I’ve never been one myself, but that’s what I’m told by people who are. To survive in the profession, the belief that you’re actually in charge of your tasks or time must be offered as a willing sacrifice for the privilege of serving vulnerable seniors.

It’s a worthy tradeoff, but a challenging one. If you’re used to being the puppet-master of your own existence, pulling all the strings in perfect synchronicity, this might not be your ideal career choice.

I recently built some garden boxes and painstakingly planted precious little seeds in straight little rows. Overnight, renegade squirrels came in and dug it all up. That’s what it’s like to be an administrator. Whether it’s an angry family member, a resident fall, an employee squabble or a complaint surveyor at your door, the squirrels are always out there, ready to scramble your elegant master plan.

“How much control do you really have in your job?” I asked a successful administrator, who laughed way too hard for way too long.

She estimates 25% of a typical day is controllable. The rest is triage because she never knows what’s next. Sure, she could close the door and shut out the chaos, but that’s not the job — or at least, not the way she thinks it should be done.

So she puts gloves on and helps the CNA. She answers the call light. She won’t walk past anyone who needs something. She sees and then she does. She models how caring for people isn’t remotely predictable, and everything is everyone’s job.

That’s what being an administrator is, and the best ones wouldn’t have it any other way. They simply learn to relax and embrace that oft-quoted Zen mantra, “I don’t mind what happens.”

Things I Think is written by Gary Tetz, a national Silver Medalist and regional Gold Medal winner in Humor Writing in the 2014 American Society of Business Publication Editors (ASBPE) awards program.

A new American Diabetes Association white paper addressing the high price of insulin was released in early May to coincide with a hearing on the topic, held by the U.S Senate Special Committee on Aging.

The paper, “Insulin Access and Affordability Working Group: Conclusions and Recommendations,” was published May 8 online in Diabetes Care.

It recommends ways that healthcare providers can help minimize patients’ out-of-pocket costs.

“The average list price of insulin has skyrocketed in recent years, nearly tripling between 2002 and 2013,” the working group reported.

“The reasons for this increase are not entirely clear but are due in part to the complexity of drug pricing in general and of insulin pricing in particular.”

Sen. Susan Collins (R-ME) called rate hikes, even for the drug’s oldest versions, “untenable” at the hearing.

“It’s become a barrier to treatment for so many Americans,” she noted.

The ADA warned providers to be mindful that rising prices may make community-dwelling diabetics less likely to follow their treatment plans.

Your problem is not with OSHA but with the U.S. Department of Labor; also, each state has an agency that enforces overtime laws.

Under both federal and state laws, employers are required to pay time and one-half of the hourly wage for all hours in excess of 40 per work week. Some employers, such as nursing homes and hospitals, can adopt another method for paying overtime: Any employee who works more than eight hours in a day or 80 hours in a two-week time frame must be paid overtime. This is the “eight and eighty” method. Under either method, the time spent working when the employee was supposed to be on a lunch break can create overtime. The fact that the employee disregarded your work rules will not defeat the overtime claim.

You do not have to “beg” employees to follow your work rules; their failure to do so could subject them to discipline, including up to discharge. You can write them up each time they violate a work rule. Also, you can tell them that they will get only three warnings of the violation and you will terminate them on the fourth.

Be aware that federal or state regulators can audit your entire payroll looking for overtime violations. Government audits usually end with an order requiring a significant financial payment for all unpaid overtime. In addition, the final order will require the employer to pay all overtime in the future.

The sooner you enforce your work rules, the better. Thus, you will minimize your exposure to the payment of overtime.

Please send your legal questions to John Durso at ltcnews@mcknights.com.

An executor for the estate of Fannye Doris Holden Scruggs Rorer is suing Virginia’s Williamsburg Landing in a medical malpractice lawsuit for personal injuries and wrongful death, according to court documents filed in the circuit court for the City of Williamsburg and James City County, Virginia.

The suit alleges that Rorer fell on April 15, 2016, while a staff member was transferring her from her bed into a lift designed for immobile patients, without any assistance and without the special pad for amputees like the victim, as required. Rorer died eight days later.

The complaint claims she was injured during at least six other lift transfers in the months leading up to her fall and death. It alleges that staff compounded the victim’s suffering by not providing the necessary pain medications on a timely basis.

The victim’s death certificate, signed by the facility’s medical director, notes that her death was caused by the fall. The suit seeks $2.15 million with another $350,000 in damages.

Kathy Kammer, senior director of community relations & communications for Williamsburg Landing, told McKnight’s in an email that the nursing home had not yet been formally served with the complaint, and therefore had not had the opportunity to respond to the allegations.

She also expressed the agency’s commitment to resident care.

“Nothing is more important to Williamsburg Landing than the health and safety of our residents,” Kammer said. “These remain Williamsburg Landing’s top priorities. One of the reasons for our high quality is that we thoroughly review concerns about any resident’s medical care. This process will continue with this matter and will ensure that Williamsburg Landing can continue to provide the highest quality care to all of its residents.”

Kathleen Audia, 63, claimed Briar Place in Indian Head Park, IL, delayed her discharge and limited her ability to participate in activities or exercises — including evaluations — by limiting her ability to communicate.

“She did not understand her right to request a discharge or what she needed to do to satisfy Briar Place’s discharge criteria,” ruled U.S. District Judge Manish Shah in the Northeastern District of Illinois. “The lack of effective communication caused Audia frustration, fear and emotional distress.”

Audia went to Briar Place for treatment after a fall and a cut to her head. She was diagnosed with depression, balance and gait issues, and osteoarthritis. But her attorneys argued Briar Place never provided a requested interpreter for initial assessment, care planning, social service coordination or physician evaluations. According to her claim, she failed those evaluations and was not allowed to walk outside because she did not understand what staff were asking her.

Fully deaf since age 55, Audia has limited ability to verbalize speech or read lips.

Briar Place sought to have the case dismissed, claiming that Audia could not prove discrimination was intentional. The judge denied the request, stating that indifference was a more appropriate standard in such cases. “Requests that go unanswered can support a finding of deliberate indifference,” he wrote.

The decision also allows a claim to proceed under the Affordable Care Act’s discrimination clause, which prohibits discrimination on the basis of disability.

In order to keep current with long-term care living trends, Harbour’s Edge in Delray Beach, FL, has been meticulously following a master plan that includes a major repositioning to make the 30-year-old community more attractive.

The most recently completed phase of the master plan for the skilled nursing, rehab and senior living community includes the creation of a new $2.75 million health center, much-needed upgrades to the main building and a Lifelong Learning Center. As Cornelia Hodgson, architect of the master plan for Lifespace, describes it, the improvements have brought Harbour’s Edge in line with the upscale lifestyle of residents along the Intracoastal Waterway in southeast Florida.

“Built in the late 1980s, the property needed tremendous updating to fit within a high-end neighborhood and satisfy an affluent and demanding consumer,” says Hodgson, president of the CC Hodgson Architectural Group. “The master plan includes refurbishing, renovating and adding amenities current with the marketplace.”

The redesigned health center, opened in 2017, has 54 beds for skilled nursing and rehab.

It includes expanded therapy spaces for short-term rehab with a gymnasium, a new kitchen and its own entryway so rehab patients don’t have to trek through the nursing home for therapy.

The rotunda in the main building wasn’t set up to be a welcome center, so the new design has windows that provide views of the outside while letting in ample natural light. The welcome desk area “projects a sense of wellness,” and gives visitors a natural entry point, Hodgson says.

Health center administrator Jennifer Stevens participated in the planning and says the design creates a flow that works for residents. The high ceilings and open common areas project an upscale image that impresses visitors, she adds.

“People are always saying, ‘This isn’t what I expected a nursing home to be,’” Stevens observes.

The project also features a Lifelong Learning Center, which includes a media room, along with video, conference and business centers, a computer center, library and performing arts center. The vision is to transition from the original 30-year-old library into a new, more engaging space with an expanded theater for more sophisticated productions and bigger events.

The renovations occurred within an existing structure, so a lot of logistical coordination was required. Harbour’s Edge management had a timeline to follow, along with a plan on how to manage traffic around the “pardon our dust” spaces.

“We had to reroute people around the construction zones, which was quite an adventure,” Stevens explains. “We had to improvise, such as converting rooms for different purposes. It required a lot of communication to make it work. It was a daily, minute-to-minute challenge.”

Lifespace wants to continually reinvest, Stevens says. Future plans call for a new skilled nursing wing and memory care.

Lessons Learned

1. Properties built in the 1980s are prime candidates for renovation and refurbishment.

2. A master plan can provide guidance and discipline.

3. Construction in occupied buildings requires diligent logistics coordination.

1. Identify and be vigilant about the riskiest sleep medications. Virtually all medicines designed to induce sleep can produce side effects. Some substantially more than others, however.

Experts agree benzodiazepines are among the riskiest. That class of drugs increases the chance of cognitive and psychomotor impairment, falls, fractures, and motor vehicle accidents, says T.J. Griffin, RPh., chief pharmacy officer for PharMerica.

Kathleen Wise, consultant pharmacist with Boomer Solutions, a member of the Guardian Pharmacy Services family, says these and non-benzodiazepine receptor agonists are recommended only for short-term use due to additional risks such as “rebound insomnia, withdrawal and tolerance.”

Other high-risk sleep meds include antihistamines, which “have strong potential for anticholinergic side effects,” as well as antipsychotic and antidepressant medications, which “are not recommended for the treatment of insomnia.” These medications not only have the potential for adverse side effects but may interact with other medications, says Wise.

Barbiturates are another medication to avoid because they can cause overdose even at low levels, and are highly addictive, adds Griffin. “Chloral hydrate should also be avoided in older adults because of tolerance within just 10 days of treatment and risk of overdose,” he says.

2. Educate staff about the early warning signs of troublesome sleep medications. Additional monitoring and quick intervention throughout the day are needed for any residents on sleep medication.

Joe Kramer, vice president of sales and marketing for Geri-Care Pharmaceuticals Corp., refers to them as “complex sleep behaviors, which are episodes in which a patient has no control over his or her movements, behaviors or actions, with no remembrance, which is identical to sleepwalking. This tends to occur when a patient has built a high tolerance or has become dependent on the medication.”

Wise says insomnia meds are known to lead to “residual daytime sedation, increased confusion, rebound/withdrawal symptoms and physical dependence.”

3. Non-pharmacological approaches to insomnia are usually preferred.

Wise asserts that risks from over-the-counter sleep aids can be avoided by: resident and caregiver education; employing non-medication therapies; creating environments conducive to restful sleep; treating comorbid conditions such as depression, sleep apnea and chronic pain; assessing medications known to contribute to insomnia; and scheduling routine medications during waking hours when possible.

4. There are a host of alternatives to pills and many are shown to produce better outcomes.

William Vaughan, RN, BSN, vice president of education and clinical affairs for Remedi SeniorCare, says nonpharmacological approaches to insomnia include both behavioral and environmental interventions.

“Emphasis is placed on going to bed and waking up at the same time each day, getting out of bed while awake, avoiding caffeine, heavy meals, nicotine and alcohol before going to bed and limiting naps,” he adds. Daily exercise and regular exposure to sunlight also improve insomnia. The National Sleep Foundation also recommends a sleep environment that is cool, dark and quiet.

Kramer encourages caregivers to put their residents’ smartphones on silent or vibrate mode before bed, and to consult with their physicians about “safer” herbal and dietary supplements such as MidNite or LUNA.

Wise asserts that cognitive behavioral therapy is the recommended initial intervention for insomnia in most residents. It consists of several modalities and addresses behaviors that are counterproductive to decent sleep.
—John Hall

Mistakes to avoid

1. Treating sleep medications as long-term solutions. Experts all agree drug therapy should be kept to a minimum.

2. Ignoring safer, non-pharmacological approaches.

3. Forgetting to carefully monitor residents on sleep medication therapy, and intervene if necessary. Things can get out of control quickly.

Sure, the 2-year-old has good manners and loves to dole out kisses.

But he also keeps his shoes — all four of them — on inside and fully expects residents to pamper him by stroking his back or running their fingers through his auburn mane.

Maverick is a mini pony, and he’s part of a varied pet therapy program at Uniting Mirinjani Weston. The facility offers “high care,” the Australian equivalent of skilled nursing, and dementia services. Pet therapy has had a successful past at the facility, and Maverick’s visits are particularly welcomed by residents with Alzheimer’s or dementia.

“Because we’ve got a lot of people from farms, seeing them have that interaction with the horse has been really amazing,” Wellness Coordinator Jo Sumner told ABC Radio Canberra. “It’s so uplifting for all of our staff and residents.”

Maverick has spent 18 months under the tutelage of equine trainers Nerida Winters and her daughter, Ellen.

“We wanted to share the experience of horse therapy with people who are in a situation where they may not get opportunities to interact with pets and animals,” Winters told the broadcaster. “We really just want to brighten people’s days.”

In the study, published in the Journal of Alzheimer’s Disease, 120 patients with early Alzheimer’s, who were recruited from six academic medical centers around the world, wore a small sensor on their lower backs while carrying out walking tasks in the laboratory.

They then wore the sensor for a week at home, carrying out everyday tasks.

The researchers found the sensor provided comprehensive and clinically appropriate diagnostic measures for walking behavior and pattern, as well as gait characteristics related to pace, timing, variability and asymmetry of walking.

“The clinical use of body-worn sensors in annual health assessments could track gait changes over time and act as a red flag for cognitive impairment,” said the study’s lead author, Lynn Rochester, Ph.D., professor of human movement science at Newcastle University.

“Free-living gait analysis at home is particularly useful as it allows objective observation of an individual’s day-to-day activity. It also has the benefit of providing continuous data over a prolonged period of time that may be more sensitive than one-off assessments.”

Previous research has found that changes to the brain begin to occur as early as 10 to 20 years before symptoms arise. If experts can identify the biomarkers present in this very early stage, there may be the chance of treating the disease earlier, which is vital to prevent damage to people’s memory and thinking, Rochester said.

“The ability to assess gait and walking behaviors in all aspects of life is a major step forward in dementia research,” she explained.

The project, dubbed Wall++, enables users to place or move light switches or other controls anywhere on a wall that is most convenient, or to control video games by using gestures.

By monitoring activity in the room, the wall can adjust light levels when it senses movement and alert a user in another location when appliances or electronics are turned on or off. The smart wall also can estimate the position and pose of people standing near it.

The team outlined its approach in a research paper presented at the Conference on Human Factors in Computing Systems in April. Members used painter’s tape to create a cross-hatched pattern, then applied two coats of a water-based paint containing nickel. Once dry, the diamond-shaped mesh becomes a network of electrodes, which are connected to a custom circuit board, resulting in a wall that acts like a giant touchpad.

The coating and underlying technology costs about $20 per square meter, which the researchers say make this a low-cost project for the potential value it can provide.

“Walls are usually the largest surface area in a room, yet we don’t make much use of them other than to separate spaces, and perhaps hold up pictures and shelves,” observed Chris Harrison, assistant professor in CMU’s Human-Computer Interaction Institute. “As the internet of things and ubiquitous computing become reality, it is tempting to think that walls can become active parts of our living and work environments.”