Adrianne Fugett 00:03
Welcome to reimagining healthcare and new dialogue with risk and patient safety leaders presented by men place. We're excited to bring you conversations with top risk and patient safety thought leaders from organizations across the country. Please subscribe to get the latest news and content. If you find value in this episode, which I know you will. Please share it with your colleagues to create meaningful dialogues in your community. And if you're interested in participating as a guest, please send us an email at speakers at med place.com. So I am really excited about our guests today that I'm bringing to you all this is Barbara Pridemore. She is an LPN who works here at Med place with me. She has going on her second year will be coming up in January. Mine will be coming up in October, I was really happy to bring barb on board. She's got a fascinating background that we're going to get into that I think all of you will find really helpful with the information Barb is going to bring forth. A little bit of background on Barb Barbara Pridemore is an LPN. She has over 12 years experience as a state surveyor in long term care. She surveyed sniffs rehabs, hospitals, dialysis centers and facility specializing in mental health care. She has over 25 years experience in geriatrics. And now y'all are understanding why this is going to be a great podcast, Barb was a staff development coordinator for a large sniff in Denver. She's also a certified assisted living administrator, I could have used your help a while ago, anyway, about six months prior to the COVID pandemic. And 2020 Barb returned to the sniff facility as a wound care nurse and saw firsthand how unfair the tragic situation was for the staff and the elderly that they serve. So this is going to be a really interesting topic, Barb, as you know, I've got tons of notes and questions. And my goal was to hopefully be able to get all of that extracted from you. If not, we'll have to do another podcast. But why don't you tell us all a little bit about how, you know, how did you get into surveying, I mean, that's a huge job. It's not easy to do to go into nursing facilities and tell them what they're doing wrong. So tell the audience a little bit about how you got into surveying? And what were some of the takeaways that still sit with you today on that experience? Well, thank you, Adrian, I appreciate you chatting with me today. The way I got into surveying, I was actually working as an administrator and assisted living facility in Colorado. And I was approached by a nurse that I used to work with who was working as a surveyor and said, hey, you know, come talk to us, it's a state, we really need somebody. And they initially wanted me to be an assisted living surveyor. And so once I went in and chatted with them, I thought, you know, I want to do something different. I want to work, you know, directly in long term care. So that's what I did. I worked for the state of Colorado for nine years. And, you know, in hindsight, I look at it a lot differently, I always felt that it really was an honor, I felt like a bit of a steward, you know, for people trying to ensure that they really got the help and the assistance that they needed. In hindsight, though, I will say this, I think I look at things a lot differently now not only from years of experience, but also working a year in a sniff I learned a lot to say that was an epiphany would be an understatement. I got to look at it from the other side. And part of that was during a really difficult time while we were dealing with COVID. So I have some different perspective. But I'm really glad that I did it. And I think it gave me a lot more empathy for facilities and what they're going through as well. Yeah. And you know, for people that don't know, it's really quite an honor an attribute of your skill set as an LPN that you've shared with me that typically, surveyors are our ns. And so it really says a lot about your experience and your ability to be a surveyor. Can you tell us a little bit about about that, and how rare it is for an LPN to be asked to be a surveyor? Sure, you know, Federal regulations require that there's an RN on every survey, and just as you would expect, in your regular scope of practice, LPN does take direction from an RN, so it's a necessity that operates that way. So when I first applied, they actually didn't have a where were they going to put me they couldn't put me as an RN surveyor. So I was classified as a general surveyor, but they did have to make a special exception to hire an LPN. And I'm always be grateful for that. And I really learned a lot and I got to work with some fantastic people over the years and, you know, just being invited into people's homes when you went to do the survey. I mean, that's personal and intimate and you really got to know people. Yeah, yeah. Wow. There is so so much ground to cover with you. So I'm going to try and you know, navigate
Adrianne Fugett 05:00
Eat as clearly as I can. Obviously, this area is not my expertise. So I know you, I know you will get us all on the right path. I've got a couple of articles that I've looked at that I think are interesting information that I think can help guide the conversation to help our listeners understand about the sniff world a little bit better. And we will make sure to post these for the podcast, but there was one article I was interested in getting your take on. It's a CBS News article, and I'm gonna read my notes. So pardon me for reading this. But they're talking about the staffing shortages, right, that we you and I know exist, especially, you know, exist in the snippet facilities. And a couple of the stats from this article said that 98% of nursing home operators are having trouble hiring that scares me. So there's that 59% say that they are losing money. And 73% of the sniff facility said that staffing issues could close their doors. So you know, and then we add COVID. So can you kind of talk to, you know, first of all, let's talk about 98% of these nursing homes are having trouble hiring. What is that about? Barb?
Well, let me say this, I haven't surveyed for several years, but I still have several colleagues that are surveyors that I stay in touch with.
Babara Pridemore 06:28
And it's a difficult thing to start with. It's a difficult job, taking care of people taking care of people in a nursing home can be especially challenging, challenging, you know, they don't feel well, they're often very ill, they're most often they're against their will. It's just a it's a bad situation to begin with. So then you've got people that really, in my opinion, have to have a calling that want to do that work. So those people are few and far between. When you get those wonderful people in here, how long can you expect them to work? short handed lots of overtime, not always feeling appreciated? And that's not any fault of the facilities. I mean, I've seen them go above and beyond to try and appreciate them to do things for them. But with limited funding, that's a problem. And how can you look at music, let's use the example of a CNA. We all know that the nursing assistants do the toughest, hardest physical labor, and they're doing that and they're working themselves to the bone. And then they come to you and say, You know what McDonald's is offering $18 an hour down the road, I can't stay here for $15 an hour, would you do what they do for $15 an hour, you know what the pot is what it is, that's what you have to deal with. So you have a lot of turnover, you have people that go down the road for 50 cents an hour, 50 cents an hour can make a big difference. Being so short handed, there's been plenty of opportunity for overtime. But then you've run into employee burnout. You know, people want to make that extra money getting time and a half or double time, that's great. But then to what end, you know, it affects them, it affects their ability to give good care, and then they get burnout in the league. And then you have the group of people that come in that just think it's a jlb. And they don't really have a commitment. But why don't they have that commitment? You know, do we really honor CNAs and nurses and health care workers and long term care in general, any of them? You know, is it really a an admirable thing held up to wow, you can be terrific and make a difference at the end of someone's life or you know, the last few months or whatever you have their life? We don't honor that we don't make it sound like a great deal. And then when they get there and do it. Sometimes it's not. So it's difficult. It's a real challenge. And I came across some information that right now, long term care is short about 240,000 health care workers. I mean, there's been a 16% decrease in employees since COVID. Wow. I mean, you know, we have to fill that gap. We have to do that. Well, and you know, you bring up several excellent points. And you and I have talked about this before, but I think what really needs to be a focus, just in general, like you said is how we view long term care providers and how we view the elderly, the vulnerable, the most vulnerable population in this country, right, because if we, you know, we've got all this accolades and respect for all the University Hospital nursing and all that kind of stuff. But as you said, we don't have that same kind of respect, whether it's intentional or not, to the whole long term care situation, and then we also don't have a lot of funding. And so when we're talking about these, you know, 98% of nursing home directors saying they're having trouble hiring
Adrianne Fugett 09:55
is a lot of that just the lack of finances. that is available in the world of nursing home. And if we become more aware of that, as a society, could that kind of help push it to the front of our consciousness as a society so that we start to see it not only viewed differently, but we actually get more funding for the most vulnerable population? I guess I'm asking you, you know, what's a potential solution? I mean, it sounds multifactorial, but what do you think?
I think we have to get our priorities in order. We say quite often that people in nursing homes are the most vulnerable and the most needy. And if that's true, why aren't we doing more as a society to honor and protect them, you know, to complain about it to lodge complaints to go on TV to, you know, participate in interviews with, you know, sensational stories of horrific findings, that doesn't really do anything but scare people? I mean, how do we how do we come together and focus on what's important? And isn't it important that we do value those people and if that's true as a society, we have to stand up and say, These people are important. They deserve to have appropriate care. There's been a big push this year from the White House. They're trying to put together a well they have put together a some guidance that they want to put out where they require mandatory staffing for nursing homes. And I will tell you back in the day, when I was a very new surveyor, I thought, man, if we had mandatory staffing, this will be so easy. You walk in here's your Census, you better have X number of RNs, LPNs and CNAs. If not, you get the deficiency. It's never been like that. The way it's based is you only Stites site staffing, if they're not getting the care that they need. And that can be tricky to find that. So when you come in and across the board say, Well, we're going to demand that you have mandatory staffing ratios, that puts facilities in a hard spot, every facility is different. Every room is different, every patient is different, what your mom might need might be different from what my mom might need. So all of those things play into, you know, their level of acuity, how much care do they need? Do you have to provide 4.1 hour of care to somebody that doesn't need it, when you got somebody over here, that's only getting, you know, 3.4 hours, and they could use that extra. So they need to have some latitude. And I know that right now, CMS is currently doing a feasibility study, to look at this, you know, it's a governmental thing. So it's a process, but supposedly, they're going to have some results from that within the year. But part of what they're doing and I encourage people to go to medicare.gov and try to get some information. They're asking the public for their input, you know, public go give your input, let them know, what do you think of what you see in nursing homes, the shortages? I mean, I don't need to list the bad things. But what do we if we're not okay with it, rather than just complain? What are we going to do to make it better, and it really has to do with prioritizing the importance of the people that live in nursing homes, as well as the importance of people that work there. I mean, I've seen incredibly dedicated people that have worked in nursing homes for over 20 years, you don't see that in a lot of places. And that is love and commitment right there. And we need to honor that, you know, we want them to treat our loved ones as close to as what we would, but yet we think nothing of you know, not being concerned about them making a living wage. So you know, it's it's a it's a tough scenario is a great question. And I wish I had the answers. But maybe this is the beginning, you know, to try and get involved, give your input. Stay focused, stay with it.
Adrianne Fugett 13:26
Yeah. And get and like, what you said I really liked is getting our priorities straight. Because if we really do care, then we do need to be a voice and speak up because we could end up needing that kind of care long term care. And so we really do need to make it a priority. I really do. I like your answer. One of the things I want to cover on because like I said, I have so many questions for you. I think you had mentioned that, about six months prior to COVID. You went back to this new facility to work as a wound care nurse. And so I'm sure that you saw some really tragic things I do want to share briefly that when my mom went into assisted living, it was in March, right when all of that blew up, and I was one of those family members that was like talking to my mom through the window who was already losing some of her mental faculties and that made it a lot worse. And I remember at one point when we were able to have conversations with masks, and you know, I went to hug her goodbye and the staff physically and aggressively separated us and as you know, being a nurse you and I that didn't go over very well and it didn't happen again. But I feel really bad for people that are not nurses that can't couldn't have advocated the way I did and I did it in a respectful way. But you know, I'm sure we're probably in a better place now in snip facilities and kind of understanding that human contact is really important with the elderly, but can you talk Talk a little bit about what your concerns are not only with just COVID, but pandemics in general and isolating this vulnerable population, our parents write even more can can you talk about that so that people really understand the importance of not doing that. And what that does to the elder.
I mean, I'll give a good example, I remember this was when, you know, it was really COVID was really bad. And we were isolating people, and all new admissions had to be isolated. And so anybody that I want to see is a wound care nurse, I'm gonna have to put on all my biohazard garb. So I go in, and you can barely see my eyes, sometimes to somebody that I'm meeting for the first time. Can you imagine what a frightening experience that is there somewhere they don't want to be here comes somebody all garbed up and you feel like what is wrong with me. And it just added to the confusion and the disconnection and yet these are people that because of all those things, really required extra attention, you know, from the staff, and extra time to be comforted in staff wanting to do that. But when was the time, once COVID rolled in, there were more and more requirements, and you had to, you know, contact every family member every day, and let them know how their family was doing. And of course, you know, you want to do that and provide comfort to them. But then they're struggling because like you, they're looking at their family, you know, through a window. You know, it just, it was nothing that we were really prepared for and I, I look back on it now. And I, it really brings tears to my eyes, it was very, very tough. It was a really tough situation. So hopefully, we've learned from that in being better prepared, having appropriate supplies. And that's another thing, just the cost of supplies, even though it wasn't readily available at all times, that was a huge cost to facilities, all of a sudden, they have to have tons of PPE that they didn't have before. And then you've got to have somebody at the front desk checking temperatures. And you know, it just it just kept growing and growing, do more, do more, but we're not going to give you more. And so it became very difficult. And I and I really appreciate Believe me, I have many, many conversations with family members. And you know how much they would appreciate us calling, but they want to stay on the phone and talk to you about their mom, and you're looking at your list going God I got 20 More families I got a call. Yeah, I mean, it's it was rough. It was rough for everybody. And I think people really get tried to come together, it was a lovely facility that I worked at. But it definitely, like I said before, was a bit of an epiphany, after doing it for a year at that was enough. But I'm glad that I did. I wanted to go back and you know, refresh my clinical skills and really have a better understanding. And I think I would be a much different surveyor today than I may be used to be I know, I would go in a building thinking, Okay, I've got to find out what's going wrong. You know, and at some point in my career, probably more than halfway through, I realized is it really better to go in thinking everything's great, everybody's got a great a right now until something happens to make it different. So that didn't help. But you can imagine, everybody knew we were coming, you know, sometime once a year, there abouts. And yet, nobody was really ever happy to see us come always happy to see us leave, you know, and you couldn't take that person on I get it. You know, but I think that the whole process could be a bit more focused on recognizing the things that they do, right? Instead of just hey, let me give you a list of what you do wrong. Because believe me when I tell you, there are plenty of places out there really doing a great job of going above and beyond. And if you do that you might get very few deficiencies or even a deficiency free survey, which is unusual kind of an urban legend. But you don't get the kudos and the admiration, how about a man got a citation for doing a great job. I mean, I just I think it's set up to be somewhat adversarial. And I don't think it was ever anybody's intent. But that's what it's become. And I think it needs to be adjusted, you know, we need to work together, it needs to be a team and community effort.
Adrianne Fugett 18:53
Well, and you bring up a really good point about, you know, ultimately we're caring for the physical care of these vulnerable patients. But there's also that psychological care, right? And if we have so many restrictions on them, which I'm not saying that, you know, during COVID, some of that obviously was unnecessary, but we It can't just simply be the physical safety, because I think you and I had talked about and I know I've talked with several nurses, the fragile mental state that many of these residents find themselves in whether they've got all of their cognitive abilities intact or not. They're still in a very fragile state. And so when we isolate them even further at the expense of just looking at their physical care, are we not potentially creating a whole new set of problems for this vulnerable population?
Certainly, but you know, what did we know you know, you don't know what you don't know. And we didn't know what was going on. And every day it changed, you know, we have meetings every day. Okay, here's the guidance from CMS today it literally was changing sometimes on a daily basis. So if you think that's tough for the staff to wrap their mind around, how do you think the family feels? And then how do you think residents feel? And God forbid if on top of any physical ailments, they have any bit of, you know, cognitive impairment, now, it's even worse. They don't understand. What's this iPad? What's what Skype, you know, I'm trying to Skype with my family. They don't get it in there. I mean, it was it was tough. It was heartbreaking. And, in hindsight, I know, everybody would have probably done a lot of things differently. But as I said, you didn't know what you didn't know. But we do know now. So what do we do from this point forward? Or are we ready to respond in a different way?
Adrianne Fugett 20:41
Yeah. Yeah. I mean, it's really clear to me that sniff care and care of our elderly is just a highly ignored area of medicine. And it speaks a lot about like you said, where we are as a society and really making the effort, whatever that means for whoever's listening to this podcast, but But what are you going to do to make a difference in geriatric health care? And, I mean, wow, I'm going back to my notes, because I have so so many questions. So the one thing that you before I move on to a whole different topic, but some of the required staffing ratios, I think you and I just with any nurse, even in a hospital, we've talked about, of course, those are great things to have. But if you don't have the finances to go with it, how do you meet the staffing ratios? You can't and it could potentially shut the doors, right?
It's exactly what's going to happen. I mean, you can't do it, you can't make the money come out of thin air. It's not like Field of Dreams, build it in, they'll come they'll come if you got the money. You know, I mean, it's just a really tough situation. And that brings me to another point many times over the years, I've had people say, My gosh, I hear these terrible stories of things happen in nursing homes, Why don't y'all just go in there and close them down. I mean, that's an easy comment to make. But people don't realize the depth and the breadth of that and what is involved. And unfortunately, I was involved in a couple of those closures over my years as a surveyor, and it's a terrible thing, the decision is made, and the facility has 30 days, to rehome, all of these people. Now think about it, when you go to a nursing home or your family helps you select one, you go there usually for a reason. Maybe it's in the neighborhood you grew up with, and you're familiar, and you've got friends there, maybe it's close to where your family lives. And you know, you're thinking, oh, gosh, won't be close to Bobby, Sue, and Jenny so they can come and see me. And then all of a sudden somebody comes in and says, Hey, this facility is not up to snuff. So we're closing it down in 30 days, we'll help you and believe me, it's all hands on deck from the state, you know, to do that, but you got to put them where you can put up. And it may not be that there's any place available in their desired area. I mean, I heard about it for years after we closed down one facility in Denver. I mean, I would see patients literally years later and other facilities, and they would say, Oh, you're the one that closed down my building. I mean, it's amazing. And it's sad. So there's got to be a better way, what we really need to do is find out how to have better nursing homes, not less bad nursing homes.
Adrianne Fugett 23:22
Yeah. You know, it's interesting, because in one of these other articles that I'll make sure we post in this podcast, it's a nursing home out of Florida. And they talk about exactly what you just talked about, there was a resident there that had lived in there for 13 years and luck called it her home, loved it. She was 95 when this facility closed after 13 years, and her whole family is, you know, packing her up and trying to figure out, you know, where is the best place for her to get the sense of community and, and it's just a heartbreaking scenario that you're describing. Yeah, wow, this is really I knew this would be a great podcast. I mean, a sobering one. But it's really, really clear to me that we really do need to pay a lot more attention to geriatric health care and long term health care, because we're just not there yet. We're kind of almost, and not to sound cliche, but we're really just pushing it all aside, right. We're pushing all of these people aside, so. Wow. So one of the things I do think that you could offer a lot of help and insight for people and I've got a couple of notes here and hopefully I'll try and make some sense but for families that are faced with potentially having to place their parents or an elderly in their care, can you guide people what they should look for, you know, in a sniff facility and also an This is a lot of questions, you know, that we may have to revisit. But for, you know, for someone that's not a nurse, how can someone know that their loved one needs that kind of care? And can they figure out a way where if they want to do some of it at home? How would they evaluate that just kind of walk us through what you would tell someone with no medical experience that that knows that their loved one is not 100% independent, but they're not quite sure they need to look for a snip? Can you walk people through how they can manage that?
Or? Well, you know, you've got to kind of subsets in my mind looking at it in a generalized way. One is the you know, mom is declining, can she be home alone a lot of discussion. The other is somebody that goes in the hospital, and then they're not able to go home, because they're two weeks. So that's more of a panic decision, that discharge planner walks in and says, Well, we don't think your mom can go home safely. And all of a sudden, something that you maybe have not given any thought to is a reality. And so you're relying on the help from the discharge planners from the hospitals, that's where they are. But if it's the other case, and you've just got, you know, your parent is declining, or your loved one, you've got to rely on the help of your medical professionals, you know, the physician is a starting point to steer you to the right place. Whether you talk to a social worker, or a well trained nurse, interview, some home health agencies, what can be accomplished at home, people are doing more at home. And it's honestly gotten to the point and I never thought I'd say this, but it's gotten to the point, if they don't need significant 24 hour a day here, it can still be it can be accomplished at home, sometimes for less money. Now, should that always be the motivating factor? Just the money? No, but it's something to take into consideration. So it is tough. You know, there's lots of places that you can look at, there's companies that help you do that there's a state planners, you know, there's a lot to do. And I would also encourage people to go on to medicare.gov, to the website to look at, they have a component on there called Nursing Home Compare. And you can go in and you can actually compare nursing homes, and you can look at their most recent and even their history of their surveys, how did they do? Where did they get deficiencies, what area where they end. The other thing I would say, again, if you've got the luxury of time, is to go on a tour of the facility and maybe go on an unannounced show up and say I'd like a tour, don't tell them you're coming. So they can pretty everything up. If that's the case, just show up, you know, regular business hours, I wouldn't show up at 1am and say, hey, I want a tour. But you know, just show up three o'clock in the afternoon, I'd like a tour, believe me, they're gonna want to tour you because they've got beds to fill. Yeah, do that if you have the opportunity, and ask them if you can chat with a couple residents, you know, go and just chat to people that, you know, you can maybe say how do you like it here, you know, people treat you well, if you see any other family members, you know, take the opportunity to talk to them and see how they feel. I mean, it's tough work. And you know, you don't always have time, but there are tools out there available, and you just have to start you have to reach out, you've got to take some responsibility for that. Or you just sit there and let the situation happen to you and other people make decisions that neither you or your loved one may be happy with. The other thing is when your loved ones are still able to have these conversations, talk to them, what are they want? Would they be willing to consider an assisted living, maybe they would say, Hey, if you can put me in a place and I could start out assisted living and then if I got sick, I could still stay because they've got an area, you know, where they provide skilled care, and I wouldn't have to leave. Or you know, maybe I want to go to this place. If you ever had to put me anyplace put me here and for all my friends are have the conversation is not necessarily easy, but allow people to make the decisions that they can make while they can. Because when they can't, and you've got to make those decisions for them. It's tough, and you may not be making the decision that they would have wanted. Had you had a conversation with them.
Adrianne Fugett 28:50
Yeah, that's some excellent, excellent advice. And before we close up and do any housekeeping, Barb, is there anything that we didn't cover that you want to share with our listeners today?
I guess just to take a deep breath. And you know, I know it's really hard and everything that we've all been to in the last two years to try and be more appreciative and less judgmental. You know, we see a lot of sensation on some of the stories that we talked about today that I didn't really want to go into detail because I did think that they were sensationalistic, we don't need more of that. There's plenty of that you can find those all the time. But that's not really the majority of the facilities. The one thing that the majority of the facilities have in common is a decreased funding and a lack of staff. So how do we support that? Do we come in there as surveyors just you know, well, let's see what we can find wrong inside them, cite them cite them. So now they have to stop taking care of people and do this plan of correction get that together make all these changes in curb, inevitably additional costs. Depending on the level the scope and severity of the deficiency. It could incur large civil money penalties, so there's a lot of working parts that as you are Dealing with those working parts guess what you're getting further away from, from the patient care?
Adrianne Fugett 30:04
Yeah. And I think, no, go ahead.
I'm sorry. No, I was just gonna say that that's really my biggest takeaway to really, you know, let's look at it from a different perspective. And I don't mean to sound pollyannish. And anybody that knows me might be surprised that I might seem a bit more mellowed about it than I used to be. But I'll tell you what, I lived it. I worked it. I know.
Adrianne Fugett 30:26
Yeah. Well, and I think one of the most compelling arguments you make in this podcast is, as a collective, we really have to become invested in wanting to make a difference in geriatric healthcare in general, but in particular, the sniff facilities and so yeah, I mean, thank you so much for your time, Barb, we could we could go on and on about this topic. And I'm sure in the future, we will do another podcast, I can't thank you, again, for agreeing to do this interview. And if people want to reach out to you, can they find you on LinkedIn? Sure.
I really appreciate you giving me the opportunity. I'm not trying to say that I'm the know all and be all by any means. But I do know a lot of people I do stay in contact. I try to stay on top of it. It is something that's near and dear to my heart. And the majority of my career has been spent in geriatrics and, you know, it's always been a blessing to me, and I hope that in some way I can do the same for them.
Adrianne Fugett 31:23
Yeah, yeah, you've definitely opened my eyes what a moving podcast and a great time I had. For those of you listening thank you for listening to reimagining healthcare, a new dialogue, risk and patient safety leaders podcast, subscribe and share if you found this podcast valuable. And if you'd like to participate again, as a guest, just email us at speakers at med place.com. And again, make sure to follow barb on LinkedIn. Thanks