Sunday, January 22, 2017

Memory Care vs. Skilled Nursing

The past few days have made evident there is a marked difference in the structure, staffing, and training between memory care and skilled nursing. You can even hear it in the halls:

. . . Mrs. Hart . . .

. . . Maggie . . .

A knock on the door, “Have you seen two discs about this size?” “How thick are they?” “About so.”

“The envelope is like for a card rather than a regular letter.”

“She packed this stuff up in the room across the way and I can’t get her to turn it lose (without running the risk of being socked)”, easily being communicated in body language. “Let her keep it and I will return it shortly.” (In about five minutes.)

We search the room for contraband. Really search the room (Twice). Look in every pocket of clothes on hangers. After three weeks we still find clothes that are not marked. We find nothing that is not ours. We still fail to find missing clothes sent to the laundry.

Skilled nursing has twice the patients per square feet of space than Provision Living at Columbia in memory care. There are no locks on the doors to keep wanderers out. “Wrong room.” There are over 80 patients here. I find, when I walk with my wife, many of them know her by name and most greet her as a friend.

Memory care at Provision Living manages wandering, and other behaviors, by the design of the building (22 in one locked unit and only 12 in another) and staff interventions (at all levels). In skilled nursing, the deviation from “normal” that calls for special responses seems to be narrower than in memory care.

Also my wife does not have her two shelves of keepsakes to play with. She retains her wastebasket packing learned in two nights of motel experience.

Three days ago she appeared very tired and unresponsive. As time passed all parties became concerned. A change in “calming” medication was being used to manage wandering, in skilled-nursing, but what is a normal behavior in memory care.

Other refugees have been sent to the hospital for evaluations that would again be within control of memory care practice. If those behaviors repeat here, I am of the opinion that a hospital evaluation may not be called for; the skilled-nursing staff has learned what the memory care staff learned many months ago. Both must learn by experience with each patient or resident. Each can only respond within the structural and licensing limits of the facility.

My wife needs memory care. The day she qualifies for skilled-nursing (and our long-term health insurance kicks in) we will have some idea what that life will be for her if calming drugs will be a leading part of managing her behavior.

We are now walking on an increasingly narrow path; a world after the heart fibrillation event in December (that could have been fatal). On one side is “let nature take its course” and on the other side, that flips from a mischievous free ranging early teenager, to a belligerent scowling sleepy existence suspended in time and space.

The compassionate care from both staffs help keep my wife in a positive frame of mind. Maintaining the family atmosphere in the activity and the classroom spaces here at South Hampton Place has been critical for her and the other refugees: the common dining room table, games, exercises, and other. By letting me duck out when things are going well, I can find time to write, and nap.

Sunday, January 15, 2017

The Flood of Provision Living at Columbia

This was not supposed to happen. The sprinkler system was state of the art. Some very special people sought shelter under the system. They were the residents and their caregivers in memory care. Together they happily participated in a grand theater where time and place were no longer in sync with the rest of the world.

They took the evacuation of the building to motels in stride. The next morning at breakfast someone said, “We are on vacation.” And the play continued. “We are on vacation.”  On the second day of being refugees, the play failed for several. “We are not going home to our apartments.”

I did not intend to write about the mechanics of the flood, but the result on the refugees becomes more pronounced as we start on our fourth week. Given the residents of the building, the flood should never have happened. It was totally unexpected given the care taken in construction, staffing, and training.

A dry sprinkler system is called for where the pipes may freeze. The pipes, filled with compressed air, are expected to freeze. The dry pipes are expected to be dry to make the system work.

But there is a catch: the pipe system leaks. A compressor and tank are connected to maintain the desired operational pressure. An air leakage of about 3% per hour is acceptable. Any moisture in the injected air accumulates in the system. This water vapor can produce ice crystals anywhere in the system that falls a few degrees below freezing.

Secondly, periodic checks of the system flood the pipes to determine that water will reach an inspection port at the far end of the system within one minute. This inspection water must be drained out, completely. The pipes must be installed to drain properly. Low point drains must be drained repeatedly until no water is found. I have found no mention of blowing the water out with dry air. The water must drain.

If it does not drain, it is available to collect into ice wherever a freezing temperature develops in the “dry” pipe system. Lots of ice produces an ice plug. An ice plug often does not rupture pipes. Two ice plugs forming some distance apart can rupture a pipe or dislodge a pipe coupling between the two ice plug locations. As the plugs grow toward each another, the pressure inside can exceed required maximums for pipe and for couplings.

This damage is not immediately evident. Any water that may leak will immediately freeze. After a good weather warm up, the ice will begin to melt. At some point water will again begin to flow. The compressed air pressure in the “dry” pipe system drops as the ice plug melts or moves to expose a break in the pipe to let the air out. Low air pressure triggers the sprinkler system to flood. (No water comes out of the sprinklers, as there is no hot fire to open them.) The fire alarm sounds (but there is no fire). The flow of water will soon become a gusher.

To the best of my knowledge the flow rate was over 1,000 gal/min for over 15 minutes. The rush of water tore out walls. Ceilings fell. Just 15,000 gallons of water can cover 12,000 square feet with two inches of water. Umbrellas were used to quickly and safely evacuate residents. The drills no one expected to use were now real. The impossible was now happening.

As I am writing this, two Provision Living caregivers brought my wife to our two-bed skilled nursing room. They confirmed that new behaviors have developed. None of them are for the better. They also agreed with me that it will be interesting to see to what extent they continue when we return to Provision Living at Columbia. (Loading waste baskets in the motel with everything lose in our room for just two days continues here in the skill-nursing location.)

Old behaviors have intensified. Just now a lady in a wheel chair called in the door that my wife had held her so tightly as to bruise her arm. (Now what Maggie wants, Maggie gets.) And again if anything is missing, Maggie has it. For the past few days I have not been writing, as I have been full time watching my wife as well as at times other residents so the caretakers can work individually with other refugees.

And we still have two to four weeks before this natural experiment ends. The facilities in skilled nursing are in no way comparable to those in memory care. The caregivers in both groups are working hard to bridge the gaps. Tonight we have another weekend ice storm continuing. (More double sifts and employee cars in jeopardy.) I am afraid we are all getting tired.