Shay Jacobson, RN, MA, NMG, LNCC, CNLCP
Martha Kern

“What do you want?”
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We would learn rather quickly that this was Jane’s standard greeting. At the age of 84, her tolerance for small talk had been replaced with terse comments and plain-spoken sarcasm.
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What we wanted, standing there at the door of her suburban home that day, was to audit her care. Jane had just resigned as her own trustee and her bank had taken over as successor. Not entirely certain that Jane’s level of care was still appropriate, the bank asked us to assess her overall well being, care needs and living environment.
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Jane stood before us wearing only a too small t-shirt and an adult diaper. Behind her we could see dusty piles of books and papers on the floor, and magnificent cobwebs hanging like shredded drapes from the ceiling.
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Jane let us in and explained that her caregiver, Rose, was not home yet. This seemed an odd state of affairs given that Rose was a live-in caregiver who had been with Jane for the past three years. If not “at home” with the person she was paid to care for, where would a live-in caregiver be?
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Rose, as it turned out, was not yet back from the house two doors down, where she typically went at night to sleep with a neighbor man who was also a legendary alcoholic.
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How Things Look Versus How Things Are

Jane’s care arrangements appeared stable, at least on paper. She employed a live-in caregiver over the past three years who ensured she was safe, fed, and otherwise attended to in the confines of her familiar home.
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The bank was not entirely comfortable in their new role as “employer”, however. The caregiver was independent and unlicensed. As trustee, the bank would have to pay her directly, as the client had done, and assume the role of employer with all that role entails.

Like most independent caregivers, Rose had no health insurance and certainly no disability or workers compensation insurance. If she hurt herself at work, the trust’s exposure would be considerable, especially if her injury prevented her from working in the future.
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We went there with the goal of not just assessing the client’s care needs, but also of assessing the caregiver’s suitability as an employee. The plan was to put her through our standard screening protocol, hire her, become the employer and thus remove the risk and exposure from the bank’s shoulders.
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And, of course, we found a caregiver sorely lacking in skill and judgment, and a whole lot more.
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Rose had perhaps started out as an able provider of care. But, over time and without supervision, she had lost interest in cleaning the house, in washing clothes (both the client’s and caregiver’s clothing was stained and in poor repair) and in keeping the client herself clean.
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Rose needed rides to the store to buy supplies and the neighbor man had a car. He offered to take her to the store and soon realized that he could demand favors in return. The resulting sleep-over arrangement left the client home alone for roughly 12 hours out of every 24, and it appeared to have been going on for at least two years.
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Too Many Shoes and Too Many Relatives
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Jane’s predicament, while not exactly common, is not exactly rare either. As Lifecare Managers, we have seen a host of abusive scenarios take hold and worsen over time, generally in instances where independent caregivers have moved in, recognized an opportunity to exploit and seized it with both hands. Examples include:

  • The caregiver who caught the bank’s attention with her overuse of the credit card. When we investigated, we found that she bought dozens of pairs of shoes, allegedly for the client. The client, however, was a double amputee and had no feet;
  • The caregiver who moved her entire family into the client’s house;
  • The caregiver who had added her name to the client’s checking account and found an attorney who would execute new Powers of Attorney, naming her as agent;
  • The caregiver who loaded the disabled, terminally-ill client into the car each day to accompany her as she showed houses and toured new properties. She was a realtor first, and a caregiver second. The client waited in the car all day.

Such abuse is quickly detected when attempted by a caregiver serving under the auspices of a licensed agency. Caregivers employed by licensed agencies are background checked and closely supervised. At our company, they must call in daily to a computer-driven system that shows they are calling from a landline in the client’s home, not from the neighbor’s where they have spent the night. They never know when we are coming to visit, and we come often.
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Some Care Issues Shout, and Others Whisper

Some care issues are more subtle than those outlined above and require a higher level of skill to identify and measure. These problems tend to revolve around the level of care provided, the environment in which the care is offered, and the overall suitability or lack thereof for the client.
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Not all neglect is explicitly intended to be hurtful to the client. Sometimes it revolves around the careful conservation of funds that will one day be inherited by involved family members.
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Family members who oversee or provide care are sometimes guilty of considering the financial ramifications for themselves over the actual care needs of their loved one. They might choose to keep Mom alone at home, despite her flourishing incontinence and tendency to fall several times a day, because moving her to a communal environment or engaging a caregiver will cost money they hope to eventually inherit.
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Our dear client, Cora, named her niece as Agent under her Powers of Attorney for both Health Care and Property. The niece chose to keep Cora, who couldn’t use stairs, in a third floor walkup apartment she could not possibly escape on her own. Cora was repeatedly robbed by neighborhood thugs but still, the niece chose not to relocate her. Doing so might partially deplete Cora’s assets, and her niece was her sole beneficiary.
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Cora’s niece was also in the habit of taking her aunt to Walgreen’s, parking her on a bench near the front of the store, shopping for herself, and then having Cora sign the check to pay for the goods. Cora’s waning cognitive abilities did not allow her to recognize that her niece was exploiting her.
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“Everything is Fine”
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Caregivers who want desperately to keep their jobs will sometimes gloss over or fail to report a client’s worsening condition and need for a higher level of care. They will tell you everything is fine when, in fact:

  • The client’s gradual loss of strength has made it impossible for them to participate in their own transfers. The caregiver is moving “dead weight” and has dropped the client more than once;
  • The client has begun to wander and has escaped the home several times when the caregiver was napping or watching television. Vigilant neighbors or the police have found the client and brought her back home each time;
  • Bed sores are beginning to form and the caregiver is not strong enough to reposition the client;
  • The client can no longer accurately discern when it is time to take medication and the caregiver, who has difficulty reading English, has been guessing which pill to administer and when to do it.

A skilled clinical assessment of a client’s care will identify these gaps in care. The client’s safety is paramount, and any of these breaches in care can undermine that safety and lead to catastrophic consequences for all concerned.
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The Facility Continuum

Facilities are not all created equal, nor are their care levels. They are not intended to be equal, but rather to offer residents the level of care that best meets their needs at any given time. Some communities offer multiple levels of care (independent, assisted, skilled and memory care, for instance) and some specialize in just one or two areas.

The client who was a perfect fit for assisted living two years ago is not necessarily a good fit for that placement today, however.
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A care audit will reveal if a client is safe and thriving at their current level of care and in the particular setting they chose some months or years ago. It may be that they are quietly struggling. Where they were once able to remember mealtimes, they now perhaps forget to go to the dining room. They wear dirty clothes because they cannot distinguish clean laundry from soiled. Bills sit unopened on the table because paying them has become too difficult to manage.
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It may be time for a change.

Audits are Protective

The purpose of a care audit is to protect the client and the trust, Power of Attorney, or other responsible party. The eyes, ears and expertise of a knowledgeable third party offer a means of assessing care and documenting its appropriateness at any given moment in time. Like a snapshot, the audit captures conditions and offers evidence that a given placement or care situation is safe, appropriate and protective of the client…..or not.

It is said that knowledge is power. In this context, the knowledge made available by a thorough care audit is even more than power – it is a necessary and effective hedge against risk.
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©Lifecare Innovations, Inc.