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Old 06-27-2011, 08:34 PM   #1
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Ready for Nursing home level of care ?

What are the conditions that generally indicate that a person is ready for a NH? My mother has been in an AL for 18 months and we have recently agreed that it was time to transition her to their dementia unit. I have met quite a number of times with both the nursing and administrative staff of the facility and my sister and I toured the memory unit again a week ago Sunday. All systems go, we thought.

During this same period of time, my mother's regular part time companion/aide had to travel for 3 weeks, and a sub was sent. My mother and this new companion are not a good fit, as she is very directive to my mother and my mother acts out and resists. She has triggered the previous negative behaviors in my mother to resurface. There was an incident a week ago, with my mother and another AL resident, where this resident unsolicitedly, told my mother how to act (!!**) and my mother responded to her to mind her own business, and then pushed her away. The companion was with her when this took place. This resulted in the other resident making a complaint at the Wellness center. I was called and I immediately went to the AL to find out what had happened. The aide downplayed the incident to me.

Now, today, when I called the community as previously arranged, to work out placing a deposit for the transition into the dementia unit, I was advised in a conference call that they will not accept my mother, and recommended a few NHs in the area. I was taken by surprise with this recommendation.

My mother is continent and ambulatory and takes only 3 medications (an antidepressant, Lipitor, potassium, and Melatonin at night). The dementia has most definitely progressed, and I believe she is depressed with the absence of the regular aide. This will be a problem, as the young woman is detained out of the U.S. helping her own mother for a couple of more weeks.

I am not one who is in denial about the disease, and if my mother needs a NH, so be it. I am just surprised that almost overnight they think she is NH ready. They are describing her now as combative, when I feel that she is reacting to someone who does not work well with her, and triggers her anger.

I am also concerned that in my conference call, they referenced the Nurse's conversations with this aide as part of their assessment. I hired this aide through an agency, and I would not expect her to be discussing her relationship and observations with the AL staff without discussing anything with me. Needless to say, I have called this agency and asked that she be removed from this assignment.

Has anyone else had an experience such as this? As I said, if my mother is really ready for a NH, then so be it, but it just seems to be a sudden change of opinion on the part of the AL staff.

Thanks for your help.
Susan

 
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Old 06-27-2011, 10:33 PM   #2
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Re: Ready for Nursing home level of care ?

Unfortunately it sounds like you are caught in a bad situation with an unacceptable match for your Mom as a caregiver but I truly don't think she is in need of a nursing home. You are also victim of a care facility that doesn't know how to manage disruptive behavior which is a part of dementia.

I truly feel that a locked facility that specializes in dementia and knows how to manage the behavioral issues is the best place for your Mom.

You have made the first step in firing the caregiver that not only can not manage your Mom, but has decided it is her place to speak for your Mom's behavior even though she had only been with her a short time. I will say that any change, including caregiver changes, will confuse a dementia patient and cause acting out type behavior.

If they will not reconsider then I would look for a dementia specific locked unit. This gives them a small secure home like setting rather than the feeling of institutional care.

My Dad was in a good locked memory care unit with a director that understood dementia and the behavior it can create. He stayed in this unit for the last two years of his life, never moving to a nursing home, with the help of Hospice in the final three months. Mom has been in this same unit for the last two years and recently added Hospice. I have no intention of moving her.

In my opinion nursing homes are for those that need nursing care. If they have a condition that needs monitoring by a nurse on a constant basis then that is where they need to be. If they have dementia and related issues then a good locked care unit is sufficient. The problem is that memory care units, who claim to know how to manage dementia... DON"T!

This is just my thoughts from years of experience, not only as the daughter of two parents with dementia but also having worked in long term care

Love, deb

 
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Old 06-28-2011, 03:55 AM   #3
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Re: Ready for Nursing home level of care ?

In order to get into a nursing home, you will need an assessment that your Mom needs nursing care. In our state, there's a specific nursing home assessment form that is prepared by a physician. A State Dept. of Aging social worker then reviews the form for any patient requiring long term care. The social worker confirms that the patient is nursing-home-ready. The form is part of any NH application, and is reviewed by the nursing home's medical staff before a patient can be admitted.

When I was going through the process, I asked how they made the determination of nursing home readiness. I was told that some of the things that they look for are incontinence (which can lead to skin breakdowns) and an inability to take care of basic functions if left alone. Examples of this inability for Alzheimer's patients would be if they are unable to feed themselves or find food left for them if left alone, to take their medications, or if they are unable to distinguish night from day or know how to return home. The doctors who completed the form and the social workers who reviewed it were very kind.

Behavior labels were the biggest problem. DH's behavior is what triggered NH readiness since his daycare center was unable to continue helping us with him. He never pushed anyone, but they didn't want it to get to that point. The facility has an obligation to protect the other patients.

DH's position on NH waiting lists was too low when we hit PLACEMENT TIME. With the help of our family physician, he was admitted to a hospital for tests. The nursing home social worker then worked to place him, since being admitted from a hospital bumped him to the top of NH waiting lists (we had already completed the NH assessment process). It was a stressful few days. The hospital was pushing our doctor to release him. They knew exactly why he had been admitted, which is discouraged by hospitals. His behavior in the hospital wasn't good, so the nurses were very unhappy to have him on their floor. He was angry, confused, wouldn't sleep and pacing constantly so he was a wandering risk. They ended up having to have an aide sit with him 24-7. He was incontinent.

I was meeting with the hospital social worker daily, and faxing financial paperwork to nursing homes. The NHs wanted to be sure I could private-pay. If he was Medicaid-only, they didn't have to accept him if their Medicaid beds were full. My guess is that NHs figure that they can always get rid of a patient during the private pay period leading up to Medicaid eligibility. Some of the NHs said that they could not handle his "behaviors." The better NHs can either be full, or have their choice of patients for beds. If choosing between patients, they don't have to take an Alzheimers' patient with behavior issues.

Yes, the NH interviewed both the day-care center and the hospital about his behavior in the hospital before the social worker finally found a placement for him. I needed to sign releases to permit this investigation, or the NH wouldn't consider DH.

The social worker finally got him into a NH where we were on a waiting list. He was put into a locked, Alzheimers' ward for patients with problem behaviors. The adjustment period took about six months. During this period, he was sent to a psych hospital for an involuntary commitment by the NH for a few days (to have his medications adjusted due to continuing anger issues). I found that this is fairly common for the behavior unit, although at the time it was extremely upsetting to us. It turned out to be a good thing, because the geriatric psychiatrist at the hospital found a magic potion of drugs that helped DH and was able to give us a lot of good information. Of all of the doctors we have met over the years since DH's diagnosis, this doctor provided us with the most sympathy and insightful information.

I also wished that DH's caregivers wouldn't talk about DH's condition and what I viewed as behavioral "bumps in the road." I was unhappy that DH had been labeled as a behavior problem, which caused problems for his NH admission.

Now I have a different perspective. I've concluded that everyone was talking to each other openly to understand exactly what is going on, in order to obtain the exact level of care needed. They've seen it all before, and can predict the next stage much better than we can. I think they're telling you that they see a level-of-care requirement coming up quickly, and that they're going to work with you. It sounds like a very caring facility.

DH has now been in his NH for about 1-1/2 years. His condition continues to deteriorate, but since he is in his 60s we may still have a very long path ahead of us.

Last edited by Beginning; 06-28-2011 at 04:01 AM.

 
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Old 06-28-2011, 07:52 AM   #4
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Re: Ready for Nursing home level of care ?

I am with Deb, your Mom should go to a memory unit. I don't know what kind of facility your Mom is in, but some facility has AL, memory unit, and NH or skilled care.

My father-in-law is in stage 6/7 Alzheimers. He started with residential care (this is a facility for memory impaired only) and he may go to NH wing (this is a locked unit too) next year but not now. The reason is he has started stopped walking. Now he is on the walker and soon in 6 months, he will stop walking and need a wheelchair. He is also very weak and may need 2 people to help him.
So far he has stayed in this memory unit that is locked for almost 1 year.
He was never in AL - he had 24 hours home care back home before he moved to this new place last summer. He was able to walk with cane and etc. He has congestive heart failure condition.

Looks like the reason for your Mom to go to NH is JUST that she is confused and combative. Well, this all depends on how the caregivers handle her. The AL staff didn't handle her right. A memory unit staff knows how to deal with people who have dementia. It takes tricks and white lies and baby talk and soothing talk to comfort them. No one should irritate her or "order" her at all. She should be persuaded or convinced to do something, not to be ordered. It is in fact an order, but the staff don't order the person with dementia. They make excuses or tricks to make the person to go for lunch or go for a shower and etc. Sometimes they just tell the person gently that she needs a shower...

If the facility does not have a memory unit, please find a place with locked dementia unit. Please also note that she would not care if it is locked as she may not be aware of it. My FIL does not care if it is locked or not and he does not even realize that.

Hope this helps,
Nina

Last edited by ninamarc; 06-28-2011 at 07:55 AM.

 
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Old 06-28-2011, 08:34 AM   #5
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Re: Ready for Nursing home level of care ?

Susan, I realized the trigger was this part-time caregiver.

Where my FIL is, they have 4 elders per one caregiver and in the day the staff always helps around. My FIL does not use one-on-one caregiver now in this new home. I can tell that when he had one-on-one caregiver back home, it was really very noisy and disturbing in my opinion. e.g., since it was one-on-one at home and no one else was around, he hit on women and wanted to sleep with the person thinking he can get married. When he was in the hospital, he used the fact that he had a caregiver next to him and made a big fuzz in the hospital. Something tells me he thought he had the "power" to make a fuzz as he had a private caregiver.

Now in ths new home, somehow he behaves differently. He is polite with everyone as if he is working with them all... He is negative with family....
Now if he goes to the ER, he is very nice with the nurse in the hospital. It is like he has 2 faces. It is like a kid who goes to a new school and has to listen to the teacher but wants the Mom to stay...

I am thinking maybe the way it is set up with your Mom somehow got into conflict with the home, and the home has no confidence to handle her because she had her own part-time caregiver who didn't do a good job and/or left suddenly.

Perhaps you can try another home with dementia unit. I know the rejection probably does not help her record in th future. Maybe you can talk to her doctor or private doctor who is not biased?
I am sorrry it has come to this.... It is indeed very hard to handle her hostile feelings.

Hugs,
Nina

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Old 06-28-2011, 08:48 AM   #6
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Re: Ready for Nursing home level of care ?

I think the new caregiver didn't really do anything but she failed to stop your Mom from pushing the other resident. Like I said, your Mom would have felt she could push the person since she has her own caregiver next to her.

People like your Mom and my FIL would not understand why their violent or hostile behaviors would add up with more trouble so they think they are doing the right thing by defending themselves.

I am sorry to say that the home thinks this means NH! The doctor may be able to prescribe some med and etc. I agreed this is too sudden for NH since she has no new medical issues.
But I think the home is thinking about other residents and they don't want the resident to hurt the other resident.
I am not sure why NH level can help the behavior issue, but maybe they have better approach. This really depends on the facility.

Someone in this board mentioned that psychiatric ward sometimes offers good med. and it helps the behaviors. But I would not try this one. My FIL never went to any psychiatric unit in the hospital at all. I heard that if it goes wrong, it can make it worse. And this is done at NH level.
Since it is too late with this home, you have to find a new facility anyway, why not try another memory unit and they may have different evaluation and may admit her.

Take care,
Nina

Last edited by ninamarc; 06-28-2011 at 02:24 PM.

 
Old 06-28-2011, 12:31 PM   #7
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Re: Ready for Nursing home level of care ?

Hello out there. I am a new member who is meeting with my mother's psych doctor tonight. I have to share with him some new behavior and let him know that I can no longer have her in my home. She is going to be 83 in November and we have already had the geriatric psych experience two years ago. A month ago she blew up at me and I became the enemy. We adjusted some meds and I thought it had stabilized. This past Monday she wanted to know what I was looking for in her room on Sunday night. I was sleeping but she said I was walking around in her room. Her moods are all over the place, does not take meals with me, only eats some pastry and cold cereal from the box, and stays in her room. She cancelled a neurologist appointment yesterday and cancelled the psych doctor for today. I am going anyway. I think it is time to admit her to a nursing home but she'll go nowhere with me. Short of calling 911 I don't know what to do. I hope the Doctor will give me some advice. He is the one who treated her two years ago. My life has changed for the worse in the last two months. I don't trust her any longer as she has become very sneaky, paranoid, and mean. I have more or less taken care of her for the past 10 years and she has lived with me on and off for at least five of those years. I cannot afford a nursing home and neither can she. Don't know where to turn.
Humble and stressed in South Carolina.

 
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Old 06-28-2011, 03:35 PM   #8
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Re: Ready for Nursing home level of care ?

If necessary, call 911. They will take her to the ER for evaluation. At that point you can tell them that you can not have her in your house. If she doesn't have money or property then she will probably qualify for medicaid. That is something she will need to file for. But I have not seen them just dump a patient out in the street. As for Mom... this is dementia induced behavior and many of us have gone through this. You don't do what they want, you do what they need. You tell doctors that she is not allowed to cancel appoints. You try to ignore had antics. You don't try to explain to her. You just do what you have to do for her. In the mean time you can start the filing for medicaid to see if she qualifies. You can investigate care options as well. But if she become violent please call 911...

Love, deb

 
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Old 06-29-2011, 06:40 AM   #9
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Smile Re: Ready for Nursing home level of care ?

Thank you Gabriel. The doctor was pleased that I showed up even without mom. He gave me similar advice as you have. He also adjusted her meds as the Excelon patch was too strong and the depakote wasn't enough. When I arrived home, mom's mood was quiet so I decided to discuss with her what the doc had said. Unbelievable how she took the advice. We are proceeding with power of attorney, living will, and DNR. She has also agreed to continue with appointments as we are making a lab and psych appointment. I have called all Dr's. to instruct them not to take calls from her. For now we are stable and she is comfortable. Need to move quick though as she could change at any time. Dr. says it is just the progression of the dementia and not to take it personal. Your suggestions and advice are right on!! I appreciate all the support I've gotten from church, Dr's. and of course, you.
The battle goes on and I am a survivor. As they say, this too shall pass.
Thanks, again.

 
Old 06-29-2011, 11:48 AM   #10
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Re: Ready for Nursing home level of care ?

TwoFace, It is how it works: the elders often listen to the professionals such as nurse or doctor or caregiver who would talk to the elders in calm tone and persuade them to do what they have to do.
My FIL was not willing to hire any caregiver back home until the home care co. president (family buisness) persuaded him to hire one.

I am glad it works out.

Nina

Last edited by ninamarc; 06-29-2011 at 12:02 PM.

 
Old 06-29-2011, 10:46 PM   #11
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Re: Ready for Nursing home level of care ?

I am so glad the doctor adjusted her meds, listened to you (which is so very important), your Mom is in better humor, and life is a little calmer for you at the moment!! You are so very right, it can change at any time. Just get that POA, will, and DNR done!! Pick a quiet day to have her sign them and hopefully there will be no difficulty. If the Depakote doesn't do the trick, know there are other meds and different dosages that might work. Never hesitate to ask the doctor for a readjust.

Remember that if she is not receptive to an idea don't argue with her. Just drop it. Go back later and try again. Don't push ideas that she is dead set against. Sometimes we have to just do things rather than asking for agreement.

I am so pleased that life has settled down, at least for the moment. Yes you are a survivor We all are!! We don't let each other be otherwise so hang around. The ride goes on!

Love, deb

 
Old 06-30-2011, 05:55 AM   #12
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Thumbs up Re: Ready for Nursing home level of care ?

Thanks for your support. This is one of the finest networks around. We all go through this sooner or later. And I did survive breast cancer, going on five years so I do have to stay around. The roller coaster only gets better.
Keep up the good work and yes, she is going to sign all the paperwork.

 
Old 06-30-2011, 03:36 PM   #13
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Re: Ready for Nursing home level of care ?

Two I will echo your thoughts that this is the finest network around!! It has been my sounding board, my support, and my go to place for years now.

Mom is a breast cancer survivor.... close to 20 years now. It gives you a heightened appreciation for life and a sense that you can do anything! You definitely are a survivor

Glad Mom is doing better and I truly hope this respite in drama will last a long time.

Love, deb

 
Old 07-11-2011, 07:40 PM   #14
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Re: Ready for Nursing home level of care ?

I just want to thank everyone for their ideas and support. I haven't had a chance to get back here, as I have been touring nursing homes and dementia assisted living communities.

Despite the assessment of the current A/L in which my mother lives, that they could not in good conscience, recommend a dementia care community, she was accepted by a Sunrise community near my home. It is small and the staffing ratio is much smaller than in the dementia unit associated with the AL that she currently lives in. I am only hoping that she will accept assistance and care from someone other than myself, as I am worn out. The staff seemed exceptionally professional and knowledgeable. I am however, way of a for profit community, but it's the only option at the moment.
The nursing homes did not seem appropriate for my mother at this time. She has no acute medical needs at this time, and it seemed as though she would be sitting in a room doing nothing all day.

Her doctor just started my mother on 2mg. Risperdal, as the AL called me to tell me that she had been combative with her aid in the dining room. we shall see how this works out. I am holding my breath until the very end of July when her unit will be available.

Again, thanks for all of the sage advice and caring thoughts sent my way!
Susan

 
Old 07-12-2011, 12:02 AM   #15
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Re: Ready for Nursing home level of care ?

Susan, give it a chance. The Respirdal will help and Mom will adjust to her new surroundings. Right now it is all new and scary to her. I will keep you both in my thoughts and prayers for a quick adjustment... and rest for you!

Love, deb

 
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