Everything I needed to know about life and death I learned in a nursing home. I was a young and inexperienced Administrator when a Director of Nursing informed me that a resident had passed away. My unrefined sense of duty and morbid curiosity drew me to her room. There was a muffled tone of crying behind the cubical curtain encircling the bed. I slowly pulled back the curtain and found the resident’s daughter sitting on the side of the bed clinching her mother’s hand. She looked up at me with her tear-blanched face, and immediately tried to compose herself. After wiping her eyes with a tissue, she took a long sigh and said to me “I feel num.” I was totally unprepared for this moment, but I felt compelled to ease her grief by saying something compassionate. I stuttered for a moment, and finally said “I’m so sorry for your loss – I know how you feel.” She looked up at me devoid of expression and replied “do you really know?” I didn’t answer her question, but as I left the room I confessed to myself; no Lance, you really don’t know how she feels.

Several years later, I vividly remember my father’s telephone call. “The hospital social worker says your grandmother needs a nursing home,” he informed me. Naturally, I wanted to care for her at my facility. Hip fractures are a defining event for elders, and I knew her recovery would require extra special attention. I was prepared for long hours of physical therapy, and the added challenge of her advanced dementia, but I wasn’t prepared for the negligent care that took place at the hospital. I heard my name paged over the public address system about fifteen minutes after she arrived at my facility. “You really need to see this,” the Assistant Director of Nursing informed me, as she ushered me down to my grandmother’s room. I never saw my grandmother without clothes on before, but the shock of her emaciated body overshadowed any feelings of embarrassment. I could not catch my breath when they pulled back the bed sheet and pointed to her severely infected suture line from the hip surgery. Lifelong memories of my grandmother flashed before my eyes like the fleeting chapters of a wind blown book. I immediately notified my father, but his calm response caught me by surprise. “I’m sure her hospital doctor didn’t know how badly she was treated,” I recall him saying. “I’m sure he didn’t, but he should have known!” I sharply responded. It always amazed me back then how quickly people blamed nursing homes for resident abuse, but nothing bad ever seemed to happen while elders were at the hospital. Our nursing staff could not reverse her terminal condition despite high potency antibiotics and vigilant wound care. I’ll never forget a heart wrenching experience the day before she died. I noticed a nurse’s aide crouching at the bedside as I approached my grandmother’s room. The door to her room was slightly open, and I was standing at just the right angle in the hallway to observe the aide. No one else was in the room, and I’m sure the nurse’s aide assumed the door was closed and they were alone.

My grandmother was moaning and breathing heavy from apparent pain. I watched for a minute or two as the aide slowly brushed her hair, which is challenging when a bedfast resident is contracted and uncooperative. After she placed the brush inside the bedside chest of drawers, she turned back to my grandmother and applied a gentle kiss on her forehead, as though it was her grandmother. The aide then stood up as though she was leaving the room. I quickly turned away to avoid an embarrassing moment with her, and tried to hide my tears as I rapidly retreated to my office. This indelible memory serves as my antidote whenever I encounter caregiver neglect. My grandmother died the next day. The cause of her death was “Sepsis – Acute MI.” My insight and personal appreciation of nursing homes increased immensely after that emotional experience.

My career as a nursing home administrator evolved from traditional facility positions to turbulent turnaround assignments. I grew into this specialized profession by managing facilities in severe regulatory and / or financial peril. My most challenging assignment was a large multi-story inner-city facility where several wrongful deaths took place prior to my arrival. State licensing authorities appointed me as their temporary manager after facility staff and corporate consultants failed to resolve chronic survey problems. This court appointed intervention removed the owner from day to day control of the facility until my management team corrected life-threatening violations. My first day began with screaming from a nearby nurse’s station during resident care rounds. I quickly rushed toward the apparent discourse. I found a resident’s daughter arguing with a nurse about her father’s care, and diplomatically ushered her into a vacant resident lounge. Her furry quickly turned into tears as she explained what happened moments earlier. She walked into her father’s room and found him lying on a bare bloody mattress with no clothes on. She discovered gaping bedsores on his lower back and buttock areas when she approached him, which she was not aware of. After this experience she marched down to the nurse’s station for staff assistance and an explanation. A nurse at the station informed the daughter that she worked for the “pool,” and it wasn’t her job to notify family members when bed sores develop. She also explained that the treatment nurse was suddenly called away from her father’s room, which accounted for his physical exposure. The nurse never looked up from her sitting position behind the counter, or stopped writing according to the daughter. She also spoke to her in a low monotone voice with no outward expression of concern. A nurse’s aide who overheard the confrontation immediately went down to the room and placed a hospital gown on her father. I offered my apology, although I was not defending the nurse or the neglect. We talked for awhile, and I pledged to her that this problem would not happen again. She expressed feelings of betrayal as she named the former administrator and director of nurse’s, and helplessness. Finally, she blamed herself for the horrible neglect her father received at the facility. Her hand began to tremble, so I instinctively clinched it with mine and said “I know how you feel.” She appeared to know by my expression that I spoke from personal experience. Caregiving conditions at the facility rapidly improved in the weeks that followed.

During a caregiver in-service a few years ago, I asked a group of nurse’s aides if harm caused by “neglect,” such as bed sores, was more excusable than physical “abuse,” such as slapping a resident. From a victim’s or outcome perspective, most participants felt that it does not matter how resident harm is caused. “They don’t experience less pain and suffering because CNA’s didn’t mean to neglect them,” one aide pointed out. Another aide shared an interesting perspective about resident neglect. She posed the following question to the group; “if a pressure sore is discovered at stage IV, how many nurses and nurse’s aides passed by that resident before something was done about it – 50 / 100? She went on to say, resident abuse usually involves one or two caregivers. However, resident neglect such as pressure sores, weight loss, and contractures usually involves many nursing staff – now that’s scary!” Unfortunately, two nurse’s aides felt that striking a resident was more abominable than unintentional lapses in caregiving, regardless of the outcome, and they challenged me to disprove their contention. I briefly shared my grandmother’s abusive ordeal at the hospital, and the valiant efforts by my staff to save her. I then offered this imposing question to the group; IF YOU HAD TO choose between two forms of harmful resident treatment, would you rather have a caregiver strike your grandmother in the face, which she completely recovers from in a week or two, or die a slow agonizing death from infected bedsores? I finally broke the long silence in the room that followed and continued my lesson plan. They knew which option I would have chosen.