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This is the Nursing Home Abuse Podcast. This show examines the latest legal topics and news facing families whose loved ones have been injured in a nursing home. It is hosted by lawyers Rob Schenk and Will Smith of Schenk Smith LLC, a personal injury law firm based in Atlanta, Georgia. Welcome to the show.
Schenk: Hello out there and welcome to episode 65 of the Nursing Home Abuse Podcast. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And we are trial lawyers focusing in the areas of nursing home abuse and neglect in the state of Georgia. Lot of good things this episode, but just preliminarily – preliminarily?
Schenk: Preliminary, I’m going to play a word association game with Will right. You tell me what links these words together.
Schenk: Hawkeye. Scarlett Johansson. Captain America.
Smith: At first I thought you were going to say something about the hit series M.A.S.H.
Smith: But I see what direction we’re going in now.
Schenk: Modern Hawkeye.
Smith: I got it.
Schenk: So that’s what has me amped up this week.
Smith: The Avengers.
Schenk: Yeah, is the Avengers is opening on April 27th, Thursday. So I’ve got my IMAX 3D. You don’t go to the movies because you can’t be around groups of people.
Smith: I don’t like being that – I’m a little claustrophobic socially. I don’t like people sitting right next to me.
Schenk: Adjust your mic here. There you go.
Schenk: So Will’s been known to wait six weeks after the release of the movie, go at 2 in the afternoon and even if there’s one other person in there, he still has to leave.
Smith: I got to go.
Schenk: Yeah, he’s got to go.
Smith: I can’t. I can’t handle it.
Schenk: Let me just say this – he doesn’t fall too far from the tree. And how do I know that? It’s because we have a special guest on the show today.
Smith: That’s right. That is correct. So today’s guest, I guess I would actually be – no, neither one of us was the tree. Our father was the tree and we both fell from it.
Smith: Today’s guest has spent the past 10 years in healthcare. He’s been everything from a combat Army medic to an EMT.
Schenk: Speaking of M.A.S.H.
Smith: Speaking of M.A.S.H. He currently works now as a registered nurse in north Georgia. He works in a progressive care unit, and that’s one of the units that’s right below an ICU unit. So most of his patients are 60 years and older and they don’t have quite enough problems to be in an ICU, but they’re getting there or they just came from there. And before he worked as an RN, he worked at numerous nursing homes across the state of Georgia, much like I did, much like our father did, and so we’re really happy to have my brother, Clayton Smith, on today to talk about what nursing home staff know that nursing home resident families should know. Clay, welcome to the podcast.
Schenk: Clay, what’s up?
Clay: Hey guys, thank you for having me.
Smith: So I was telling the listeners that you currently work in north Georgia and you work in a progressive care unit. What exactly is a progressive care unit?
Clay: So a progressive care unit is often shortened to PCU. It’s kind of like it’s a step-down unit from ICU. So typically it’d be common in the hospital and if you’re very, very sick or you need close monitoring, in a PCU, you can have things like telemetry monitoring. We can watch your EKGs. Usually you have a smaller staff ratio, so for example, on a typical med-surg floor, that nurse may have six, even seven patients. In a PCU, they usually have three patients or less.
Clay: A lot of them are very sick. They may have advanced breathing issues and they may be on different sorts of cardiac medications. You have to have special training in order to take care of these types of patients.
Smith: Have you ever worked in an ICU?
Clay: I have. Yes.
Smith: So you’ve done med-surg…
Clay: Really the biggest difference is in an ICU, they can be ventilated or they may be on some sort of advanced machinery.
Smith: So you’ve worked everything from med-surg to ICU.
Clay: That’s correct.
Smith: Okay. And you’ve also worked – and I know you did because you and I worked together – you used to work at some nursing homes.
Clay: Yeah, I’ve worked in a lot of nursing homes. I worked in assisted living facilities. I’ve worked in hospice units. I’ve even done a little bit of home health. So I’ve kind of run the gamut with the exception of probably pediatric care of just about doing everything.
Smith: So what we wanted to talk about today is, from your experience, for example, imagine if you were going to decide to put one of our elderly family members in a nursing home and we just had no choice. I want you to talk to our listeners about some of the things that you would be looking for if you went to this nursing home and checked it out. So to begin with, what’s the first thing that you’re looking for when you walk through the door of that place?
Clay: Well yeah, so the first thing I would tell people, and this is actually something I have to do a lot – a lot of our patients that we get are very sick and, unfortunately due to the change in their status, will have to go to some long-term rehab or either – even if it’s for a short period of time or even for a longer period of time, you’re going to probably have to go to a nursing home.
The first thing is to actually step foot into that nursing home. And you don’t have to just pick one. You can shop around and go in there and look for yourself. But there’s a number of different things you can do. If you go into these nursing homes, you can kind of get a general feel for that facility yourself. If you notice that you don’t see a lot of staff, if you see people are kind of running around, if you don’t see a lot of patients, if patients are kind of in their rooms most of the time, that’s not actually a good thing. I know it can be kind of off-putting walking into some nursing homes and seeing a lot of people in wheelchairs and walkers and they’re kind of hanging around the entrance, but that’s actually a good sign because that means that if they’re not in their room, they’re out in the open, then there’s enough care there to provide for them. They’re not being hidden away in some room somewhere. You’d know that if your loved one was there, they’re not just going to shove them into a room, close the door and then rarely visit them.
Clay: Perhaps there are certain things you can pay attention to, just stuff like even the food. That’s something that people don’t pay attention to a lot of times, but the quality of the food can tell you a lot about the facility itself. You imagine if you’re in a nursing home, you’re going to have to eat this food every single day all the time. If you notice that the food looks just really, really bad, like not something that you would ever get anywhere in the worst school cafeteria, that probably says a lot about the other types of care they’re going to provide. So unfortunately sometimes diets may sometimes restrict the types of food that people may get, but food plays a big factor. So pay attention to things like that.
Pay attention to just the type of staffing you see, if you feel there’s enough staffing, how clean the facility looks, smells. You know, unfortunately some places, the smells may be something you can’t avoid, but especially if it smells like stale urine or stale feces, that’s unacceptable.
Smith: Man, I agree with you.
Smith: Go ahead.
Clay: I’m sorry.
Smith: Go ahead.
Clay: I was saying, don’t be afraid to go to the director of nursing there. You have a right to ask these people questions. You can go to the director of nursing and you can ask them like, “What are the staffing ratios like? What types of shifts do the nurses have? How many people do you have on board?”
Schenk: Right. So other than those questions with regard to what’s the nurse to resident ratio or what kind of food you’re serving here, what are some other questions you would have for the director of nursing? And let’s back up for a second, Clay. How would you identify the director of nursing?
Clay: Well you can just go up to the front desk. Go up to the front desk and say, “Hey, listen, I have a loved one that’s going to be coming to this nursing facility potentially. I want to do a tour. I’d like to ask the people in charge.” That in and of itself should tell you a lot. If you meet a lot of resistance, so for example, if they’re not very open, if they’re like, “Well we’ll have to…” or they keep putting you off or they just don’t seem willing to work with you, that should kind of tell you a lot because they should do that. Their job is to help you and assist you and help you along this way. So if you go in there and people are very friendly and you have people coming to you and asking if you need anything, especially if the director of nursing comes out of her office or his office and comes to talk to you, that’s a really good sign.
Clay: Nobody is too important that they can’t come talk to you.
Smith: Yeah, I agree with that. Yeah, I think you should be able to speak to the DON or the administrator. I mean I know the administrator is oftentimes not on site or he or she is doing something else. They’re not doing actual nursing work, but if you’re going to put your loved one there, I agree, you should be able to speak with anybody.
Schenk: So Clay, we’ve gone into the nursing home that we’re surveilling for our potential loved one.
Smith: Let’s say it’s met every check box, all the check boxes.
Schenk: Yeah, the checklist. The food’s fine. The director of nursing came out. Everybody’s friendly. Now your loved one is actually a resident of this facility. What are some day-to-day questions that you would have for a CNA in terms of – we’ll just say the healthcare, like for example, should somebody ask, “If my mother being turned?” Or should you ask, “What’s my mother’s…”
Clay: Absolutely. Keep in mind, you have all the rights in the world to ask anything that you want. Now they may not be able to give you stuff, like you can’t ask for lab work, for example. You may not be able to ask for certain things like this, but you can ask for something like what you would call the plan of care. So depending upon how sick or how much care your loved one needs, so if they’re very mobile, they’re very active, perhaps their plan of care if probably very small. But if, for example, your loved one has dementia, is bedridden or any of these things, then ask them. Say, “What is the plan of care? I want to see exactly what you guys are saying or doing every single day.”
Schenk: So Clay, what is a plan of care? Is that a term of art? Describe what a plan of care is.
Clay: So a plan of care is – you have medical plans of care, you have nursing plans of care. This is something that every single patient, regardless of whether they’re in a hospital, a nursing home, assisted living, every single one of them has a plan of care or a nursing plan of care that is created that’s geared towards that individual. So I’ll give you an example. Let’s say I come into a hospital and I need to have my gallbladder taken out. I might get a plan of care for something like this patient is going to be very sick. Let’s watch their nutrition. This person may be bedridden for a period of time, so we’re going to implement a turning schedule. They’re a risk for fall so we want to make sure we put fall precautions in place. They’re a risk for bleeding so we’ll put bleeding precautions. That’s what a plan of care means.
Schenk: So when you say when the loved one goes to the facility and wants to see the plan of care, is it handed to them as a paper document? Is it on a computer screen? How is it normally handled?
Clay: I mean it can be given to them in a paper document or they can just explain to you what they do. What a lot of times these places should have is they should have a board or something in the room where they kind of talk about the plan – they can even go over the plan of the day that has to do with the plan of care. So for example, I want my loved one to get up into the chair three times a day, and there’s like a box that’s written on the board, and each time they get up, they put a checkmark on it. Or I want to make sure that my loved one is on a turn schedule, so they write out the hours on the board and they can go off from there. So all these things you have access to.
Smith: So let me ask you this – and you know how this goes, the squeaky wheel gets the grease, especially in these nursing homes. What are some things, if not necessarily just asking questions, what are some things that resident families need to do?
Clay: Well you know, unfortunately even in the best care scenario where you have a place that has a lot of staffing, like you said, the loudest voice in the room is going to be heard.
Clay: So you are always going to be the best patient advocate for that person. That’s not to say that the staff doesn’t care about your loved one, but they have a lot of other people that they’re taking care of, and everybody wants their loved one to be taken care of the most. So just be insistent with the staff about what it is that you want.
Schenk: Well let me ask this. So Will asked a second ago about what factors, what characteristics in the day-to-day physical health of your loved one are important to ask a CNA about, and you listed the number of bowel movements, intake. Why are those things important?
Clay: So all these things are important because these are stuff you actually take for granted now as an adult when you’re healthy and you’re active and you’re mobile and you don’t have dementia. When you start to develop these things as you get older, all these things are critical for good health. So you can talk to a lot of older people. They almost seem to be fanatical about their bowel movements because the bowels do start to slow down when you get older. That’s just a natural process of aging. You start to have less motility of the gut. Peristalsis is decreased.
Smith: What is peristalsis?
Clay: I’m sorry?
Smith: What’s peristalsis?
Clay: So peristalsis is the process of digestion through the intestine, so that’s the movement of the intestines itself to push through the intestines through your body through your rectum. Peristalsis can be slowed from a number of things. Surgery can slow it, certain medications, but another process unfortunately is aging. So as people get older, peristalsis slows.
Smith: I would also imagine just based on remember what nursing home food is like, and even in a good nursing home, it doesn’t seem very fibrous.
Clay: No, and you’re right. But the thing you should remember the most, the number one way of increasing peristalsis is mobility. So fiber helps, but as you get older, and especially if you have a loved one who is immobile, they’re bed-ridden, their peristalsis is very poor. They’re probably having very infrequent bowel movement. Now medications can help push that out, but that’s something to be mindful of because impactions can happen. And if they have impactions, they can get very sick.
Smith: What is an impaction?
Clay: So an impaction is when you have kind of like a buildup of feces near the rectum and it’s unable to go through either because a) peristalsis is just not happening or a low fiber diet, so this is all the more reason why paying attention to the food is also important. They’re not getting enough fiber, they’re not getting enough nutrition, they’re not hydrating appropriately. All these things can exacerbate and make the problem worse.
Smith: So what can an impaction do? Like what harm can it cause?
Clay: Well worst-case scenario with an impaction is that you can, after several days, it can increase risk of getting infection. You can get sepsis. You can also get something called autonomic dysreflexia. Now this is rare and it usually happens more with spinal cord injury victims, but essentially when you get so impacted, it starts to press on your nerves, it can create a body response where you have severe hypertension, high blood pressure, and it can be dangerous. So you can die from this.
Smith: So it sounds like after you get your loved one in the nursing home, you’re just making sure they’re fed. You’re making sure they’re getting in and out of bed.
Clay: That’s correct. But any good nursing home should be doing these things.
Clay: So if you notice that your loved one is declining, if they’re able to communicate with you and they’re telling you one thing and the staff is telling you another, err on the side of caution. Listen to your loved one.
Schenk: So with these questions, in your experience, generally is it easy to get this information from the nursing home staff? Like for example, “Hey, when was the last time my mother had a bowel movement? When was the last time my mother was turned? When was the last time my mother got something to eat?” Is this information readily available from the chart on the wall you were referring to earlier or from the plan of care?
Clay: Well you may have to do some asking. You may have to stop the staff and get them to talk to you. But they should answer these questions. And if there’s resistance to them answering these questions, if they either say, “I don’t have time for this,” or “I don’t know,” those are bad signs. They should know. I have worked in enough of these facilities. I know my patients. This is part of good nursing care.
Smith: Yeah, I agree with that. What about like do you think you should looking on your loved one for sores, because we talk about bedsores a lot and we’ve had clients that didn’t even know that their loved ones had bedsores?
Clay: I see where you’re going. I would say that this is probably one of the most important things to do, and a lot of this is going to really depend upon how sick your loved one is and what kind of comorbidities do they have. So if you have a loved one who has severe dementia, they are already immobile, they’re incontinent, so they’re not in control of their bladder, all these things can lead to someone having an increased risk of having a bedsore, a pressure ulcer.
Clay: So talk to the staff, see what they’re telling you.
Clay: If you’re able to look, definitely do that.
Smith: Well good, this is good information, Clay. It’s insightful because you spent 10 years and you’re still doing this and you have a wide variety of experiences. Do you ever plan on going back to a nursing home and working?
Clay: It depends.
Smith: Not really.
Clay: Nursing homes can be very difficult to work at.
Clay: So I’ve had offers before for director of nursing positions, but I kind of like working in the critical care field, so we’ll just have to see.
Schenk: Yeah. Well that’s fantastic. All right.
Smith: Yeah, all right, man. We’ll have to have you on again sometime in the future to talk a little bit more about some other things, but we really appreciate it, Clay. You’ve been an excellent guest.
Schenk: Thanks for coming on, Clay.
Clay: Absolutely, any time. This is something I’m obviously very passionate about and I’m very glad you guys do the work you do.
Smith: Thank you. You’re not so bad, then.
Schenk: Can I do the Mark Wahlberg thing and do the “Say hi to your mom for me” thing?
Schenk: Say hi to your mom for me.
Clay: Hey, I will.
Smith: Thanks, Clay.
Schenk: All right, man. Your brother on the show. That’s pretty wild.
Schenk: If my brother was on the show, actually the show would be about the Avengers. We probably should have had him on.
Smith: Yeah. Or the Avengers League.
Schenk: I don’t know why you call it the Avengers League.
Smith: The Justice League.
Schenk: The Justice League. This is different. This is a whole different universe. All different companies.
Smith: Yeah, Marvel comic books.
Schenk: This is like when I confuse Dune for like Cyberpunk, both of those universes you are way into. Who is it – William Gibson?
Smith: William Gibson is Cyberpunk. Frank Herbert is Dune. Yeah, I think Dune is an amazing novel. It’s probably the best science fiction novel that’s ever been written.
Smith: I think most critics would agree to that.
Schenk: I would say it’s “The Last Command,” written by Timothy Zahn, which is the third in the Star Wars trilogy that introduced the character of Grennan Theron. That’s what I would say is the best work of science fiction ever made.
Smith: I don’t think any critic would say any novelization…
Schenk: Actually most people agree with me. Don’t Google it, but just understand that’s the truth.
Smith: Well what else is the truth?
Schenk: I think what else is the truth is that we’ve reached the conclusion of episode 65 of the Nursing Home Abuse Podcast.
Schenk: Will, again, I posit this again. If you were randomly walking down the street and someone came up to you and said, “I have absolutely no idea how to consume the Nursing Home Abuse Podcast,” what would you say to them?
Smith: I would say, “Well you can find us online on our website, Stitcher, Spotify, in case you want to listen to us working out at the gym, or anywhere that MP3s are downloaded.”
Schenk: And what if that person says, “Your website is Stitcher?”
Smith: No, no, no, you can download us on audio or MP3.
Schenk: “Our website is NursingHomeAbusePodcast.com” is what you would say to the person.
Schenk: We’ve done this 65 times at this point. Well anyways, if you’ve stuck it out this far, we appreciate it and we will see you next time.
Smith: See you next time.
Thanks for tuning into the Nursing Home Abuse Podcast. Please be sure to subscribe to this podcast on iTunes or Stitcher and feel free to leave us some feedback. And for more information on the topics discussed on this episode, check out the show website – NursingHomeAbusePodcast.com. That’s NursingHomeAbusePodcast.com. See you next time.