In addition to basic family concerns for the well being of the loved one in an Alzheimer's care facility (Feeding, cleanliness, comfort and safety) there are a few basic but more subtle concerns that should have the caregiver's close attention. My experience with June in such facilities for over 3.5 years can be outlined in 4 basic categories. (My time with June at the facility averaged approx. 30  hours a week. In the beginning I started out initially spending approx. 25 hours a week with June. That time quickly changed to an average of 30 hours. By the time June passed away on 23 October 2008, I was averaging 32 hours a week.) As June had progressed more deeply into Alzheimer's, I felt a greater need to be close at hand. I was fortunate in that the nursing home facility that June was a resident for most of her time in a facility, was only 1 mile or 4 minutes away in a residential area.

I have always maintained a written record of my time spent at the nursing home caring for June. I did this by way of a daily log or journal. This dated log or journal contained my time of arrival and departure and listed the daily events in June's life such as meals, bathroom breaks, naps, activities events, and my care concerns. Also recorded were the names of the nursing staff's on duty during that time. Where appropriate, comments were made on June's condition and reactions or lack of reactions. Jobs that were well done by the staff were also noted. This daily record was kept on my computer, and was of great assistance in my participation in the routine periodic care conferences conducted by the facility. It enabled me to determine if there were any negative patterns in June's care. It also gave me the necessary documentation for specific discussions with the staff about such problems. I would recommend that all care giver's maintain written records and documentation for later reference and future guidance.

           (Photo on the above right is June one month after her diagnosis with Alzheimer's,  February 1998.)

All references to June are one's taken from or based on my daily logs, journals and care conference notes. This essay will be a work in progress as I review my 3.5+ years of written documentation. What you see in this essay is the Alzheimer's nursing/assisted living facility from the standpoint of my experience with June and her needs (at two (2) different Alzheimer's facilities). It may also reflect observations made at my mother's nursing home. It is also the result of my observations and close contact of/with many other Alzheimer's  residents in varying degree or stages of this terrible disease.

The normal and usual chain of command to direct requests/complaints for corrective action
 would be:

a.  The day or evening duty Nurse for the floor or group involved.  (This is usually an LPN.)
b.  The Director of Nursing or the Health Care Coordinator. (This is usually an RN.)
c. The Administrator or Director of Operations. (This is an executive office or front office person.)

 Four (4) basic categories or areas of Care-Comfort Concerns.

1.  Falls by a resident.

2.  Comfort Level Care Concerns.

3.  Infectious Diseases. (Colds, Flu and Gastro-Intestinal.)

4.  Theft of a Resident's Personal Property.

Each area of concern will be treated in detail below. These are all areas for alertness and watchfulness by the caregiver in order to render whatever help they may provide to solving or controlling the problem. The Caregiver is in position to provide assistance by their awareness and their insight into ways of possible prevention or correction of a problem.

1.  Falls by a resident.

Problem: Approx. 1800 nursing home residents die from falls each year. 10-20% of falls result in serious injury.

The scope of the analysis and discussion of this subject is such that it requires special treatment in a separate article. The subject of falls is one that impacts every nursing home resident and  supporting family member.  An in depth treatment of the subject is contained in the following article which also includes June's experiences with "Falls.": Please click on the below link:

 "Falls by residents of Alzheimer's Facilities."

  2.  Comfort Level Care Concerns.

Alzheimer's residents who are in the late stages of this disease, lack the physical or mental capacity to help themselves and are therefore dependent on the nursing staff and caregivers for their physical comfort. While most nursing assistants and other nursing home staff members are caring individuals  who desire to do a good job, the varied and constant demands on their time is such that frequently and unfortunately, oversights occur with a persistent regularity. On occasion there will be a nursing assistant who is careless or otherwise unsuited for such an important job. The loved one's family caregivers can be of considerable help to their loved one by acting as a back stop in seeing that proper care is received. The staff is frequently so intent on the job at hand that they overlook other events that may be taking place nearby them. Sometimes their focus on the job at hand is so narrow that related needs/concerns are overlooked. I am always reminded of the Sherlock Holmes declaration: "You see but you do not observe." My notes and journals are replete with comments such as "Does anyone look",  and "Why am I the only one that sees this." All comments below were taken from my care conference notes or daily journals on June and are actual events.)

           (Photo below right is June 7.5 + years later in an Alzheimer's facility. Her face now has a faded look.)


           a.  Bathroom breaks. (Normally procedure: - every 2-3 hours.) Many middle stage or late stage Alzheimer's residents are incontinent.  If they are not taken to the bathroom regularly, it will mean that they are sitting or laying in soiled or wet under clothing or pants. Many are unable to ask for bathroom breaks or help.

         Notes  from June's Daily Log or Journal:

"Most of the time I request it." (First care conference note.)

"Bathroom breaks better but not today." (Second care conference note.)

I would automatically position June outside the bathroom near the dining area for proper bathroom timing whenever I was on premises and taking care of June. However many times the NA's would be waiting for me to finish feeding June in order to take her to the bathroom. I was usually the last one out of the dining room.

          (Note: This is one of the few apparent success stories as the result of my corrective efforts. After the initial few Care conference notes - it ceased to be a problem.)

             b.  Wheel chair seating comfort. (Many of the middle stage and most of the late stage Alzheimer's residents are unable to move themselves or adjust themselves for comfort. If the nursing assistants or other staff does not place them comfortably in their wheel or Geri chairs, they are forced to sit that way until the next bathroom break when they are removed and replaced in the chair.) Wheel chairs have means of adjustment. The backs may be elevated or lowered and head rests adjusted higher or lower. The leg-foot rests can be elevated-lowered or adjusted for length. Arm rests are adjustable. Pillows and padding can be added for comfort and to avoid bruising.

 (Photo below right is June in her Geri Chair - Lap pillow and back pillow for comfort. Photo is by Jim Gehrz on 31 October 2007.)

         Notes from June's Daily Log or Journal:

"June was slouched to the right...chronic problem...needs centering in chair...foot rest needs adjustment.....M--- needs to issue instructions on proper seating."

"Seating continues to be a routine problem...most of time seated improperly...tight against left side and slouching to the right...."

"Improperly adjusted foot and leg rests."

"June's left arm dangling over side of chair and her head slouched over that side."

"Improperly seated - leg rests not appropriate...no pillows."

"Improperly seated...left leg was off of the foot and leg support and hanging loose behind and against the leg support."

"again improperly seated...right leg off of both the leg and foot rest and behind the rest with her shin bearing against the rest...Nurse standing there did not see it"

"Frequently not seated properly in Geri Chair...not centered...chair not locked in position."

"Chair not locked in elevated position."

             c.  Bed comfort.(Because middle and late state Alzheimer's residents cannot move them selves or change the position of their body, it is normal policy to have the resident's position changed by the staff every three hours during the night. This is a preventive for bed sores and at the same time provides more comfort for the resident. Obviously there are many other common sense items and practices  that will contribute to the comfort of the resident.)

               Notes from June's Daily Log or Journal:

"June put down for a nap with her shoes on and no cover blanket."

"No cover blanket - very cool in the room."

"Nap time...Drapes not pulled, overhead lights on, door wide open."

"Head of bed not elevated". (Because June would occasionally cough up food and fluids there was a standing medical order that the head of her bed should be elevated at 30 degrees to avoid possible choking on coughed up food and fluids and to lessen coughing.)

"Glasses not cleaned."

"June put down for her Nap - "glasses still on."

"Lights left on...covers not adjusted properly...glasses not removed."

"Body at an angle in the bed."..."Not elevating head of bed 30 degrees."

"Sometimes the nurse in checking vital signs will pull blanket back and fail to replace it...leave bright overhead light on and door open at nap times - frequently."

             d.  Clothing comfort. (Many middle stage and most late stage Alzheimer's residents are unable to adjust their own clothing for comfort. If the nursing assistants do not dress the residents carefully, they may be left sitting for hours  with  clothing exerting uncomfortable pressures on their body. Mayo clinic warns of clothing that binds or chafes or is constricting as a primary cause of boils. "The constant irritation from tight clothing can cause breaks in skin, making it easer for bacteria to enter the body." They point out that the main sites for boils are buttocks or thighs were most likely to sweat and experience friction. This is particularly important in the case of Alzheimer's victims who now possess a faulty immune system due to age and disease. June did develop a boil (left inside thigh groin) that required hospital  emergency room  care (9/2007) lancing and draining of the boil. When one views the below history, there is little question of why she developed such a boil.)

           Notes from June's Daily Log or Journal:

"June had her pants legs pulled up half way to the knees on both legs...her pants were bunched up behind her...tight in the crotch"

"Strange bulge noted on tongue of right shoe...tongue of shoe was doubled over and shoe laced up...one pants leg half way up.."

"Improperly seated -..pants legs halfway to knees...seam on right leg twisted from side to the top...big bulge of clothing protruding left thigh."

"Her left Bra strap and pad twisted and upside down."

"Pants bunched on left side and used as a handle" (lifting) "Pants legs partially to knee."  Pants pulled up in back." (Used to lift.)

"Elastic TED stockings top bunched up and uncomfortable...pull trouser pants legs down properly."

             e.  Thirst comfort. This is a critical area for late stage Alzheimer's residents. Many are incapable or asking for water.  May have difficulty accepting liquids or swallowing properly. A dedicated and patient staff is needed to ensure proper liquid intake and thirst comfort. This is an area that can be monitored and assisted by family members.

It is common with most everyone to desire a drink of water before bed time. The late stage Alzheimer's resident can not ask for water. This was an area where I placed special attention in regard to June's care. One of my favorite nurses was a lady who took extra time every night before going off duty to ensure that June had a glass of fluids.

It is not uncommon to have Alzheimer's residents dehydrated to the point that they need hospitalization.

               f.  Bruising and Abrasions - skin tears. (Many middle and late stage Alzheimer's residents are on blood thinners or simply bruise easily because of their age. They may be helpless and unable to assist with their own transfer movement.

(1.) They require careful handling to avoid injury.

(2.) Transfer belts are provided to help prevent such injuries.

(3.) Depending on the residents needs, it may sometimes be necessary for two nursing assistants to move the resident from bed to chair or chair to bed or bathroom. Two people can distribute and reduce the localized weight and the handling pressures that are normal when only one nursing assistant makes the transfer. Some injuries are inflicted in the dressing process. June was totally helpless and as a result needed 2 NA's to move her without injury...however, injury to her would still on occasion take place.

          Notes from June's Daily Logs and Journals:

"Abrasion and open wound 1/4" x 2" on wrist.. not deep but it looked awful.. NA said it was a scrape by her watch in pulling over her sweater in dressing her.  It later healed with a scar."

"Large bruise above her wrist...No one knew anything about it."

"Skin tear in area of large bruise.. required a dressing...bruise done during morning dressing process...healed with an "L" shaped scar."

"Large bruise on left hand...no one knew anything about it."

"Broken finger nail middle finger left hand...no one knew anything about it."

"Large nasty looking bruise....areas of purple pooled blood (below surface) 3" x 3.5"...No one knew anything about it.".

"Skin tear and flap on left forearm....no one knows when it happened."

"Large Arm Bruises."  (Need pillow on sides to keep arms from wedging between arm rests and chair body.)

 3.  Infectious Diseases. (Colds, Flu, Gastro Intestinal and Pneumonia.)

The National Institute of Health advised on April 2003: "The common occurrence and dire consequences of infectious disease outbreaks in nursing homes often go unrecognized and unappreciated. Nevertheless, these facilities provide an ideal environment for acquisition and spread of infection: susceptible residents who share sources of air, food, water, and health care in a crowded institutional setting. Moreover, visitors, staff, and residents constantly come and go, bringing in pathogens from both the hospital and the community. Outbreaks of respiratory and gastrointestinal infection predominate in this setting, but outbreaks of skin and soft-tissue infection and infections caused by antimicrobial-resistant bacteria also occur with some frequency."

Nursing Homes and assisted living facilities have special risk problems  and challenges with the common seasonal infectious diseases.  There are three main reasons for this. The first two are exposure risks.  

a. The nursing homes have a wide variation of staffing help requirements. (Nursing assistants, nurses, doctors, activities personnel, maintenance personnel, kitchen staff, therapy staff, social services, housekeeping staff, delivery staff, religious workers and administrative staff. This staff comes from varied backgrounds, cultures, environments and are constantly and repeatedly coming onto, moving about and leaving the premises. 

b.. The families and friends of the residents also come from varied backgrounds, culture's and environments  and also are repeatedly coming onto, moving about and leaving the premises.

c.  The residents themselves because of their faulty immune system due to age and disease present a very high risk for infection.

The practice of good sanitary procedures go a long way to prevent the spread of infectious diseases. Frequent washing of the hands. The nursing assistants are issued disposable latex gloves to use when handling residents,  transferring residents or for bathroom breaks. The  gloves are to be discarded immediately after use. Wall mounted liquid sanitizers for use on the hands are mounted in most of the rooms and hallways. Some facilities will isolate a resident when the resident comes down with the flue, cold or an intestinal disorder. Handling of eating utensils and drinking glassware is very important. Some staff members are very diligent, others are not. The resident's family members and friends can be of assistance by bringing obvious violations of good sanitary practices to the attention of the Director of Nursing or the Administrator of the nursing facility.

The American Medical Director's Association's official publication, "Caring for the Ages", October 2009 had a number of articles that were directly in point on the subject of infection control.  Below are some quoted excerpts.

"The Association for Professionals in Infection Control and Epidemiology (APIC), urged all health care institutions, including nursing homes and skilled nursing facilities, to require their employees to be vaccinated.  If workers decline vaccinations, they should be required to sign a statement acknowledging that their action may put patients at risk"......"APIC cited survey data from 2005 to 2006...just 42% of those with patient contact had been vaccinated against seasonal influenza...all employees with direct patient contact should be immunized annually"..."All of the vaccination strategies studied that involved a 70% coverage rate could have a significant mitigating effect on an H1N1 epidemic"...A 50% vaccine coverage rate would mitigate an epidemic spread to levels similar to that of a relatively mild  seasonal flu epidemic.  But a 30% rate of coverage would not be effective."

"Clearly, combining vaccination with other mitigation measures, such as social distancing and targeted use of antiviral agents, could be quite effective."

"Other measures to control the spread of ...virus currently recommended by the CDC include wearing gloves and gowns when in contact with infected persons, practicing proper hand hygiene, covering coughs and sneezes and isolating individuals who appear ill."

One group of nursing homes has a special program and strategy for infection control..."At Golden Living, we have a flu "czar"...by designating someone specific to handle this, we make it clear how important this is. We have a great campaign for vaccinations."..."We don't see vaccinations as the end all...our strategy starts by building a moat to keep the virus from getting in at all. This involves consistent widespread use of masks and sanitizers, faithful reporting of warning signs and symptoms, as well as vaccinations....Golden Living put the video (DVD from AMDA "Influenza Immunization and the Health Care Worker") on its learning management system and made it required viewing for all staff...We have an Internet site that includes flu updates, ...we have facility flu-prevention checklists, and we push normal practices such as hand washing....flue awareness and prevention can be an upbeat, team building experience for staff. The 2009 slogan for Gold Living's flu campaign is "What will you do this year?"...produces buttons and posters and everyone is encouraged to get involved."

          Notes from my daily logs and journals for June that best outline the scope of this problem area: 

"Residents with nasal discharge hanging from their noses....one blew in her hand and then flung it at the floor."

"Nurse sneezing into hand and then dispensing medication."

"Why are residents who are obviously sick permitted to sit across from people (same table) who are not sick and cough all over them?...M... has bad cold or pneumonia and was coughing all over the table." (Small tables of 4.)

"For a small (19) resident group there has been a horrendous showing of colds and pneumonia...".

During the height of a flu infection kitchen staff noted handling eating utensils with bare hand on the mouth end rather then the handle end. When I handed 2 clean unused glasses to a kitchen staff member she took them by inserting bare fingers  inside the glasses.

"I use the 2 hand sanitizer's (dining room) several times a day - except for P.., I rarely see any one use them."

"A sick male resident in a wheel chair who had vomited during day was permitted to be seated at small table with three other residents for the evening meal. He almost immediately vomited onto the table. He was removed to his room. A few minutes later he was out moving about in his wheel chair among other residents and without restrictions. My complaint to the Director of Nursing resulted in instructions that such residents should be confined to their rooms."  

4.  Theft of a Resident's Personal Property.

Problem: Theft from nursing home residents is a common and frequent occurrence that is quietly kept under wraps:

The scope of the analysis and discussion of this subject is such that it requires special treatment in a separate article. The subject of falls is one that impacts every nursing home resident and supporting family member.  An in depth treatment of the subject is contained in the following article which also includes June's experiences with "Theft.": Please click on the below link:

"Targets for Theft - Alzheimer's Nursing Home Residents."

 

June's obituary as printed in the Minneapolis Star Tribune following her death in October 2008 can be found on the top blue navigation strip under the label "In Memoriam" and on the drop down menu as item: "June K. (Rolstad) Berg - In Memoriam".