MAY 31, 2014


Public rage today is impotent; it has no mechanism to produce consequences.

Glenn Greenwald, With Liberty And Justice For Some, Picador, New York, N.Y., 2011, p. 152.


Richard Martinez, the father of mass shooting victim Christopher Michaels-Martinez, speaks to the media on Saturday. Photograph: Michael Nelson/EPA


It saddens us to see the outrage of the father of one of the victims. A victim in the most recent killings in California. An image falling on eyes with short memories. Unfortunately, we don’t share his outrage for long, if at all.

We are not reminded of his permanent emptiness on a daily basis. The empty bedroom; the bed not slept in; the bicycle leaning against the garage wall; the toys no longer strewn all over the living room floor. It’s when the victim is a family member or friend that we express our outrage. Then we feel the anguish, the sorrow, and the daily reminder of loss.

We barely showed our outrage over the killings at Sandy Hook. The horror of Sandy Hook was not strong enough to produce a sustained dialog. Those thoughts were quickly replaced by the joys of our own Christmas experience. Soon the faces were forgotten. The families eventually tried to move on. Some started campaigns to stop the senseless violence, but not many supported the effort to curb the killing that has become an everyday occurrence.

The reality?

Few people care. We are too embarrassed to show our outrage; too politically correct; too afraid to express our deepest feeling; too insensitive to share in the emotions.

We are a nation of people that don’t care. Unless it happens to us, our family, our friend, our neighbor; we don’t care. We have insulated ourselves. The constant barrage of death and despair in the media acts as an insulator. Once we get tired of it, we turn it off, move on, and forget.

The anger and raw emotion demonstrated by the father of a victim may open the wounds of those that have shared his experience, but, in fact, his passionate expression of anguish will quickly be forgotten. Just as those faces from Columbine, Aurora, and Sandy Hook. Images that have faded and been forgotten. Their sadness and outrage are forgotten until the next tragedy.

We are confident that the mainstream media will remind us of the next tragedy in infinite detail.

The next time you walk past your kid’s bedroom and see it a mess, smile and be grateful the child will be safe asleep there tonight. The next time you find the bicycle in the middle of the driveway, get out of your car and move it. Be grateful it’s rider is safe inside the home. Show your love and gratitude, not your anger.

Share Richard Martinez’s sorrow for a brief moment and be thankful it is not you. Be filled with hope that your loved one will not be the next victim of the senseless wave of violence. Then, turn off the thought like the TV, and move on.

Media has conditioned us to forget. We forget because we are helpless.




According to figures supplied to me by my nursing home, their turnover rate in 2015 was a staggering 41%.

When I asked the Director of Nursing what her goal was for reducing turnover in 2017, she looked at me like a deer in the head lights.

She gave the impression she had no idea what I was talking about.

I wasn’t surprised.

It begs to ask what they talk about in staff and Quality Assurance meetings.

Because of direct care workforce turnover and callouts, managers are forced to pull nursing staff from one unit to another creating a mediocre resident experience to all those affected. Rather than isolating those unit managers with the highest turnover and using the existing management’s expertise to mentor those that need help and direction, they continue to move staff around diminishing the quality of care to each affected resident.

The obvious fallacy is that there is no one with experience, expertise or desire to deal with turnover.

My nursing home has had nine years to fix the problem.

Staff turnover is not unique to my nursing home but exists industry wide.

My nursing home is quick to tell you, and proudly so, that their turnover rate (41% in 2015) is below the national average (44.4% in 2013).

The condition has been so pervasive that even the aging state and federal inspectors can only identify the problem through numbers supplied by the nursing home.

Surveyors are ill-equipped to offer solutions. It is also not their job. They are, in fact, nursing home “monitors.” They just tell you that you have an employee turnover problem.

Does anyone believe that those numbers are an accurate reflection of reality?  Of a commitment to quality care? Especially when it’s a state agency inspecting another state agency?

I don’t think so.

I believe that there is an unwritten code that says that one state agency doesn’t disparage another state agency. Particularly one with the word “Veterans” in the title.

There is no correlation between the numbers on paper and the quality of the care provided. It’s disingenuous to think otherwise.

Recently I engaged an RN in a robust discussion about employee turnover and the switching of nursing assistants to other units to fill short staffing and call outs.

She adamantly stated that the quality of care had not diminished on her unit as a result of management pulling CNAs from her domain.

“Each substitute was certified and qualified. They were all certified.”

She had lost sight of the personal assets a permanent CNA or LPN brings to the profession.

A CNA brings the unseen skill set of knowing each residents’ preferences. Not just one, but all twenty residents in the dining room.

The unit manager’s priorities are no longer focused on resident’s comfort and dignity, but instead, satisfying the administrative timeline for paperwork, reports, and meetings.

The following day at the breakfast table I witnessed an LPN that no one had seen before, uncover an open, bleeding wound next to me. She began treating the wound in front of all of us. It wasn’t until I commented that the whole scenario was unprofessional that she moved the patient from the table to the hall rather than his room.

Throughout the lunch and dinner meals, I saw LPNs pass medication to residents at the tables while they were eating.

Saturday of the same week no one got me up at seven for breakfast. Breakfast is at eight, and I was awakened at eight-thirty. They were shorthanded, and I was assigned a new CNA from an agency.

The same Saturday and unfamiliar LPN on the evening shift offered me only nine of the twelve pills I’m supposed to get.

Just an example of the inexperience, absence of training, and a lack of understanding of what quality service and care are in the nursing profession. It has been replaced by administrative requirements and away from the resident’s dignified experience.

Statistics and numbers collected from paper reports in no way reflect the hidden assets and skill set that a direct care professional brings to the long-term employer.

There is no substitute for the knowledge, familiarity, understanding, and positive encouragement that the regular CNA brings into the life of the resident.

The exchange of feelings is mutual.

Regular CNAs become family. They are the friendly face residents look forward to seeing each morning. Part of my inner circle. My confidant.

CNAs look forward to coming to work and seeing their residents—their progress and they worry if there is a decline.

The direct care workforce generously share their family with those of us whose families have abandoned us. Residents know the CNA’s and LPN’s family through shared pictures from smart phones and look forward to updates: their newborn, their pets, their ups, and downs.

In return, CNAs receive from the residents support when needed, encouragement, and praise when deserved.

The direct care professionals are the lifeline residents depend on—to the end.

They are the first to ask about the test result.

They are the ones that cheer for our recovery, praise our successes; they are the welcoming, reassuring smile when we return from the hospital.

The direct care professional brings incredible strength. They commit so much of themselves knowing all too well it will only be temporary and will end in loss and a feeling of emptiness.

They are the first person we call when our burdens become too heavy.

They provide us with the last hug we’ll ever get. The last hand we’ll ever hold. The last hint of affection we’ll ever feel.

They are the ones that weep secretly—silently—so that they don’t appear weak when we die.

To break that bond is hurtful, counterproductive, and produces negative outcomes at all levels.

It’s devastating!

Another reminder that the aged are but a useless commodity without feelings.

The administration’s view is that the residents will get over it.

Some may not have enough time left, but the feelings of the residents are of little concern.

Longevity in a nursing home is the greatest uncertainty looming over all of us.

CNAs are just another familiar face that soon becomes but a faded memory when removed from our lives.

Our last bit of warmth, and the acceptance that our contribution in life is appreciated.

C’est la vie.

Nine years the turnover has persisted at my nursing home. Pleas from the residents and the employees have fallen on deaf ears, and concerns have gone unresolved.

The administration continues to cling to the last vestiges of a failing, uncaring, philosophy.



Please comment and share.





Most of the empirical research examining the relationship between turnover and quality has been conducted in the nursing home setting.



High turnover rates of certified nursing assistants have been associated with poorer quality care for nursing home residents (Bostick, Rantz, Flesner, & Riggs, 2006; Castle et al., 2006; Castle & Engberg, 2005; Mittal, Rosen, & Leana, 2009). Bostick and colleagues found that higher worker turnover rates in nursing homes were correlated with greater use of physical restraints, catheters, and psychoactive drugs, more contractures, pressure ulcers, and quality of care deficiencies. Barry, Brannon, and Mor (2005) found that nursing homes with low turnover and high retention rates experienced lower pressure ulcer incidence rates relative to nursing homes with high turnover and high retention rates. While there are no published studies examining the effects of HHA [Home Health Aide] turnover or other workforce quality measures on client quality of care, studies have highlighted the important role that a positive relationship between the client and the aides plays in quality of life outcomes (Eustis, Kane, & Fisher, 1993; Rodat, 2010).[1]

Most of the empirical research in the literature review examining job satisfaction and turnover intentions/turnover comes from nursing home studies with few that have looked at direct care workers across settings and fewer specifically examining the home care environment. While other factors also play a role, job satisfaction has been found to be a predictor of direct care workers’ intent to leave the job across long-term care settings (Sherman et al., 2008; Matthias & Benjamin, 2005; Decker, Harris-Kojetin, & Bercovitz, 2009; Castle, Degenholtz, & Rosen, 2006; Rosen, Stiehl, Mittal, & Leanna, 2011; Kiyak, Namaze, & Kahana, 1997; Castle, Engberg, Anderson, & Men, 2007). High turnover can have negative consequences for consumers and their families, employers, and policymakers. Workers who remain on the job may be more rushed because they are “working short” and, therefore, provide inadequate or unsafe care (Jobs with a Future Partnership, 2003; Dawson & Surpin, 2001). In addition, turnover and reduced availability of direct care staff make it difficult to provide continuity of care to clients. This lack of continuity disrupts the relationship building between the client and aides, an important contributor to quality of life for disabled individuals. It also limits the time for aides to understand clients’ needs and preferences (Wiener, Squillace, Anderson, & Khatutsky, 2009; Dawson & Surpin, 2001; Jobs with a Future Partnership, 2003; Butler, Wardamasky, & Brennan-Ing, 2012). Aides may be unable to adequately meet the needs of clients, resulting in poor nutrition, discomfort, secondary health conditions, and increased isolation (Kaye, Chapman, Newcomer, & Harrington, 2006). Clients may be turned away and denied access to care because there is not enough staff to meet the demand (Dawson & Surpin, 2001; Jobs with a Future Partnership, 2003). Worker shortages ultimately limit successful public policy implementation, as Medicare attempts to lower costs through the use of post-acute home health care and state Medicaid programs expand home and community-based services and attempt to integrate acute, primary, and long-term services and support for the dual-eligible population (those eligible for Medicare and Medicaid).[2]

Workplace Characteristics: The direct care worker’s assessment of the quality of the relationship between the supervisor and the aide as well as having supportive leadership have been shown over a large number of studies to be a strong indicator of job satisfaction in nursing home and home care settings (Karantzas et al., 2012; Gerstner & Day, 1997; Decker et al., 2009; Beulow, Winburn, & Hutcherson, 1999; Bishop et al., 2008; McGilton, Hall, Wodchis, & Petroz, 2007; DeLoach & Monroe, 2004; Castle et al., 2006; Dawson, 2007; Parson et al., 2003; Karshe et al., 2005; Bishop, Squillace, Meagher, Anderson, & Wiener, 2009). Research also supports that the perceived quality of the supervisor influences an aide’s intention to stay or leave the job, with aides who have a more positive relationship less likely to intend to leave or actually leave the job (Karantzas et al., 2012; Eisenberger, Stinglhamber, Vandenberghe, Sucharski, & Rhoads, 2002; Bowers, Esmond, & Jacobson, 2003; Stearns & D’Arcy, 2008; Brannon et al., 2007; Choi & Johantgen, 2012; Banazak-Holl & Hines, 1996; Bishop et al., 2008; Mittal et al., 2009; Parson et al., 2003; Barborotta, 2010; Straker et al., 2014). Dill et al. (2012) found the opposite–that nursing assistants who reported a higher degree of supervisor support were less likely to intend to stay on their job.[3]


These personnel are considered the “hands, voice and face” of long-term care, responsible for helping frail and disabled older adults carry out the most basic activities of daily life. The majority work in nursing homes and assisted living facilities; however, increasing numbers provide in-home supportive and health-related services. Estimating the size of the home care workforce is particularly difficult—many are missed in surveys because they are directly employed by consumers and/or their families. A recent study suggested their numbers are significantly undercounted (Montgomery, Holley, Deichert and Kosloski, 2006). According to 2006 BLS data, [Bureau of Labor Statistics] the total paraprofessional direct care workforce in both the health and long-term care sectors consists of:

■ 1,391,430 nurse aides, orderlies and attendants, largely employed in nursing homes;

■ 663,280 home health aides, a slight majority of whom work in home-based care settings; and

■ 566,860 personal care and home care aides, two-thirds of whom work in home-based services. The majority of these direct care workers are employed in long-term care settings.[4]

Poor Working Conditions: As is often true in the larger health care sector, the long-term care industry tends to follow an almost military, hierarchal approach to workplace organization and management. Mentoring, coaching, the use of teams and collective involvement of staff in decision making is the exception rather than the rule. Both nurses and aides complain about managers who lack respect for the knowledge and skills they bring to the job and refuse to share information, as well as poor supervision and a feeling that they are powerless to change their work environment (Bowers et al, 2003; Kimball and O’Neil, 2002). The retention of long-term care personnel will not be accomplished without significant changes in human resource practices and systems.[5]

Inadequate/Misplaced Investments in Long-Term Care Workforce Education and Training:

The professional long-term care workforce is not trained to address the special health and medical care needs of elderly consumers. Nationwide, there are few nurses or physicians trained in geriatrics. Nursing home administrators—the chief executive officer in nursing homes— only may need to have a high school diploma and pass an exam. Training requirements governing administrators in other settings such as assisted living or home health range from rigorous to minimal. (Miller and Mor, 2006). Nursing schools, community colleges and technical schools typically do not cover long-term care nursing in more than a cursory way in their curriculum. Anecdotal evidence suggests they may discourage nursing students from even considering long-term care careers. Nursing schools largely fail to prepare RNs to carry out administrative roles—although that is a primary responsibility in longterm [sic] care nursing. They do not adequately prepare RNs or LPNs in effective supervisory approaches, although one of their principal responsibilities is to supervise paraprofessional staff. Nurses also are trained poorly to understand the workforce implications of a culturally diverse paraprofessional workforce or the growing ethnic and racial diversity of older adults who are the consumers of longterm [sic] care. To become certified as nursing assistants or home health aides, individuals are required to have less than two weeks of training. Home care aides are not subject to any federal requirements, and few states require training. Most direct care paraprofessionals appear to learn what is expected of them and how to do their jobs after they have been hired. As a result, large numbers are unprepared for the demands placed upon them and leave their jobs within the first few months. Continuing education requirements for both professional and paraprofessional personnel are minimal. They are typically perceived as book learning without any real link to the reality of the tasks they must perform on a daily basis. There are few rewards for keeping up with the latest information on evidence-based practices or the availability of new technologies. Raising education requirements also could have an undesirable effect if it discourages or delays prospective personnel from entering long-term care jobs; however, improving training may be the only path to creating higher-quality jobs that are more competitive in the labor market.[6]


Strengthen Long-Term Care Nurse Competencies in Geriatrics, Administration, Management and Supervision: Directors of nursing and other nurses employed as administrators and supervisors in long-term care settings need incentives to develop competencies in geriatrics, administration, management and supervision. Long-term care providers could join together to identify nurses and paraprofessional staff with strong leadership potential and develop this potential. Schools of nursing should significantly increase the level of training and education in geriatrics for all nursing students, increase the availability of clinical preceptorships in long-term care settings and offer preparation in frontline [sic] leadership and supervision essential to the effectiveness of the longterm [sic] care nurse.[7]


[1] https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey
[2] https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey
[3] https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey
[6] http://www.leadingage.org/sites/default/files/LTC_Workforce_Commission_Report_0.pdf
[7]  https://aspe.hhs.gov/report/predictors-job-satisfaction-and-intent-leave-among-home-health-workers-analysis-national-home-health-aide-survey





Bed-holds continue to be a controversial subject kicked around the long-term care industry for too many years.

Just what is a “bed-hold”?

bed hold:

A reservation that allows one to stay in, or return to, a care facility. The reservation is usually made just before relocation to the facility or during furloughs away from it (e.g., in hospital or on family visits).

Medical Dictionary, © 2009 Farlex and Partners

But who pays?

It’s particularly troublesome in state-run veterans nursing homes.

The subject gets sticky because you have two government agencies with conflicting goals. On the one hand, you have the federal government trying to ensure that the veterans are getting quality care, and the state-run Medicaid footing the bill.  Sometimes the regulations overlap, sometimes they don’t. Often, one hand doesn’t know what the other is doing.

The issue boils down to one of money. Someone has to pay for the empty space, or so it would seem. All too often, this responsibility falls to the individual resident—to pay for the privilege of returning to a familiar place—a place of comfort and tranquility—a place called home.

Let’s go back for a moment and examine the intent of the federal regulations. Clearly stated:

Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

42 CFR § 483. 42 CFR § 483.25 Quality of care.

The federal government takes into consideration the bed-hold and continues to pay its portion of the empty room during the veteran’s short absences from the nursing home.

(c) Per diem will be paid under §§ 51.40 and 51.41 for each day that the veteran is receiving care and has an overnight stay. Per diem also will be paid when there is no overnight stay if the facility has an occupancy rate of 90 percent or greater. However, these payments will be made only for the first 10 consecutive days during which the veteran is admitted as a patient for any stay in a VA or other hospital (a hospital stay could occur more than once in a calendar year) and only for the first 12 days in a calendar year during which the veteran is absent for purposes other than receiving hospital care. Occupancy rate is calculated by dividing the total number of patients in the nursing home or domiciliary by the total recognized nursing home or domiciliary beds in that facility.

On the contrary, the state of Virginia makes no provisions to cover the bed-hold for anyone—including veterans.

The residents at the veterans’ care centers have taken the time and what limited resources that are available to them, to decorate their rooms. Rooms filled with cherished memories—memories from a lifetime of accomplishment, service, and sacrifice, only to have it all taken away by an unexpected medical event requiring only a brief stay in an acute care hospital.

The Virginia Department of Veterans Services must submit to the state legislature a request for funding to provide deserving veterans the peace of mind they deserve—that they will not be uprooted once again and will be able to return their home.


Please comment and share. Thank you.




When staff shortages in long-term care reach a level where it affects my quality of life I can no longer remain silent.

Much of the industry has yet to embrace the concept of PERSON-CENTERED CARE PLANNING (PCCP). It is interesting that the Federal Government has accepted the principle along with the obvious benefits to resident care that accompany it.

Central to this concept is the belief that the resident or responsible party is fundamental to voicing his/her preferences as to the care received. The government has made it an integral part of the annual inspection and nursing home certification process. The MDS (Minimum Data Set) 3.0 mandates certain policies, procedures, and questions to be asked of the resident if the long-term care facility is to participate in Medicare/Medicaid. Specific questions about the resident’s preferences as to his/her environment and quality of life.

Section F of the MDS 3.0 assessment includes, “Preferences for Customary Routine and Activities.” Questions like:

  • How important is it to you to listen to music you like?
  • How important is it to you to be around animals such as pets?
  • How important is it to you to keep up with the news?
  • How important is it to you to do your favorite activities?

I cannot emphasize enough that the resident or the responsible party read each line of the MDS assessment form and understand its significance in obtaining the necessary and desirable care.

An important aspect of the PCCP is the recognition of the resident’s need for stability in their daily routines. Staff shortage causes a disruption in the individual’s expectations and places the resident outside his comfort zone. Inconsistencies and repeated assignment changes have an adverse effect—often upsetting the resident for days at a time.

‘‘Minimum Nurse Staffing Ratios for Nursing  Homes.’’

CMS’s own study reported that facilities with staffing levels below 4.1 hours per resident day  (HRPD) for long stay residents may provide care that results in harm and jeopardy to residents (Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report, 2001, Abt Associates).

https://www.gpo.gov/fdsys/pkg/FR-2015-07-                           16/pdf/2015-17207.pdf  pg 42200

A report by the National Association of State Units on Aging, published in 2005, entitled, ‘‘Nursing Home Abuse Risk Prevention Profile and Checklist’’ concluded that understaffing and inadequate training of NAs [nursing assistants] are major causes of abuse, especially for individuals with dementia.

https://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf  pg 42224

Residents in a long-term care suffer through enough indignities each day. The changing of staff only worsens the condition. To have a constant parade of strangers come thru my room to attend to my daily needs, to help me dress, to help me shower, is unsettling, to say the least. I have my routine, a certain sequence of events, a certain way I prefer things to be done. I have to repeat my desires with each and every stranger from each and every department.

The regular staff knows:

  • What time I like to be awakened
  • What my morning medical requirements are
  • How I like my bed made
  • That I don’t like the overhead light left on
  • I like my door left open in the morning after I’m dressed
  • I like the bathroom door closed
  • That I drink a small milk and small prune juice for breakfast
  • That I want my personal coffee cup filled with only hot water in the morning
  • For lunch and dinner, I drink regular coffee
  • I provide my ice and cold drinks for my room and dislike being interrupted
  • Laundry personnel put my clothes away in the proper drawers
  • They know what time I prefer to go to bed

All the above contribute to my comfort and a feeling of contentment and control. My expectations are met.

Staff members working extra shifts to fill in for shortages can only result in a decline in the level of care residents receive. Three and four days of sixteen hours each increases the risk of injury to the resident, the staff, an increase in med errors, and a premature onset of employee burnout. It results in an unhealthy work environment. Nerves get frayed, tempers are short, and instances of resident abuse rise as does friction between employees causing more turnover.

A report by the National Association of State Units on Aging, published in 2005, entitled, ‘Nursing  Home Abuse Risk Prevention Profile and Checklist’’ concluded that understaffing and inadequate training of NAs are major causes of abuse, especially for individuals with dementia.

The research showed that nursing assistants in 10 Philadelphia-area nursing homes selfreported  [sic] abusive behaviors over a one month period. During this period,

51 percent reported yelling at a resident in anger;

23 percent insulted or swore at a resident;

8 percent threatened to hit or throw something at a resident;

17 percent excessively restrained a resident;

2 percent had slapped a resident; and

1 percent had kicked or hit a resident with a fist.

https://www.gpo.gov/fdsys/pkg/FR-2015-07-16/pdf/2015-17207.pdf    pg 42224

Administrations cover up understaffing by transferring staff from one unit to another. One such employee had her assignment changed three times in forty minutes. This just spreads the resident  and employee disruption and dissatisfaction throughout the entire population.

The following is a benefit analysis for proper staffing:

How Does Consistent Assignment Benefit Residents?

Residents do not have to explain to new caregivers how to care for them day after day.

Staff can respond to resident needs more quickly, confidently and naturally when they know the residents.

Residents are more comfortable with the intimate aspects of care when they know their caregivers.

Residents with dementia are much more comfortable with familiar caregivers.

Residents can have stronger relationships with staff.

Staff are more likely to detect residents’ clinical problems early when there is consistent assignment.

Residents have more choice and control.

Residents participate more in activities.

How Does Consistent Assignment Benefit Nursing Home Staff?

Staff members know individual resident’s preferences, needs and routines.

Staff give better care and can be more organized when residents and team members are known.

Having meaningful relationships with residents increases staff job satisfaction.

Staff absenteeism decreases.

Staff have more positive attitudes.

How Does Consistent Assignment Benefit Nursing Homes?

Nursing homes have better staff and resident satisfaction.

Nursing homes have better quality measures and fewer survey deficiencies.

Nursing homes have fewer family complaints.

Nursing homes have decreased staff injuries.

Nursing homes have lower staff turnover and absenteeism, which help reduce costs.


It’s difficult to understand why, with the positive gains to be made by proper staffing, that understaffing continues to be a chronic problem in long-term care. Prolonged staff shortages and high turnover are a direct result of the administration’s mismanagement and their lack of concern for the care and well-being of their residents and their employees.



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Representative Jeff Miller’s [1] bill, H.R. 4031, Department of Veterans’ Affairs Management Accountability Act of 2014: [2] Does it go far enough fast enough?

It is no secret that the Department of Veterans Affairs has serious problems. A crisis created throughout its hierarchy; a problem that creates delays in service resulting in needless anxiety, frustration, and frequently, death. [3]

The bill, ‘‘Department of Veterans Affairs Management Accountability Act of 2014,” will allow the Secretary of Veterans Affairs to remove members of the Senior Executive Service (SES) for performance.

Why not hold all management to the same accountability standard as the SES? Senior bureaucrats have stripped away any incentive for personal accountability and diminished responsibility throughout the organization. Those on the front lines of customer service should be as accountable as the seniors. It will do no good if senior management does not have the ability to dismiss unproductive or incompetent employees for performance shortfalls.


Civil service supervisors are unaware of the image their operation projects to the public. They no longer view their area of responsibility from the customer’s viewpoint, but instead, are busy responding to the whims of their supervisors and the occasional out of control grievance. Leadership is unaware of what happens on the front lines — under staffing, long lines, distracted, unresponsive, rude, and condescending employees. Employees are more focused on the timing of their next bathroom break or their cell phone vibrating than the client standing front of them. Supervisors have become too busy with a backlog of other priorities. Priorities designed to present ambiguous numbers and false positives. Priorities totally disconnected from the chaos that continues up-front, unabated. Priorities mandated by civil servants that are even more detached from the public’s perception of their operation.

H.R. 4031 makes no attempt to untie the hands of SES. SES is at the mercy of the lower chain of command with neither the ability nor the desire to make appropriate changes when necessary. There is little incentive to expend the energy or the resources to even meet, much less to exceed the veterans’ expectation. To change and insist on accountability throughout the Veterans Administration would require a fundamental transformation in the workforce and personnel practices. That is not likely to happen. The desirability of government employment would diminish. One of the well known perks of a government job is job security.

H.R. 4031is a step in the right direction and deserves support, but does little to untangle the mess created by mismanagement and poor planning that has plagued the Department of Veterans Affairs. H.R. 4031 will not be the silver bullet. Continued pressure on our representatives is imperative. The motivation of the department to self-govern has proven that they are more concerned about furthering their own interests rather than those of the veterans. Carefully concealing and shrugging off incompetence ensures a backlog of work and strengthens the employees’ grip on job security. Government can no longer protect the incompetent and unproductive civil servant. … Regardless of their position in the hierarchy.

“Despite the fact that multiple VA Inspector General reports have linked many VA patient care problems to widespread mismanagement within VA facilities, and GAO findings that VA bonus pay has no clear link to performance, the Department has consistently defended its celebration of senior executives who presided over these events, all the while giving them glowing performance reviews and cash bonuses of up to $63,000.00” [4]






My project started with a simple question: How do nursing homes discipline disruptive and inconsiderate residents?

The motivation for this project was my appreciation for, and a reasonable expectation of, continued calm. My stay in the nursing home has been relatively free from noisy interruptions from other residents. For the most part, it has been a quiet existence, and I’ve been able to pursue my interests uninterrupted. However, my concern has always been having a noisy, inconsiderate resident move near me. How does the nursing home administration manage, control, or remove such disturbing individuals?

The simple answer? They don’t!

Nursing homes ignore the problem and those innocent residents subjected to the objectionable noise are left to cope with it. Residents that continually scream and holler throughout the day and night are soothed and quieted by a CNA (Certified Nursing Assistant). If that doesn’t calm the unruly resident, little else can or will be done. The nursing home is more concerned with the individual’s rights rather than the individual rights of those in the immediate surrounding community.

“Many screaming residents are ignored or isolated because their behaviors are so disruptive.” http://alzbrain.org/pdf/handouts/2009.%20behavior%20book.pdf pg 47

I have found that the problem has grown into a science of its own. Psychologists have filled this vacuum and have capitalized on finding solutions to the problem through seemingly endless studies and an equal amount of solutions. None of which are being actively applied in nursing homes.

The issue is referenced by different names: Verbally Disruptive Behavior (VDB), Problematic Vocalization (PV), Repetitive Disruptive Vocalizations (RDV) or, Disruptive Vocalization (DV). All are easily searched on the Internet.

One of the initial interventions, the simplest and least expensive, is the introduction of music to the screamer’s environment.

The Effect of Music on Repetitive Disruptive Vocalizations of Persons With Dementia by Julie A. Casby, Margo B. Holm. file:///C:/Users/User/Downloads/883.pdf

I can say with a high degree of certainty that interventions have never been considered in my nursing home.

One study suggests that the responsibility for intervention falls squarely on the shoulders of the occupational therapist and the activities department.

“Music appears to alter the abnormal or disruptive behaviors of persons with DAT [Dementia of the Alzheimer’s type] residing in LTCFs [Long Term Care Facilitys] (Burgio, Scilley, Davis, & Cadman, 1993). Therefore, music may provide occupational therapists with a means to decrease the incidence of RDV [Repetitive Disruptive Vocalizations ].” file:///C:/Users/User/Downloads/883.pdf page 884.

“The effects of the interventions were clinically and statistically significant, indicating the importance of providing stimulating activities a richer environment to cognitively impaired nursing home residents.”  https://www.researchgate.net/publication/13827140_Management_of_Verbally_Disruptive_Behaviors_in_Nursing_Home_Residents

The seriousness of the collateral damage has been misunderstood and unseen by nursing home administrators. It’s not found in the Minimum Data Set (the resident’s quarterly assessment), nor on the Health Department Survey of nursing homes (the annual inspection).

“Among the disruptive behaviors that are exhibited by nursing home residents with dementia, problematic vocalizations (PVs) are the most frequent, persistent (Nelson, 1995), and annoying (Cubit, Farrell, Robinson, & Myhill, 2007; Whall, Gillis, Yankou, Booth, & Bates, 1992).” (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140256/).

“Negative consequences of PVs include increased distress or anxiety of the resident and others in the environment (Burgio, Scilley, Hardin, Hsu, & Yancey, 1996), often causing social isolation (Draper et al., 2000) and over medication (Cariaga, Burgio, Flynn, & Martin, 1991), which in turn results in higher health care cost (Murman et al., 2002).” ((http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140256/).

My concern is justified by the statements above. “Negative consequences of PVs include increased distress or anxiety of the resident and OTHERS in the environment….” [emphasis added].

“Screaming behaviors can provoke assaults by other demented residents.” http://alzbrain.org/pdf/handouts/2009.%20behavior%20book.pdf pg 47

By whatever name, the result is the same. It not only affects the distressed individual resident, but all those in close proximity. It is a concern that the Center for Medicare/Medicaid Services (CMS) and nursing homes have ignored far too long and must be addressed.

“Verbally disruptive behaviors (VDB) are verbal or vocal behaviors that are inappropriate to the circumstances in which they are manifested. These behaviors are a source of concern because they disturb persons around the older person and may be an indicator of distress.” (https://www.researchgate.net/publication/13827140_Management_of  Verbally_Disruptive_Behaviors_in Nursing_Home_Residents)

The psychological/psychosocial well-being of the elderly in the nursing home community is no less important than the individual’s proper nutrition, social services or physical rehabilitation, yet it is ignored by nursing homes.



SENTIMENT LOST: Sympathy, Care and Kindness


Unknowing and uncaring family members ignore those closest to the aging at the end.

I have spent over a year sharing a table, eating three meals a day, celebrating holidays, birthdays; discussing politics, opinions, innermost feelings, ups, and downs with people who, until recently, were total strangers.  Over time, a bond is formed.  It’s the last friendship.

When a resident first arrives at a nursing home,  fear and loneliness set in. Residents reach out to those they become familiar with; those they eat with and those they connect with in activities. It is a bond cemented by the commonality of a depressing, unspoken reality.  We are all waiting to die.  That’s the reality. We are reminded of it each time someone passes.  Another empty room, another empty space at a meal table.

When a resident dies the family is drawn in to handle final affairs, nursing home relationships are overlooked. I have shared the good, the bad, the pain and suffering of my declining years with those that I have become familiar. They too have shared their history of family dysfunction and disease with mutual confidentiality. Intimate details and feelings not even shared with family.  Perhaps the family is fearful that I know too much.

I have never been given the opportunity to pay my respects; unable to express sympathy, sorrow, or sense of loss with a family I had grown to know only briefly. The deceased is whisked away.  Removed from meaningful relationships by a family that treated my friend as if he had become a burden in later life—disposing of what remains as if the dead had no friends in the nursing home. No kinships. Nothing!

I’ve experienced it twice.  Once with Clarence, who shared with me his family history in Virginia and West Virginia.  Again with Tom.  His life story spanned both Virgina and Florida.  I was fortunate to see them both just days before they died.  I don’t know if they were aware of my presence.  It was the last goodbye.

I was ignored by both families.

Fleeting, fragile, short-term friendship. Another empty chair at the table.

Such is life—and death—in a nursing home.

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Dreams were about to be broken.

I can clearly remember that July day in 1980.  It was mid-afternoon, sunny, hot, and humid.  As I reflect back, it was an unsettling time for me; the divorce, the lawsuit, and the knowledge that emotions would be uncertain.  All were weighing heavily on me.


We had finished loading the pick-up truck with the few possessions I was to take with me: an office desk and chair, a credenza, clothes, shotguns, pictures, and papers.  Left behind were the things of value.  She had custody and control over all that I was leaving behind.

My four children had gathered on the front porch to say goodbye.  Diana, 11, and Pam, 10, were old enough to understand what was happening.  They, however, had been spared the details.  They had also been prepped for the event that was unfolding.  Diana and Pam stood by trying to control any feelings they may have had.

Matt, seven, the youngest, was too young to grasp the immensity of emotions and clung to his mother’s leg.  Steve, nine, the oldest boy struggled to hold back his tears.  His mother explained to him that his daddy would be going away for a while.  I too was failing in my effort to hide tears.  As I turned to leave, Steve, moisture in his eyes, handed me a book.

Many years have passed; I have traveled many miles.  The book traveled with me from Asheville; to Raleigh; to Roanoke; to Indianapolis; and finally to Bridgeport, CT.  The treasured book always was packed and moved with me.

It was not until the late nineties that I parted ways with the book in Bridgeport. I was forced to leave the book behind due to necessary downsizing.  Downsizing made necessary by economics and poor judgment.  In haste and oversight, the book was left behind.  An oversight that I now regret. I am reminded of that book every day.

Every day I look at the picture that hangs on my wall in the nursing home where I now live.  The picture serves as a reminder of that book and what I left behind; a reminder of the pain and emptiness I’ve felt over the years.  The hurt that I’ve caused and the wounds that will not heal. I now, so very, much would like to have that book so that I may return it.

It will have been 34 years this July since I’ve seen that teary eyed little boy; that little boy offering me a going away gift.  A book that meant so much to him then — and means so much more to me now.  The book is long overdue.  No one can imagine the price paid over the years; the years of sadness and remorse, and how lonely I’ve become.

Each day I look at the picture of my four kids.  The picture serves as a reminder of that book and all that I left behind.

I am so very sorry.


BREAKDOWN OF FAMILY: The Overlooked Consequence


Nowhere in the framework of society is the breakdown of the family more evident than with the aging. With the need for two incomes to support the family, no one is home to care for the elderly. The solution to one of the most perplexing issues facing a family has been found.


“In the U.S., nursing home chains have flourished since the 1970s, subsequent to the passage of Medicare and Medicaid and the extension of public payment for nursing home residency.“ — Light, D.W. (1986). Corporate medicine for profit. Scientific American 255: 38-45.

This act has completed the acceptable end of life drama for many households. The painful and depressing disposal of the elderly in a satisfactory and a seemingly compassionate manner has now become a reality. Family members can wash their hands of the sick and dying, delivering them to the care and comfort provided by others, paid for, to a large extent, by the government. The next of kin can now pursue their selfish endeavors cheerfully and guilt-free.

The degree of disintegration in families was readily apparent when I attended a Family Council Meeting in a nursing home; a meeting of relatives and responsible parties to discuss the care and comfort of a loved one put away in a long-term care facility.  These meetings are held at regular intervals throughout the year.  It gives family members an opportunity to meet with the administrative staff, presumably to air out differences, address grievances, and ask questions. This is the occasion to talk to the policy makers of the nursing home. My most recent experience was a sad example of family apathy, lack of family concern and lack of family participation. Two concerned people showed up for the meeting in a 200-bed facility. I was one of them.

Family breakdown has been the bane of the society for decades.  It’s not something that slowly crept up on us from nowhere. It’s only now becoming a concern for those of us that have ignored or tried to justify the cause of the of the decline of the family. Family values have been replaced by the need for two incomes so we can buy the newest, the fastest, the prettiest, the biggest, and the bestest, in the ongoing, self-imposed, undeclared competition with our peers. Equality and freedom of choice in the family—without direction or leadership—is the cause of family breakdown. When each has an equal voice, each goes in their own direction aimlessly with no leadership. Fundamental principles are cast aside, and each family member goes in a different direction to satisfy their selfish desires, free of responsibility and accountability. Each is allowed and entitled to do “their own thing.”

Sadly, it is the elderly that now suffer. They suffer alone. Once again, big brother has stepped in to fill the void. Once, when families were tethered together with common goals, objectives, and family values, sons or daughters cared for their old and dying. This is no longer the case. It is now the task of the government under the guise of Medicare and Medicaid. A new industry has risen to the forefront. Now dying and death offer a profit motive to the corporate world…and it’s flourishing.

With government and private corporations cooperating, also, come the countless cottage industries of government regulators, private and public sponsored watchdogs, medical specialties, psychologist, and social workers all clamoring to get their piece of the economic pie. All are well-intentioned and overzealous at their new found treasure trough. They are preoccupied performing never-ending studies to enhance their self-interest, the results of which are ambiguous enough to affirm the need for further studies and additional funding—and stimulating their job security.

Without the breakdown of the family, they would all be out of work.



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