A day in the life.

Forty years ago, Loretta's [*] world was full of opportunity: trips to New York and Europe, interesting work, marriage, a family. Dressed in her strapless gowns and glittering jewels, she could have doubled for Elizabeth Taylor.

But chronic illness closed in and closed off the larger world, particularly after she lost her husband and ability to walk. She stayed home with live-in help until her children moved cross-country. After following, she discovered adequate home care was unavailable. She cried for a day, then found the skilled nursing home where she's lived for more than four years.

It has a good reputation, few deficiencies, and about 100 residents. Loretta, now in her 60s, has little in common with them. Most are old enough to be her parents, at least one-fourth are confused, and an equal number are restrained.

Loretta herself is restrained by physical limitations. She no longer stands and can barely use her arms to eat. Nevertheless, she influences her environment. Mentally unimpaired, with little to do, she's become expert on facility people and practices. She knows the staff, the schedules (for menus, activities, and personnel), and the shortages. She practices special strategies (like stockpiling supplies) and pays unfailing attention to social niceties, to ease staff burdens and build relationships.

What is life like in a nursing home? This is Loretta's world.

7:15 a.m. The loudspeaker crackles to life, announcing the day's date and upcoming news group. Loretta woke hours ago but doesn't plan to attend. "I went when they had news at 3, but times change, things change," she says philosophically. "I don't miss anything. I can listen to news."

Her roommate was up much of the night, says Loretta. Helen, 30 years older and frail physically and mentally, rarely speaks. Loretta, on the other hand, readily recites the activity calendar for the day, the week, the month. She's eager to get to Bible class at 10; religious services have been postponed for months.

Loretta is still waiting for her breakfast tray. "I'm last in the hall," she explains to her visitor.

7:31 a.m. A dietary aide enters without knocking. "Good morning, Terry," says Loretta. Terry nods as she places the tray on the bedside table, leaving it two feet from the bed. That might as well be miles for Loretta, whose arms can extend just a few inches. An aide in housekeeping scrubs knocks, looks in, and leaves.

"Today's breakfast is a fried egg," says Loretta, who knows without looking. She keeps monthly menus and activity calendars posted on her wall and in her wheelchair bag. "We just picked our monthly dinner. We get to pick one meal every month. We wanted lasagna for September, but a lot in the kitchen quit and they were short, so we got it the last week of October, when we had wanted bratwurst."

8:02 a.m. Edna, the CNA arrives. "Edna, I was thinking you're never this late," says Loretta.

"I saw your light, but I had lots of lights on," Edna replies, spreading a towel and a napkin on Loretta's chest. "There's no bath aide today ... I'm superwoman."

Loretta commiserates, then mentions, "I don't know if my head is high enough."

"I can raise it for you," says Edna. "Do you want juice?" She offers it with a straw, and Loretta extends her head to drink. Edna starts to leave, then turns. "I forgot to do your head," she says, raising it. Moments later, she returns. She spreads the egg and butter on the bread, tears it with her bare hand, and places the pieces on the napkin on Loretta's chest before leaving.

The egg isn't hot, but it's all right, says Loretta, raising it to her mouth. "I guess the towel wasn't high enough," she says, brushing at egg dripping down her neck. "She's the only one on the whole hall" says Loretta. "That's shorter than usual. They used to have four." She explains the staffing for the different wings and dining room since the facility opened separate Alzheimer's and rehab units.

She knows the facility well. She's had three rooms due to hospitalizations. "I couldn't take the hospital anymore," she says. She can't lift her head, so she couldn't even watch TV. "I came back here and said, 'Room, I love you. I missed you.'

"My son feels bad I'm in a nursing home. I say, 'Bad? No!' At home I was completely alone. Here, I can go out to eat and to activities; I visit other facilities.

8:20 a.m. An RN enters silently. Unlike most staff, she's wearing her badge. "Hi, Michelle, are you any better?" Loretta asks.

"I saw the doctor Monday, and he gave me something for this chest thing," Michelle says, administering eye drops.

"My nose is running, but they say it's not allergy season any more," says Loretta.

"No, just very dry," Michelle says as she leaves. That's their entire conversation.

"When I came, I had a big hole in my butt so deep you could see bones and muscles," Loretta says. Healing took years, requiring out-of-town trips to a hospital's wound clinic. After surgery last January, she had a gel bed until July, when another patient needed it. "I didn't like the new mattress, so I told Michelle and she got me this one," Loretta says.

8:30 a.m. Edna knocks, wakes Helen, and begins dressing her for the second breakfast seating. Helen's shoes are missing. Loretta tells Edna where to look. "When you're done, could you take my towel and put me on the bedpan?" she asks.

"I'll be back in a minute," Edna promises as she removes linens.

8:37 a.m. Edna returns to Helen. "I have to take her to the dining room, then I'll get your bedpan," she promises.

"My antibiotics and other medicine give me severe diarrhea [when] I'm on them," says Loretta. "It burns my skin on my stomach, bottom, and legs if I'm not changed quick enough. They all know it. She'll come back after going to the dining room." But she puts her light back on anyway.

8:46 a.m. An aide arrives with fresh water. "How are you, Alice?" asks Loretta.

"I'm good. How are you, Loretta?" responds the aide, the first to use her name. "I see you still have your nice holiday decorations."

"Thanks," Loretta beams, than asks for help finding her stick. Alice quickly finds it.

"It's my third hand. Thanks," says Loretta.

"You're welcome," says Alice. She replaces the water pitcher. "Bye, Loretta." It's the first complete social interaction.

A housekeeper silently enters and collects trash. "How're you, Selma?" asks Loretta.

"How are ya'?" Selma responds, removing Loretta's soiled bib.

"Thanks for taking that off," says Loretta.

"You're welcome," Selma replies. "If I have time, want me to help with those decorations?" Loretta reels off a list of decorations, noting her favorite.

"If you want, I'll help put that one up," Selma offers.

"Oh yes, thanks," Loretta answers as Selma leaves. Loretta's clock announces the time. It's set well ahead.

"I like to be early," she explains. Timing is a frequent problem. Mondays, Ellie used to read aloud at 2 p.m. but now it's 1:15 p.m. "That's a hard time because of second eating," Loretta explains. "If trays are late or people eat slow, we can't start."

Patrick, another resident, often wheels her to meals and events. Last night, he took her to Bingo at 6:45 p.m., but the second seating was late and tables weren't cleaned.

9:00 a.m. The light is still on. A nurse knocks as she enters and opens Loretta's closet without asking, explaining, "I need to look in here for a package of diapers... promise I'll bring it back." She leaves.

9:05 a.m. "Okay," says Edna, returning at last.

"I have a little mess already," Loretta says in a stage whisper.

"Who's that?" Edna asks, noticing the visitor. "A friend," answers Loretta.

Edna gets Loretta on the bedpan, then calls a nurse for wound care. After a quick clean-up, Edna dresses Loretta in a hospital gown, then a housedress. Her housedresses are nearly identical, but Loretta describes the one she wants. Edna seeks help for a transfer, leaving Loretta tilted precariously on the edge of the bed. "They didn't raise the head of the bed as far as they should," she says. "Now I'll get my pills and go to Bible class." She always carries her bib, stick, tissues, and straws--dozens of them. Without them, she can't drink any beverages she's given.

9:45 a.m. Edna and Tim, another aide, transfer Loretta to her wheelchair. She says thanks; he says she's welcome. Both leave. "I don't think I'll make Bible class now because it takes two to get me up," says Loretta. When they're short, it can't be helped."

9:50 a.m. Edna returns and lifts the pillow; it's dripping with feces. "It's shot. It's gone," she says. "It's ruined, and you wet through to the mattress. Now I'll have to get another. I've got to go wash out the linens."

"I don't have my face washed or my jewelry or pills yet," says Loretta anxiously.

"Well, I have to clean up all the mess and wash out the linens, then I'll be back," answers Edna. "You can wait till then."

The halls are quiet. Loretta sighs. "Well, I guess the rest are either lying down or in Bible class," she says. "Edna is wonderful. The trouble is they're short. They train' cm, they get certified and leave. Lots get hurt because they need two people to lift, but they try anyway. She's the only one on the hall--that's seven rooms times two, plus a few more by the nurses' station." Edna came in Sunday, Loretta recalls: "She said she was so tired, but she came in on her own time to be sure they got their baths. She wasn't paid for it. She's very nice."

Loretta accepts that the aides often don't bring the bedpan until after she needs it. "I'm never grouchy. Sometimes it feels like a razor blade. I was okay today. Sometimes I cry or get into laughing fits. They're better than crying."

10:03 a.m. Tim returns with Helen. "I'm going to pull the curtain," he says quietly.

Carla, the housekeeping manager, knocks and removes the mattress. Loretta requests the pad that keeps the mattress from sliding. "Nursing has it," says Carla. "I asked, and they said you have it," answers Loretta. Carla leaves silently, then returns with the pad and new mattress. "I'm still waiting to get ready," calls Loretta as Carla and Tim leave.

10:10 a.m. Helen gets into bed. "Now she'll keep me up all night," mutters Loretta.

"That light's on," calls Helen, referring to her own light.

"You left it on yourself," Loretta answers.

"I should go back to Alzheimer's," says Helen.

"It's getting later and later," Loretta frets. "I should at least get my pills and my face washed."

Edna returns cheerfully with an update on her schedule. Loretta mentions that Tim recently came by to change Helen and that she's since gone back to sleep.

"Loretta should take care of Loretta," snaps Edna, shifting suddenly from her good mood. "Which jewelry do you want? What's the hold-up?" She then notices Helen. "Why are her pants different?"

"Tim changed her," Loretta explains again.

"Did she wet the bed again?" Edna asks Loretta.

"It is," Helen answers.

Edna sighs. "It'll be a miracle if I can get through today."

"That won't occur," says Helen.

Returning, Edna bumps Loretta's foot for the third time. "Sorry."

"That's OK," says Loretta.

"One day you'll just kick me," says Edna. "Which pin, pink or silver?" She spends several minutes finding and placing jewelry Loretta has selected: earrings to match her necklace, two bracelets, a brooch, and smaller pins, placed just so. "You know where they go," Loretta approves.

"Want some perfume?" asks Edna, spraying two varieties. "I don't like perfume, but it smells better than you smelled this morning." She wheels Loretta to the nurses' station.

It's 10:30 a.m. Loretta reviews the large calendar. A red "today's date" arrow points to yesterday. Bible group is over.

10:40 a.m. A nurse unlocks the med cart, and passes Loretta's pills with a glass and straw.

"Is that water? Why not juice?" Loretta asks.

"With diarrhea like you had, I can't give juice," the nurse answers.

"What about milk?"

"If you want it." She gives more pills, more water, then more pills. "Oh, did you want milk?"

"Never mind," says Loretta. "But if it wouldn't be a problem, it would be easier for me to get my Darvocet for pain now, and my Lomotil."

"The Lomotil's there now," replies the nurse. "But do you need the Darvocet now?"

"Well, I could wait," says Loretta.

"Yes, why don't we wait," says the nurse.

10:45 a.m. Loretta is wheeled to her table, which overlooks the kitchen and the corridor through the dining room. Loretta greets passing residents and employees.

10:53 a.m. Gwendolyn brings Loretta's customary two cups of coffee with appropriate creamers and sweeteners. Loretta beams as the two talk briefly.

11:03 a.m. Donna passes and greets Loretta by name. "Are you on with me tonight?" asks Loretta. Donna shakes her head, "Sorry. I'm on West, working 12 hours."

"Aw," sighs Loretta as Donna leaves. "I lose all the good ones. I knew all the people who left. I'll have to learn all the new ones. I don't talk much with residents; they either don't hear well, or they're much older or they're out of it. I talk mostly with the help, or with my roommate, 'til she gets in the Twilight Zone.

Loretta remains close to Wilma, a former roommate. They ate together, shared activities, outings, and jokes. Hospitalization cost Loretta her room and Wilma, since nobody else would move.

In the next half hour, carts roll by, Gwendolyn brings buttermilk, and the med nurse brings pills.

11:30 a.m. Lunch is served on a segmented tray: The room fills with residents and the hum of conversation, mostly from staff and visitors. Loretta says her regular table mate doesn't speak or hear well, and rarely eats or drinks. "She gets confused," confides Loretta. "She asks if we see her father, but I don't think he's living."

12:10 p.m. Thomas, a CNA trainee, walks up behind Loretta, greets her by name, and asks how she is. Unlike most employees, he's wearing a name badge, albeit handwritten. He's the first to initiate a purely social interaction.

12:15 p.m. "Hi, Charlotte. How are you?" Loretta asks a passerby dressed in a tailored suit.

"I don't know, how am I?" Charlotte says.

"You're doing fine," Loretta reassures.

"Am I?" she asks dubiously.

12:30 p.m. The dining room is deserted when Loretta is wheeled to her room. She greets residents and staff members as she's rolled through the halls; some respond, most look blank.

At the nurses' station, where the date arrow is still on yesterday, she requests tape for her decorations. The dispenser is empty. "Here's mine," offers the respiratory therapist. "And the price is right."

"That's my philosophy," beams Loretta. "Ask and ye shall receive." He promises to get more.

At her room, Loretta asks Edna to close the bathroom door; leaving it open annoys the adjoining residents who share it. Helen, asleep, grumbles when Edna suggests lunch. "I need the hospital," she mutters. "If I'm in the hospital, I don't have to get up."

The therapist brings the promised tape to a grateful Loretta and admires her decorations.

For the next 90 minutes, Loretta watches her remote-controlled television. Aides pop in and visitors pass unseen.

2:10 p.m. When she arrives at music, Angela, the volunteer pianist, calls "Hi, Loretta!" Usually, Patrick brings her early enough to sit among the eight residents around the piano. Since tables and chairs block half the room, other residents in wheelchairs queue along the wall. Latecomers sit outside until someone leaves.

The first songs-"Daisy," "Dixie," and "Danny Boy,"--get little response, but "The Old Gray Mare" gets a big laugh. So does "The Gang's All Here." By 2:15 p.m., residents start trickling out, but most stay to sing "Take Me Out to the Ball Game."

2:30 p.m. A few songs later, music ends. "Great day! Good job! I loved it!" cries Angela. "Wait, you can't take Loretta until I say goodbye." The brief, theatrical hug is Loretta's first nonessential physical contact that day, the only one not part of patient care.

As Patrick wheels her out, Loretta explains, "She talks to me because I usually sit up front and know the songs."

They check the posted dinner alternates. In the dining room, Patrick pours two coffees with cream and sweetener for Loretta. On request, he gets a banana, and Loretta gets cookies. "I've got connections in the kitchen," Loretta twinkles as Patrick expertly backs her into her room, bypassing her old walker. She asks him to turn on her fan, the gift of a former CNA.

Loretta's room is crammed with furniture, including her old dresser. One drawer holds personal linens--another, decorations for each major holiday. "I visualize just where I want them, then ask someone to put them up for me," she explains.

Maintenance staff tacked stuffed animals on the walls and installed shelves loaded with dolls, religious sculptures, and knickknacks. Figurines dangle from doors.

3:30 p.m. Sue, a social worker, asks the identity of Loretta's guest.

Loretta raises her own concern. "I wish we could get rides to go shopping. The clerks would help us shop."

"We can't; that would be a liability problem. We fought it, but the decision came from above," Sue says of the discontinued shopping trips. "We're not taking a right away, we just have to charge $25 per trip."

3:45 p.m. Cynthia, an aide, helps herself to Helen's scented lotion, commenting, "She said it's okay."

"Guess who!" teases another aide who enters, playfully covering Loretta's eyes. It's the first non-essential contact by an employee. After three guesses, Loretta identifies Juanita.

"It's so hard to get to know them," she sighs as they remake Helen's bed. "There's new ones all the time."

"Designing Women" ends, followed by "Golden Girls."

4:25 p.m. The med nurse brings pills and juice.

4:45 p.m. Helen returns with Jill, a nurse, and asks her to close the dividing curtain. "It's too bright in here," she complains.

"That's because you've got your light on," says Loretta. "When the curtain's pulled, I can't see anything."

"I'll pull it halfway," soothes Jill.

Loretta lost peripheral vision decades ago. She loved reading, but can't read small print or hold books or newspapers, so she revisits plots and characters from books she read years ago. She passes time by mentally reviewing family events, illnesses, and youthful travels. She also consumes cooking shows voraciously.

5:07 p.m. Jackie, an LPN, brings dinner. Loretta has numerous directions. She wants a sliced banana with brown sugar. She wants her burger covered with ketchup and mayonnaise and topped with salted onions. Loretta is prepared. Ripe bananas are on her dresser. Her refrigerator, a family gift, is covered with cups of condiment packets, and the top drawer is filled with disposable napkins, plates, and bags of utensils, all provided by Sue.

Jackie supplied the onions in Loretta's refrigerator. "When I said I wouldn't mind having some, she chopped a sweet one from home," says Loretta. Her family brings cold cuts and bread to replace food that is unappealing or hard to chew.

6:15 p.m. Cynthia returns for more lotion, complaining, "My foot's so itchy." When Loretta reminds her that Helen hasn't eaten, Cynthia promises to get food.

6:30 p.m. Juanita returns to feed Helen. Before leaving, she helps Loretta blow her nose and removes her food-stained bib but leaves the cluttered tray.

6:53 p.m. Cynthia intercepts Helen en route to the bathroom. Helen tearfully begs Cynthia not to put wet clothes on the bed. Loretta reassures her repeatedly, without success.

"They won't put you in a wet bed!" Loretta finally shouts. She shakes her head. "She says she doesn't hear well, so I yell ... she thinks they're doing something diabolical."

7:20 p.m. Marcie, an aide, asks if Loretta needs anything, then removes the tray as requested. She and Loretta both encourage a reluctant Helen to bathe.

7:25 p.m. cynthia puts an arm around Loretta, asking, "Can I have some of your candy?" "Of course," says Loretta.

7:32 p.m. Cynthia returns for more lotion.

7:58 p.m. Helen returns and falls asleep. Loretta watches skating.

8:38 p.m. "Knock, knock! The big bad wolf is here with meds!" Loretta reviews each pill with Jill. Once they gave her the wrong one, but she caught the error, she explains proudly.

9:15 p.m. The treatment nurse replaces her dressing. Juanita, who's preparing Loretta for bed, spills water on her chest. "Never mind, just dry it with a tissue and I'll be fine," says Loretta. "I could spill breakfast on it tomorrow."

She thinks for a moment. "I don't like that breakfast, so I'll just have toast. But I'm already looking forward to tomorrow. In the morning, there's exercise, and in the afternoon, a volunteer plays music ..."

Lights dim as the facility quiets. Nobody comes to say good night. Loretta clicks her remote control and waits for sleep.

Wendy L. Bonifazi of Fort Collins, Colorado, is a contributing writer to Contemporary Long Term Care.

(*.) Editor's note 

"Loretta" and all other names used here are pseudonyms. In the interest of presenting a resident's typical day, rather than focusing on the shortcomings of any one provider, writer Wendy Bonifazi limited her search for a willing resident to highly regarded facilities. But even good facilities have bad days; and everyone wants to look their best. To assure authentic staff behaviors, Wendy observed Loretta's day without identifying herself as a reporter to anyone at the facility.

Originally, we planned to inform the administrator of her visit after the fact, asking him then whether or not he wished to identify the facility in print. We later decided, however, that anonymity was in participants' best interests, and readers' too, by allowing us to tell the full story.

Since Loretta and Wendy discussed all plans privately, one incident stunned them As Wendy reports, "Before I left, Loretta's roommate, Helen, asked abruptly, 'Do you tell the truth?' I assured her I did. Her request was urgent: 'My mother told me if it's bad news, don't read it. If it's good news, read it. But will you tell the truth for us? Will you tell the truth for once?'

"Though Loretta doubted Helen could know I'm a journalist, she' seemed as shaken as me. I kept my word, and told the truth."