Judith Ann Challis, Ph.D.
84 Cobb Road - Brewster, New York 10509
October 15, 2011
Putnam Ridge Nursing Home and Rehabilitation
46 Mount Ebo Road North
Brewster, New York 10509
Attention: Chaya Willingger, President;
Eric Greenberger, CFO;
Laurence LaDue, Administrator
Dear Owners and Investors of Putnam Ridge:
Sometimes it only takes one person to make a facility really work and sometimes just letting a few things go can make a facility less desirable. My Aunt Mary Canade was in Putnam Ridge Nursing home for some time and has since passed away. There was a social worker, Jonathan Meyer, who helped me when there was a problem to always make things right. So when I was in a car accident where I broke my ankle and much more, and needed to go to rehabilitation, my first choice was Putnam Ridge. For after all, I knew Jonathan was there and if I had problems he would help me to make them right. I was at Putnam Ridge for approximately two and one-half weeks. But Putnam Ridge had changed hands and Jonathan was no longer there and many things are not right. And thus I decided to write to you. I can only conclude that the owners either do not know of these problems or how their policies might be creating problems. For anyone with a heart, would not allow such conditions to exist.
I know it is a difficult task to run a nursing and rehabilitation facility. I am grateful there was a facility near to my home and the ones I love. So, first, thank you.
Secondly I do not believe in pointing out a problem, without at least suggesting an answer. So I will try to suggest remedies that may or not work for the problems discussed. We live in economically stressed times so will try to make my suggestions practical.
My arrival coincided with the arrival of Hurricane Irene and first impressions are probably better when you are not experiencing a facility in disaster recovery mode.
Disaster Recovery
During Irene the power went out. At first, for quite a few hours no one could get the generators to work. When they did finally kick in, only the lights in the hall, the dining room, and essential things like oxygen worked. This means, if I wanted to use the bathroom I had to transfer in pitch darkness from a wheelchair with the faint bit of daylight from the hall to light my way. Not being able to see to toilet or wash is simply dangerous. And I think even the most liberal among you would understand a desire for privacy while toileting with male aides and workers in the hall.
Remedy: Inexpensive battery operated lanterns as a cheap fix, or a better generator system as a more optimal fix.
Aides came in upset from Apple Unit, where Dementia and Alzheimer’s patients reside with long scratches on their arms where patients had scratched them in fear, and reported the patients, were terrified in their dark rooms and acting up badly. They were used to being able to watch TV or somehow be stimulated. I found it stressful just to know there were others in the facility suffering, and that if my Aunt were still alive she would have been one of them.
The HVAC was inoperative and the facility was hot, dank, and humid. There were one or two fans at the nurses’ station only. I was in a cast and the room (I eventually got a flashlight/clock/thermometer from my husband) was up to 85 F at times. The windows are locked down to an inch or two according to state code. So it was hours of stewed patients.
Remedy: Inexpensive battery operated fans or upgrade generator system.
Additionally, aside from the bathroom being dark, from the day I entered, the toilet in the room I had was leaking all over the floor, and the faucet leaked at the taps as well. Once this was fixed my room was moved and in the second room, the toilet leaked on the floor (and it was not until it pooled large pools under the sink that it was fixed) and the taps leaked. This brings me to the topic of deferred maintenance.
Deferred Maintenance
Most of the plumbing in the rooms seemed to have problems. I had a friend come and use the bathroom designated for the public and the water was turned off at the sink, so she could not wash her hands. As a nurse she found this upsetting, and as a health care facility wanting to control disease and infection, I hope you do too.
The shower chairs had rusted wheels so they were very hard to move. The aides could only move them very small distances. When you are living life on one foot and only going as far as you can hop this is critical. You could just as easily swap my broken leg out for most of your other patients with knee replacements, broken hips, unsteady due to age or medications as well.
As previously mentioned, the water at the sink in one bathroom open to the public did not work. My sinks and toilets leaked in both rooms. My husband, when he had me in the Great Room picked up a tissue from the couch and looked for some hand sanitizer, but when he walked up and down the halls it looked like there were places where we remembered from the past owners as hand sanitizer being present where it looked like the units were removed.
One day, an aide having a bad day, slammed my
breakfast tray down, and orange juice exploded all over the floor. She gave it
a quick and cursory wipe. Even though housekeeping washed and washed the
floor the room was plagued with ants that were there even as I left. At times
I would even find them walking in my bed. Yes, I did complain. There should
be a record. But in spite of the many washings and efforts that were made, even
on the last day I was there ants were dancing across the floor.
Remedy: In house regular inspections by a supervisor with follow-up reporting on whether items are repaired.
Food
After being at the facility a week,
it finally dawned on me that I was paying over $300 a day and living on my own
protein bars and my own fresh fruit cut up over bits of cottage cheese from the
kitchen and this was not acceptable. There are tasty sounding options on the
menu. Once I ordered stuffed peppers and received green goo with bits of rice
floating in it.
You are always offered the option of a grilled cheese sandwich, a deli meat sandwich, the same deli meat over iceberg lettuce, or fruit over a small amount of cottage cheese. How often can you eat the same food?
This picture demonstrates what I mean by plates of
“goo”. This is one of the meals I was served.
I spent most of my stay eating cottage cheese with fruit (and it was only after much fighting I got this changed to fresh rather than canned) and finally tiny tiny servings of grilled chicken over iceberg lettuce. Much of the food in the main selections was inedible goo, served with large portions of cheap starch. I just want to let you know…I DID NOTICE! Eggs made from reconstituted powered eggs with a serving size of about two tablespoons. I took pictures so you can see what actually arrives rather than what the menus tastily proclaim. Often items listed on the menu slip did not arrive on the tray.
This picture is the standard size of a Putnam Ridge breakfast. One slice of toast and quite literally a tablespoon or two of eggs is the serving size.
One Sunday night, weekends are the
worst time; my tray was brought to my room with a beverage, a bowl of soup and
a slip reading grilled chicken over salad. I was in the bathroom and came out
to find the empty tray. I called an aide I gave the slip to an aide.
She said she would take care of it. After 45 minutes an aide came to ask me if I was finished with dinner. What dinner? It never came. I called the kitchen. I talked to a staff member and asked them for my chicken over salad. She said they did not have chicken. Upon further conversation, she said, ooooooooooooooh, well we do have it but it is frozen. That is the type of problem I am talking about. No one cared that the tray was empty, not the staff in the kitchen or the person delivering the tray or any supervisory staff seeing it leave the dining area. No alternatives were offered. I finally managed to get a couple of ice cream cups out of the kitchen. Another Sunday (previous to me asking for alternatives) dinner was two slices of wilted bread with a tablespoon of egg salad asymmetrically slapped in one quadrant. It was horrible.
The kitchen and I finally came to compromise, mainly that of cottage cheese and fruit and chicken over iceberg lettuce. Herein lays the problem. My doctor told me to remain in a positive nitrogen balance. I have a leg with much bone and muscle damage that I need to rebuild. That means high protein. 2 ounces of cod once every other day and a tablespoon full of powdered eggs in the morning did not meet my doctor’s advice to maintain a positive nitrogen balance for healing. It is not enough food or protein for a person in my state to successfully heal. It is not about volume, it is about nutritional quality. I know you “pass” your state inspections, but hopefully your bar is higher than simply not getting red marks on a piece of paper.
How can I comment on the food? I hold five degrees including a Ph.D. and have taught both General Nutrition and a graduate level Clinical Nutrition course. Food to keep an elderly person alive and breathing is different than food that will make them thrive, support their declining neurological functions and so forth. Orthopedic patients in healing from surgery and possibly damage from accidents will need more protein and if on pain killers that effect bowel function, more natural fiber. How about feeding patients so they thrive instead of merely don’t die while in your establishment?
Certainly, coming to a facility where the words nursing and rehabilitation are in the name, we expect more than being basically kept alive on a cheap, high carbohydrate diet. Please look at the pictures. Do these meals look like ANY of your recent meals? Would you feed your wife, your mother, your father, your child, or yourself food that looked like this? Would you eat powdered eggs for breakfast every day? Would you serve for Sunday dinner two slices of wilted bread with an asymmetrically placed tablespoon of egg salad off to one side for dinner? Answer honestly.
I know in this economy you are never going to feed the patients filet mignon. But how about different items for breakfast instead of day after day of eggs, eggs and eggs and maybe a pancake with a single slice of bacon (or maybe just more powdered eggs) once a week? How about food that looks appealing. How about various green lettuces with vitamins in them instead of iceberg lettuce that is nutrition free?
How about different menus for orthopedic patients that don’t have swallowing or chewing problems and are tailored to their healing needs? Larger portions of meat or proteins (the chicken leg above is tiny, look at the fork for perspective). Have options for different needs and likes of patients and serve meals you would serve your families.
A selection that is not the same cheese and deli meat and cottage cheese repackaged. Your alternatives: Grilled Cheese, grilled deli meat and cheese, iceberg lettuce and deli meat, cottage cheese and canned fruit (or fresh fruit if you fight). Deli meat in on a different plate arranged differently is not a different choice.
I’ll even bet that if you offered a “meal plus” option and charged a few dollars more a day for it, all your short term patients would pay it and many of your longer term would as well.
Remedy: A set menu that can be ordered from for any meal, similar to that in use by Hudson Valley Hospital. The menu can be limited, but would have salads such as a fresh Cobb Salad, a grilled Chicken Salad, a few sandwiches on a hard roll or bread, hamburger, pancakes, or an omelet, and a few desserts.
Serve meals you would be proud to serve your family.
Response times
Putnam Ridge runs on schedule. And if your needs don’t fit in the schedule you are pretty well out of luck. One morning my 95 year old room-mate asked to be taken to the bathroom, as she had to get help to get in her wheelchair and on the toilet by herself, at 8 AM. The aide said she would be back. 30 minutes went by. It was time to deliver breakfast trays. She asked several times more and it was not until 9:30 AM an aide finally saw to her needs. I talked to the second aide, as it was a different one that finally took her and her response was it was OK because she was wearing a diaper. So she could just toilet in her diaper and wait until someone got around to her.
Another morning I awoke, going through the night without taking any pain medication for the first time all night long. I had two surgeries on my leg, one lasting around nine hours, plates, pins, PAIN! Again it was near breakfast time. After asking my aide twice, and calling the front desk, after over an hour, as I was in severe pain of an 8+ or more I called the administrator in tears crying and asking for my medicine. It came quickly after that.
Another time before I could get on the wheelchair without assistance, I sat on the toilet for a half hour, after I rang the bell and even after I used my voice to call loudly, my legs dangling and falling asleep before I could get help to get off.
Everyone deserves dignity, respect, and to have their needs met.
There were more….
There are small things, your manual says a cup of tea or coffee or a soda is available at anytime. Ask any aide and the answer will be, sure I’ll be back in a few minutes but most of the time you just never see the aide again.
I don’t think your staff is the problem, I think you don’t have enough staff. Some of your nurses are wonderful and do the job of two or more. They troubleshoot problems when they occur, but there are many staff that are very weak and just disappear rather than work as well. You may sit there and say we meet profitability margins and the state code. But this is not right. If this is meeting the code and the code drives the industry, the code needs to be changed. I can only imagine you do not know the impact.
Remedy: Needs come before schedules. Patients’ pain medicines, need to toilet, and other items come before “scheduled tasks”. Regular sensitivity training needs to be implemented. My feeling is that many of your CNAs do not know the appropriate behavior and responses to maintain the dignity of your patients. Supervisory staff needs to supervise more. Just because the towels are folded or the trays passed out, does not mean the job is done. Patients should be surveyed on a weekly basis to see if the staff is meeting what they perceive their needs to be.
State Inspection
I was also there during your state inspection. If everything met code, the code needs attention. NOW!
Hygiene
Patients requiring assistance were allowed a shower twice a week. Just sponging yourself with a tiny towel (and often washcloths were not available) in between is not enough. When is the last time you went two or more days without a shower or a bath?
Remedy: Offer additional showers to those who want them. A menopausal woman who has nightly sweats may want to shower more than an elderly patient who barely moves and finds that showering too often dries the skin. Different patients need different treatment.
Communication
When you are isolated away from work, away from friends, and unable to go to a store for yourself having a working phone and internet is key. The phone service and even my cell phone were sporadic. Calls from the outside were not allowed after I believe 7 PM. I’m not 95 (and neither were a number of your other short term patients). I don’t go to bed at 7 PM. I needed the internet. There was no entertainment appropriate to my age and mental status. “Crazy Bingo” or old movies in the Great Room with the elderly population were not my cup of tea.
I had devices with me that I could shop on and access the internet and do email but there was no Wi-Fi service to my room. There are two computers in the activity room on Birch Unit. One does not hook up to the internet, the other does, but the mouse has a short and you have to continually play with the mouse to keep it working.
The internet is extremely slow. Why did I need the internet? So I could obtain a wheelchair ramp to my house, get a stair lift for my house and a wheelchair ramp for my bathroom door and so forth. Putnam Ridge has no list of resources for items such as these, or personnel who will find them for you.
My only care-giver, my husband, has a full time job and the more I could do, the more I could take off his back. Communication with the outside world would allow patients to transition to home in an easier fashion, keep up with news of their friends and relatives, buy little things like hearing aide batteries, denture cleaners, skin cream, and even talcum powder, not provided by the facility and have it delivered to their door in the mail.
Transition
Finally time to go home! Yay! Or as the other orthopedic room-mate I had said to me, “Time to get out of this hellhole.” Unfortunately, your facility is getting a reputation and it is not the one you want.
First, I found to go home, I needed a few items not provided by Putnam Ridge, such as the ramp to get in the house but there were no available resources and the internet was pretty much difficult to use to try and find things on my own.
Secondly, I found everything was a fight. I love your PT department and think for PT they do a great job, except when it comes to transition you home. Both my OT and PT came to me, before they presented my list of needs to the doctor for approval or to workman’s comp and tried to make me request less. The session ended with me in tears. YOU are supposed to be on my side! Helping me to function safely at home! Did I really need two raised toilet seats? With a torn meniscus in my left knee and a compound fracture in my left leg, did I need a second small wheelchair that would fit through doors so I could get to my bed and toilet upstairs? AFTER everyone encouraged me to put a stair-lift in my home at a personal cost of 3K plus, and additional rental, tried to convince me to put a bed downstairs (no room) and live out of that bed, without access to a shower or bath for months.
Putnam Ridge PT, friend of the insurance agencies. In the end, after much fighting, I did get what I needed. But what if I was a timid 80 year old? I have a voice, what about those that can’t fight for themselves? Does this happen to them as well?
As I am leaving I met with Visiting Nurse Service. At the door, they promise me 20 hours of a home health aide a week, a PT and a nurse. I even have this written on their stationary. As of last Friday (after being home 3 days without any help-fortunately some friends pitched in last minute) I found out I my insurance will not pay for an aide. Why tell me up front I am getting one, imply one is coming, and then I get home and there is NO support?
If I knew ahead of time and what’s wrong with planning ahead? I could have made arrangements in advance. I found out at 4 PM on a Friday afternoon that I did not qualify for an aide and had no help at all. I was pretty screwed. Would you want this to happen to your mother? Your wife? You, if you were alone and disabled? The answer always seemed to be, why can’t your husband just stay home and do it? If my husband doesn’t show up at work he won’t keep his job. This is not a reasonable remedy. You do not help the patient by simply dumping the problem back in their laps.
Remedy: Do your assessments a week before expected discharge and let the patient know that they will have support or not. If the insurance won’t pay for it, at least they will have time to arrange for private pay, friends or relatives to help them with that transition. Don’t just dump them at home and say, “off our property, done!”. Give them support for transitional needs. I would suggest opening a comments page on your website where patients could submit reviews of nursing or home health aide services they liked, sources of ramps and equipment that they had a good experience with. To avoid controversy you could just share the positive comments and links to resources. There are ways to meet these needs without you doing all the work.
Final Thoughts
I have several more sections, but I better quit here. Last thoughts, don’t mix orthopedic with non-orthopedic. Every night I listened to two dementia patients yell for hours as they “sundowned”. It was hard to have a restful environment. People would make noise at 3 AM in the hall, someone would come in 4 AM for a temperature, and at 5 AM someone would come in, turn on the lights and ask loudly if anyone needed their diaper changed. I don’t wear a diaper. Haven’t the over two weeks I was there. Around 7 an aide would bang around delivering a tiny towel. At about 8 the games person would bang on the closed door, and come in and bray, “Do you wanna crossword?” I answered in the negative regarding doing a crossword for 2 and a half weeks. Hey, she got to make a checkmark on her sheet though. How about some Wi-Fi? Little things can make a big difference. Just a small level of thoughtfulness. I had a staff member when I was using a bedpan call me Miss Pissy, and I had to ask her to wipe me dry, and also to change the wet pad. This was before I could get out of bed by myself and she expected me to sit on the wet pad and sheets for an hour or two as it was breakfast time and that was OK. No, it is not OK to sit in your own piss. A little sensitivity please. Patients should be allowed dignity.
In closing, I’m going to be OK. I’m going to be at home and recover and get back to my life. So Putnam Ridge is hopefully behind me, and I am glad it was there when I needed it. However I am sad and upset for the people that are still there, the elderly, feeble of mind and those without a voice and the timid who can be bullied by a lazy aide (or perhaps overworked and under-resourced). Because the aide that called me Miss Pissy will do it again and insult and demean another without sensitivity training. 95 year old women will sit with cramps and made to sit in a diaper with feces because people are too busy handing out breakfast trays. Someone will wait in pain because staff is too busy to get to them.
That makes me mad. It makes me sad. It is not right. You wouldn’t do it to your mother! I hope it is because you did not know. It would be a very sad state of the world indeed if you did and merely were watching your profits.
Sincerely,
Judith Ann Challis, Ph.D