Lessons learned from my Uncle Lou.

A decade or two ago, I remember reading about state crackdowns and seeing television magazine exposes on nursing homes for engaging in patient abuse and neglect. The homes mentioned were cited for sanitary violations, as well as for applying bed straps and other restraints, apparently more for the convenience of their paltry-size staffs than for patient protection. Just before admitting a beloved uncle to a local care center, though, I thought that things had improved for the better.

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My 97-year-old Uncle Lou had weakened and fallen at home. After a brief hospital stay, he was released to the only nursing home that had room and would accept his insurance, as he was in need of physical therapy to help strengthen his atrophied limbs before returning home.

Here was a man who had emigrated from Italy early last century, worked hard, owned his own barbershop, was well known and loved in the community, and finally retired after having traveled the world with my aunt. He is the last surviving member of a large Italian family. After my father died, Uncle Lou told me to consider him as my "make-believe" father.

At the nursing home I visited him nightly, gave him his favorite protein drink, and tucked him in. He was now mostly bedridden when not sitting up in a wheelchair. He had been in the facility only 20 days, but he was miserable. Every night he shook his head and pleaded with me to "get me out of here!" He complained that he buzzed continuously for service but waited endlessly for small deeds like a drink of water, a diaper change, or to be repositioned in his bed for comfort from low back pain. In addition, since he could not lift his hands or arms to feed himself when seated in a wheelchair in the dining room, he often went unassisted and skipped a meal if my aunt was not there or he wasn't fortunate enough to find a merciful aide to feed him.

On his first day in the facility, he had slid out of his chair onto the floor, sustaining a bruise to his arm. Staff had failed to place a lap bar to secure him in. "I never in my life!" wailed my feisty uncle. "The newspapers are gonna hear about this!"

Our biggest challenge came on a Sunday evening around 9 p.m. His daughter, my cousin, who lived out of town, had already gone home, as did my aunt, after spending all day with him. When I arrived at the facility, my uncle was already in bed. However, I noticed he had no protective bed bar raised on the side of his bed to prevent him from falling out onto the hard tiled floor. I wanted him to have one, and so did he. When I asked the nurse and aide at the nearest nursing station to please provide one immediately, I was informed that my 87-year-old aunt would have to sign for one. Since it was late and she lives some 30 miles away, I offered as the next nearest relative to sign for one right then and there. I was told, though, that our requests were inadequate, that there was a new state law, a ridiculous "blanket rule," and they would get in trouble for violating it. This new state law considered a bar provided without written permission by (in this case) a spouse to be an "abusive restraint." I asked them if it would be better if my uncle suffered a fractured skull. It was abusive, I said, not to give him a bed bar and added I wouldn't leave that night until he got one.

I had waited 20 minutes when a nurse came and said the doctor on call was telephoned and had given the OK, but had added that if my uncle attempted to "hurl himself over the bar," his injuries would be worse than if he merely fell out of bed. Obviously, that doctor had not seen my frail, weak uncle.

This could have been attended to earlier. In fact, I believe the question of something as basic as the need for a bed bar should be raised at the point of admission. Loved ones often cannot think clearly in the throes of emotional and financial upheaval and the major life change that comes with having to place one's spouse in a nursing home. Thank God my uncle was lucid and had all his faculties in sharp working order, to be able to speak for himself.

Many of the aides and nurses had a sense of warmth and humor and seemed to care when dealing with him. But some of the others seemed apathetic, overworked, or just not visibly or audibly present on the premises. For example, on another night while visiting my uncle, I heard a man shout for help several times. I went out into the empty hall to investigate and called out, "Is there anyone working here?" I saw a door ajar as he continued to call for help and, peering inside, I saw a burly, heavyset, crippled man sitting on a commode and fast becoming impatient. I pleaded with him to stay put while I found help, and he promised he'd wait. Fearing for his safety, and not sure I would be able to lift him by myself, I proceeded down the hall to the nursing station and found it deserted. Amazingly, I was left in charge. At that point, I could have ransacked the joint, rifled through medications, or done anything else I wanted to do. Desperate for help, I picked up the phone at the desk, buzzed the switchboard, identified myself, reported the incident and our location, and said, "Send a nurse quickly!" A few minutes passed before someone in white made her way slowly down the corridor from the other wing and said she'd send the aide on the floor there to help him. By that point, the man had found the wherewithal to help himself off the commode and into his wheelchair without falling and injuring himself. Then, help arrived.

I suppose at only $140/day (the average price in my area for nursing home stays paid by patients and/or their health insurance plans) facilities such as this one cannot afford to hire more staff members to ensure against these breaches of safety and security or, better yet, hire more of the right kind of staff. If I had been a surprise "spotter" or state auditor, though, heads would have rolled that night.

I am a proponent of exemplary customer service, especially when peoples' lives, psyches, and physical well-being are at stake. A nursing home is not a department store, but neither should it seem like a warehouse or waiting room. Although I didn't find evidence of the kinds of neglect spotlighted on TV exposes, I still found the level of service wanting.

It means that the federal government might have to start giving priority to humane causes--including the needs of those in the final phase of life--instead of cutting human service programs. And taxpaying citizens might have to start caring enough to lobby for sweeping reforms in nursing home care, and then put their money where their mouths are. I would think any politician sponsoring reform legislation would get a heavily favorable vote, if only because of the sheer numbers of aging people, not to mention the growing number of midlife baby boomers with aging parents who need to know that their loved ones are appropriately cared for and not living in fear or in danger of neglect or abuse. Surely I am one taxpayer who would be willing to pay that price.

Money or not, how does one guarantee a strong work ethic or a caring heart in those workers who are caring for our aged parents or ourselves? Perhaps, with state aid, there should be more stringent evaluation and surveillance systems and immediate firing practices in place for slackers and those who otherwise don't make the grade. And perhaps

there should be "blacklists" that specify incidents, dates, and times of those who are unfit to be in the caring profession at all. I bet the quality of care would improve--and quickly!

I recognize that it is hard work to serve other people. But the needs of elderly patients, no matter how exasperating, should be paramount and met with a sense of urgency by all staff all the time. And it should be a joy for them to serve.

Uncle Lou did get his wish to go home just in time for Christmas and, as it happened, two months before he passed away. During his nursing home stay, which seemed like a prison sentence to him, he had been attended to a bit quicker once my aunt, cousin, and I made our presence repeatedly visible and asserted ourselves on his behalf. I advise people with loved ones in a nursing home to show their faces as often as possible to ensure their loved ones get what they want and need.

Meanwhile, one doesn't need an advanced medical or administrative degree to conceive of or implement improvements in nursing home attitude and level of care. Just a little caring and generosity of spirit would go far in changing the much-maligned and dreaded image of the nursing home.

Gloria Schramm resides in North Bellmore, New York. Access to her recent e-book, Soul on Fire: Encounter With Mother Teresa, is available at www.1chapter.com/details.cfm?TableName=Commentaries&BookID=41. To send your comments to the author and editors, please e-mail [e-mail].

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