Wednesday, July 27, 2011

Letter to a Rehab Director: Part II (four part series)

This is the first segment of the list of issues enumerated in the letter that is being sent to a rehab in response to the care my relative received. The rehab needs to improve its procedures; and as you read this list of problem areas in this post and the ones that follow, you will begin to see problematic issues that are most likely happening in rehabs and nursing homes across the nation. The names and places are masked/fictionalized; the experiences occurred.  (click here for beginning of the series)

From a letter to Executive Director, Katherine Doe of Pillow Elder Home and Rehab Center
(list of problem areas)
  • The coordination of care between shifts was not seamless nor was it smooth. Mrs. White noticed that various aides were not apprised of her condition after the "changing of the guard" into the evening shift. There seemed to be no follow up from one shift to the next, to maintain a consistent quality of care. Secondly, if she needed help with the ostomy bag and would ring the bell, the system was redundant. First, an aide would come to tell Mrs. White it was "not her job," but the nurse's job to drain the bag, change it or do anything with it. Forty-five minutes later, the nurse, having been busy with patients would come to deal with either draining or changing the bag. By that point, Mrs. White had been waiting with feces all over her because the bag had leaked. There was no easy way to prevent this from occurring short of putting on additional staff (aide and nurse) for ostomy care (and inevitably to change the bed linens which would be soiled). To forestall this problem the nurse and aides might have scheduled particular and frequent times for the nurse/aides to drain the bags so they would leak less frequently. Mrs. White was not mobile to clean herself up. If Mrs. White was less sentient, it wouldn't have mattered if the wait to clean up her feces ranged from forty-five minutes to five hours. But a sentient person is not happy to be covered in feces for any length of time. Perhaps, the metaphor is too painful to endure emotionally and it certainly contributed to Mrs. White's upset and nervousness and need for anti-anxiety medication. (I note your poor rating in keeping patients' emotional well being stable in comparison with other similar facilities across the state. Reducing stress is critical to promoting healing. High stress levels slow down the healing process. So emotional well being and comfort should be a priority at your facility to get patients well to leave the rehab. It appears to be low on your list of priorities; just giving someone a pill to shut them up or quiet them down is not the answer. Being attentive to a patient's needs is the answer. Mrs. White's needs to be cleaned up in a timely fashion because of bags leaking and being put on improperly were not met and induced a high stress level for her, decreasing her well being and decreasing more rapid healing.
  • Not all of the nurses were familiar with the types of bags used for ostomy care. What was frustrating was when one type of bag was chosen from Hospital X, a few of the nurses at Pillow Elderly Home had to be shown how to put it on and drain it. At other times, the bag was put on incorrectly so as to increase the likelihood of its leaking feces. Suggestion, if an ostomy patient is coming to rehab, the nurses should be familiar with all the care that pertains, supplies to ease the pain of the bags being taken on and off, familiarity with all the types of bags and how to put them on properly, familiarity with understanding the necessity of their frequent drainage in addition to the necessity of anticipating when to order sufficient bags and attendant supplies so there is no running out. Yes, the situation is one of trial and error. But that is easily said when one is not the recipient of the caregivers' "trial and error," in getting it right. (an often painful process when the bag is repeatedly taken off and the skin around the stoma opening is raw and red...and there are no supplies to ease the pain or abate the redness which is the beginning of a skin breakdown...which was the situation that happened with Mrs. White.)
  • There was a lack of communication between the nursing station on the fourth floor and Physical Therapy or Occupational Therapy. I was present when Mrs. White was supposed to receive OT. We were waiting; I checked with the desk. OT had been changed with PT. No one had told Mrs. White or me. I went to PT on the 14th floor checking to see if PT was coming and I was assured by the one in charge that a gentleman was coming to give Mrs. White PT. We waited an hour. I checked back with the desk and got a different story. Purely by chance, the Social Worker came in on another matter and Mrs. White told her she was disgusted; here she was supposed to be receiving rehab and not only was there no rehab on Saturday and Sunday, but there was no rehabbing being done that Friday afternoon. The Social Worker spoke to the nurse who had to call PT. Then it was revealed that the person we were waiting for had left for the day (hours before). No one told the desk; no one told us. I and Mrs. White's personal assistant ended up giving her the PT. (They also made it up to her by giving her PT on Saturday, thankfully.) In regard to PT and OT, we never knew which was coming. We weren't sure when they were coming...a specific time, per se. If there is there a set schedule of times or a "fly by the seat of your pants" arrangement, we never knew which was in operation and neither did the nurse's station which was not always in the loop. The inefficiency declines the overall quality care given at this facility. The elderly need routines to promote their sense of calm; chaos does not promote calm, but quite the opposite...their agitation. Such was the case with Mrs. White.
  • PT and OT are only given five days. This doesn't progress the patients as quickly as they should be progressed, especially for the elderly who have to wait two days, Friday to Monday to work on their mobility again. When the elderly arrive at PT and OT on Monday, they are stiff, achy and not mobile. Why? They have not been moving over the weekend; this is really untenable. Medicare is paying for a day when there is mobility for others, only not the patients who are supposed to be in rehab for the PT and OT. If I and Mrs. White's personal assistant and nieces weren't there to work with her physically on the "staff's days off," and intermittently during the day she would still be in rehab or moved to the connected nursing home because her 30 day Medicare would have run out. I spoke to a friend of mine who is a nurse with a Master's Degree from Stony Brook University; she works at North Shore Long Island Jewish. I told her the situation. She responded, "It's not a good rehab. They are open 24/7 and they should be giving PT and OT six days a week." I pressed the issue, dubious about what my nurse friend was saying. She affirmed, "It's not a good rehab!" I would like to think my cousin Mrs. White was at a good rehab. Now I don't know. Maybe I shouldn't ask such questions of a professional who is in a position to deliver an informed judgment. Maybe I should just live in a delusion, forgetting what I saw and what my relative experienced!
    Letter Continued July 28, 2011  Part III (of the series)

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