Inside Our Nursing Homes
I haven’t posted on my blog for several months, and I apologize to my dedicated followers. At the end of June, I suffered from an acute case of food poisoning. I did not realize how dehydrated my body was. I wanted to take a shower to help me feel better. Little did I realize the decision would give me a rather up-close view of nursing homes. This blog is a warning to you and your family. The chances are you may also face the same challenges one day in the future.
I bent over that fateful day in June to turn on the water in the shower/tub. When I stood up, the room started swirling. The next thing I remember is the ambulance crew moving down the hallway toward the bathroom. When I looked down, I could see the broken piece of the fibula pushing the skin of my leg up. I wanted to pass out again but couldn’t.
Sadly, because of the Covid surge, my hospital had to divert the ambulance. An influx of new patients maxed out the ER we planned to go to. They directed us to another hospital.
I remember the IV as they tried to get fluid in me and a technician with a portable X-ray machine. I was still on the bed in the ER the next morning when they explained I had broken my tibia and fibula. They showed me the pictures. The tibia had a zig-zag break from the knee to just above the ankle. The fibula suffered a horizontal break just below the knee.
Lessons from the Car Wreck
If I can impart one lesson from the 1979 car wreck, it would be this: If your gut is talking to you, don’t be afraid to speak up!
As I looked at the pictures of my lower leg, I told the doctor, “I believe my foot broke, too.”
He looked at me for a few minutes before ordering the return of the portable X-ray. Sure enough, the third metatarsal bone and two toes also broke in the fall. Had I not spoken up, the medical team would have ignored the broken foot.
Because of the massive problems created by a team of doctors who refused to listen to me after the truck crossed the center line in 1979, I’ve learned to be a major part of my care team. I talked with the surgeon many times about the broken leg and foot. Those discussions included lengthy concerns about the pre-existing conditions he might encounter with surgery.
Our little dog, Shelby, jumped up on that lower leg five months earlier and caused a deep, six-inch skin tear in the middle part of the shin. The tear was not yet completely healed, and the new skin was as thin as saran wrap. I didn’t believe stitches or staples would hold if the surgeon inserted the plate and screws he wanted to use. After consulting with skin specialists, he came back and told me he totally agreed with my assessment.
The second suggestion included an incision above the knee with a rod inserted through the knee and into the tibia. That sounded like a viable solution except for my history of autoimmune reactions (diagnosed as Lupus by Abbott Northwestern Hospital in Minneapolis years ago). We also needed to consider that the left leg already had a rod in the upper leg bone after a hip replacement some years earlier.
In the end, the surgeon recommended we not do surgery. Instead, he suggested putting a long cast on my leg. He explained to me that Medicare would not consider the cast as surgery, so they would do the procedure in the hallway, just outside the ER. That allowed them to take advantage of the anesthesiologist’s services.
I remember thinking how odd it felt to be surrounded by nurses, an anesthesiologist, and a surgeon in a corner of a rather dark hallway as I slipped into unconsciousness.
When I woke up, I had a cast covering my toes all the way up my thigh.
The Nursing Home
They transferred me to a nursing home/rehabilitation facility after spending four days in the hospital. At that point, it took three people to transfer me from the bed to a wheelchair. I’ve never felt so utterly helpless.
The First Challenge—The Threat of the Pandemic
Covid cases were increasing in the county and state. With an auto-immune disease, I’d already self-isolated for 15 months because of the pandemic. When I broke my leg and foot, sixty-two percent of my friends and neighbors had refused the vaccine. The risks were undeniable.
At the time of intake into the nursing home, Wisconsin’s rate of fully vaccinated nursing home employees was south of sixty percent. https://www.wpr.org/many-long-term-care-staff-wisconsin-reject-vaccine-despite-risks I was frightened. There was no way to determine which people coming into my room were vaccinated. (Forty-two percent of the Covid deaths in Wisconsin have been nursing home patients.)
The most difficult thing for me was being in a hospital bed without the ability to reach the things I needed, including a mask. One employee consistently pulled her mask down the minute she entered my room. Had she had the vaccine?
The Risk of Infection
There is no way you can control the risk of infection when your loved one is in a nursing home. I’ve never experienced a business environment where at least one employee didn’t feel they had a right to ignore the rules. Until the situation changes, make certain a mask is always accessible to the patient in a nursing home setting.
Only a few days after they discharge me, the county put my facility on quarantine because of an employee testing positive for COVID-19. In Wisconsin, nearly 1 out of every 4 jobs remains unfilled, according to the Wisconsin Health Care Association and Wisconsin Center for Assisted Living.
The Second Challenge—Basic Needs
Before the pandemic, I drove eight hours to southern Iowa to visit my mother’s best friend and my second mother. She had a fall and ended up in a nursing home in her nineties. I arrived at 3:30 in the afternoon. By 7:00 PM, they had not served her dinner, and I contacted the nurses’ station. The meal was over and cleaned up, but they could offer her a bowl of soup.
I thought that was the worst thing I’d ever heard of and sent a message to her out-of-state daughter, which included pictures of every surface in her room totally covered with objects. I thought it was highly unusual. Being a patient taught me that this is not unusual at all. There are so few surfaces in those rooms that the patient and nurses cover every square inch. If you can’t move on your own, the only thing you can reach is the dinner tray next to the bed.
It wasn’t long before I learned what it was like to miss a meal. I want to be very clear here. The people who cared for me during my time at the nursing home were among the most caring and committed individuals I’ve ever met. Not once was I overlooked out of malice or incompetence. These places are understaffed and overworked.
Yes, I could have hit my button to point out that they did not feed me. That would have been an alert to double-check, and I wanted to know what the odds were that the weakest people might miss the care required. During my month at the nursing home, they overlooked my meals three times.
The Third Challenge—The System
Medicare provides its own set of challenges for nursing homes.
Most of us are part of a Preferred Provider Organization (PPO) as part of our insurance Medicare Part A and B coverage. Their oversight depends on the quality of medical coding used when billing Medicare.
In my case, the code used correlated to a “simple fracture of the left lower leg with osteoporosis”.
I will remind you both bones in the lower leg broke. It was not a “simple fracture” of one bone.
Besides the broken leg, my foot and two toes broke when I passed out. No one addressed my autoimmune issues either. By the end of the first week, the lupus reaction to trauma covered my entire left leg with a red burning rash under the cast, including blisters that became infected.
The thing with a simple fracture of the lower leg is that typically a plate and screws stabilize the leg. It wasn’t an option for my surgeon. Instead of a simple cast, mine weighed about fifteen pounds and went from my upper thigh to my toes, making any type of movement nearly impossible. The first thing you need to do is to verify that the coding is accurate and complete.
Dealing with the PPO’s
Medicare, directed by the PPO companies, wasn’t at all compassionate. The average stay for a simple fracture of the lower leg with no complications was a 28 to 30-day stay in the nursing home. The coding was only the beginning of my problems. The PPO representatives made my life a nightmare.
I had been a patient for roughly three and a half weeks when we received the first phone call from the PPO.
My code indicated Medicare should cut me loose in a few days, but no one had explained that to us in the beginning. I worked so hard in PT. Could I have worked harder? I don’t know. The therapists seemed delighted with my progress each week.
I’d been down in physical therapy the day of the call from the first PPO.
When I returned to my room after PT, I was exhausted. To get from Point A to Point B, the cast had to be held out in front of me, and I hopped on my right foot with a walker. Other times, they put me in a wheelchair.
On that day, I asked them to transfer me to my bed after therapy. The cast and leg had to be lifted at the same rate as I sat on the bed. Then that leg and the right leg had to be swung at the same time onto the bed, so I didn’t throw out my hip replacement. It amounted to a “Hop and Flop” maneuver.
Inability to Respond
After the three aides left the room, the phone started ringing. It was the nursing home’s phone, and it was on a nightstand roughly eight feet from my bed. I thought it would never stop ringing and there was no way I could reach it.
About an hour later, my husband called. He told me some woman called and told him I refused to answer my phone. She told him my Medical Directive gave her the right to contact him. (This is incorrect. According to my attorney, it takes two doctors to declare me incompetent before they can use my medical directive.)
She continued by telling him my Medicare coverage would expire in two days and the two of us needed to get together to decide what we were going to do to take care of me.
It terrified my husband. He’d watched how many people it took to transfer me for weeks. He did not know how he could do everything by himself when I got home. It might have been different if we lived in town, but we’re nine miles from town and there are no services where we live on the lake.
A Short Reprieve
The nursing home staff couldn’t believe what happened. The social worker and the others put together a very long report with additional codes and sent it out immediately. That report bought me one more week where everyone scrambled to help me achieve the minimum amount of self-care that might keep me safe when I got home.
The following weekend, the nurse came in and handed me a document that said my Medicare coverage would end at midnight on Sunday night. It stated clearly that someone had contacted me and explained everything to me. This was a different PPO from the original one.
I will admit that midweek someone called me and asked me if I understood why they contacted me about the Medicare deadline. Thinking it was a call from the previous PPO and that we resolved it, I answered “Yes.”. I did not know this was a call about a new deadline, and she did nothing to explain that to me.
On Monday, I told the nurse how frightened I was and that I intended to remain a private patient because there were still challenges. I needed to figure those out in order to safely return to my home. I was still hopping on only one leg making safety at home a huge issue.
Why can’t you pay for physical therapy?
That’s when I found out they could not provide physical therapy once Medicare ended. I’ve never heard of refusing cash for services, but that’s how everything ended. I went home the following day.
Did I fall when I got home? I nearly did, but my husband was constantly beside me every time I moved, and he caught me when I got in a tight place and tipped the walker, trying to get turned around.
I started thinking about how they give notice to senior citizens. Based on the people I met in the facility, half of them wouldn’t understand what was happening and many wouldn’t even remember the phone call.
We have a serious disconnect with Medicare notices to nursing home patients.
I believe these calls should require a member of the nursing home staff to be included on the call. If there is any question as to the mental status of the patient, we should then require the nursing home staff to share the details of the call with the family or personal representative/guardian.
I used to work for a doctor and have had experience with Medicare claims and the labyrinth of details and potential for errors. The woman who told my husband I refused to answer the phone never asked him if I had a cell phone.
Why would she?
Remember the PPO answers to the Insurance Company and Medicare
That nursing homes provide in-room telephones makes it simple to scam the system. If the call comes into the switchboard and the PPO chats with the operator for a few minutes, the phone records will make it appear that she talked to the patient during that time and the time the phone rings in the patient’s room. Ka-Ching! Job done and payment received.
How simple it is for the PPO to make it appear they did their job and notify Medicare of another closed case.
The Third Challenge in our Nursing Homes
YOU are the third challenge. It is up to you to make sure you understand everything and that your patient’s record is correct. The nursing homes can only be as good as the information they’re provided.
I never dreamed my lack of interest and attention to detail might derail the efforts being made on my behalf. It all started over a year ago with my annual physical.
The problem I encountered in the nursing home began with a diagnosis made while we were on vacation down on the Gulf Coast. I was having problems choking when eating bread products. The doc inserted the dreaded tube down my throat and discovered I had inherited my mother’s and grandmother’s hiatal hernia. I requested they send those records to my regular doctor.
During my physical, I complained of having sporadic acid reflux, which woke me up several times a week. The doctor prescribed a new medication, and I picked it up on my way home. Before taking it, I read the sheet from the pharmacy. The words increased risk of fracture jumped out at me.
A Personal Choice
I already have osteoporosis, I certainly didn’t need to take anything else that might increase my risk of fracture. I set the bottle on the dresser intending to let my doctor know I didn’t want to take it at my next appointment. Covid changed those intentions as the days became months.
That brings me back to nursing homes. They used a different pharmacy than mine. Every pill they brought in looked different from what I’m used to taking. I lost all concept of what I normally take and when. I was there for three weeks when they requested my presence at a staff update meeting. Physical therapy, dietary, social services, nursing service, etc. attended the meeting.
At the end of the meeting, they asked me to sign a document that reviewed everything discussed. I signed it but pulled it out to read when I returned to my room. The medication list stumped me. There was one item I didn’t recognize.
Good Intentions at the Nursing Home Gone Awry
I called the nurse to find out what the drug was and discovered it was the medication for acid reflux I’d chosen not to take. I simply wanted to protect myself from experiencing a fracture, and now I had five of them. The medication also carried a warning not to discontinue without notifying your doctor. I told the nurse I refused to take any more of the medication.
The fact I took medication in the nursing home that might interfere with my healing is totally on me! I should have notified my doctor immediately that I wasn’t willing to take the risk of a bone fracture nine months earlier. Now, all I could think of was whether it had caused any problems with the healing process.
The Second Problem Involved My Personal Physician
The second problem had to do with the fact that the diagnosis for the hiatal hernia was not part of my medical record. I assumed the doctor’s office didn’t add it because they were waiting to do another test to confirm it. Nursing Homes depend on the information provided by our physicians.
Consider the fact I choke at least twice a week when food builds up in the esophagus, and I’m unable to push it past the hernia.
I won’t eat a meal without a full glass of water beside me to help push the food down into my stomach. During Covid, our nursing homes are understaffed. For a patient who is choking, the time necessary to answer the call light may not be sufficient. I couldn’t get to any water while there, and the glass they bring you with your meal isn’t a large glass. It might not have been enough. As a result, I typically skipped meals when the only choice was a sandwich. The risk of choking was far too great.
Make sure your primary physician has a correct list of your medications and diagnoses on the day you enter the nursing home. It may be too late after that.
The Aftermath of Nursing Homes Care
Am I angry? You bet I am, but only at the PPOs. I’m sure there are honest and capable people trying to perform this job, but I ended up with two who broke every ethical standard I believe we should honor for our senior citizens.
I was lucky that I didn’t fall again after being sent home too soon. According to the doctors, my injury was so severe that I won’t have complete healing until 6-8 months after the event. And yet, two women decided it was time to kick me loose after only 29 days of nursing care and rehab.
Think about that for a minute. I had five broken bones in both my leg and my foot. My left leg was about as useful as a rubber band and the PPO’s decided 29 days of care were more than enough.
What I haven’t shared is that my Lupus flared as soon as I got to the hospital. It started as a hot red rash on my forehead. As soon as the cast went on, it also flared on my broken leg under the cast. It starts out looking like a severe case of measles and progresses into large blisters like chickenpox. (Lupus causes an identical rash whenever I suffer trauma or after exposure to intense sunlight.)
My Recommendations: We all need to be more vigilant about Senior Care:
- Pay attention to your loved one’s needs, especially if they’ve been in an accident.
- Ask the social worker up-front what the allowable time is in the facility based on codes used.
- Question the code(s) used and whether they are appropriate.
- Are the codes used sufficient?
- How does the nursing home ensure they have fed every patient?
- Understand the method used to bathe the patient and how frequently it is done.
- What are the standards for hair care?
- Ask to see a list of medications as soon as they admit you.
- Ask to see a list of any current medical diagnoses
Leave nothing to chance. If you haven’t been involved in the care of a senior citizen, you need to get fully involved in their care if they are in a nursing home.
- Stagger your visits so you can observe the care at different times of the day.
- Call your loved one at mealtime and asked them what they had for breakfast, lunch, or dinner.
- Ask for the phone number of the Social Worker.
- Check with the city/county to find out what services are available in the home after discharge.
- Determine whether you want the nursing home to provide a phone to the room, understanding it could create the same problem I encountered.
- Provide accessible snacks for your senior in the event they miss a meal.
- Talk to others with patients in the nursing home and get their suggestions/observations.
I am in my early seventies and was aware of everything that happened in the nursing home. I will leave you knowing that I am concerned for the safety of our most vulnerable seniors. They are too easily the victims of unintentional neglect and errors.