weeks ago she still knew my name and called me "the doctor lady". (I'd tried for weeks to convince her that I really wasn't an MD, but she insisted on calling me that because she considered me something of a miracle worker, and to her, anyone who could fix her legs up just had to be a doctor.) Having her angry with me, and being unable to reach her and make her understand why she had to have a "sitter", was supremely frustrating..........and I won't forget soon her accusatory expression and her obvious feelings of betrayal when I told her how things were going to be.

And THAT is what a nurse manager does all day. While the floor staff thinks we're sitting on our duffs playing on the computer and thinking up new ways to add to their workload, we're handling stuff like this. I still love my job and don't want to work anywhere else, but it's times like this when I dream about handing my keys to one of the complainers and letting her do my job for a day or two.

As the exhausted, breathless referee said to the football player: "Here........you referee for a while and let ME play!"

Whee! The People

About VivaLasViejas, ASN, RN

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