The End of Rashes

The End of Rashes

The 15 November conference in the previous post started what became a three week period during which I was present at each Nystatin treatment. It was absolutely necessary that the “the affected area and around the area be treated.”

Some 75% of recorded observations were ranked either GOOD or BETTER after being extracted from notes over a month old. None were ranked totally CLEAR. I did not know what totally CLEAR was. The area was usually swollen and red for months with an increase in the upper inner thigh rash during the last two months.

Her condition was slowly getting better but in a very random fashion. It was now winter. A change from powder to crème by the dermatologist and a daytime toileting schedule changed this in the next four days (yellow) in the groin area.

Each morning her groin condition was ranked GOOD. Each evening not GOOD. The abdomen showed a greater improvement with the first CLEAR and has remained so during next two weeks. The yeast infection was gone.

The first sight of totally CLEAR groin area skin was an experience. The swelling was gone. It looked normal. Suddenly a spark ran through my body. A tingle rattling around in an empty shell from head to toe. It radiated from deep within my body to the surface of my skin everywhere. In an instant it was gone.

For a moment I was weightless. I was once again looking down from over my right shoulder at the four of us. My body reacted far faster than my mind. My experience in the guided meditation class did not prevent this happening.

Now all the caregivers were reporting dryness around the clock. The rashes were coming to an end. The groin area during the next few days became so dry that it itched and was scratched. The fan was no longer used to dry.

With the yeast infection gone for over a month and the groin rash responding in a few hours, we were at last at the stage of management. Use Top Care and/or the fan as needed. We now know that wetness over four hours produces an odor and skin irritation, any time during the day or night.

A two-hour dryness check is the simplest way to promote healthy skin and odor control. The 10:00 pm and 2:00 am checks may be skipped if there are no skin problems (or MoliCare with pH control fiber is used). The night becomes two four-hour sleeping periods. Being up every two hours with a virus is exhausting. 

The pink blush on Christmas Day is a third cause for coloring on fully CLEAR skin. It is still not clear if this blush is just where the skin has been scrubbed or it is an allergic reaction in the general area.

The 95% cotton/5% spandex camisole replaces brassieres now and may help dry next summer. Now back to normal grooming with the fan and Top Care ready for next summer. A big thank you to the group of caregivers who helped out and now know that each shift has an important part to play on a winning team.

We now know that my wife's body is a far better monitor of the rashes than Arlo's video clips. A rash is an alert to health care practice. I am still puzzled that the yeast rash was so easily expected to last for a long time by both doctors when the packaging and other information imply that two to three weeks should bring it to an end with Nystatin. The implied dryness needed for it to be effective should prevent the infection in the first place!

Incontinence Management

I have made many drafts of posts as this chart grew; each had a different ending. This post tells a summary of an interesting and frustrating story.

Provision Living at Columbia used MoliCare incontinence pull-ups for almost two years. Their novelty was the control of pH that controlled skin irritation and odor. Attends stretch tabbed briefs are easier to change in bed than pull-ups. Attends pull-ups are less expensive than MoliCare pull-ups.

The hot summer of 2018 came without a spring. My wife likes the outdoors. She sweats. Nystatin powder requires dry conditions to work. We never achieved the necessary dryness until November; leaving her to endure five months of irritation to the point she was scratching in her sleep.

[She cannot talk. She also suffered a concussion at the end of August; with partial recovery of the use of her fingers at this date.]

The chart begins with my return from a week trip to San Antonio, TX. A one-hour conference in our apartment with the Director of Nursing and the Director of Memory Care, with two other family members, set the time for Nystatin treatment “at 12-hour intervals at the same time each day”: 8 AM and 8 PM. The effect was immediate (lower blue line).

The 1:00, 3:00 and 5:00 am (actually 6:00 am) dry checks found at the start of the chart continued for the next three weeks. After meeting with the dermatologist, December 11^th, , a toileting schedule was delivered to our apartment. Again the effect was immediately evident. In a few days the 12:00 and 4:00 am dryness checks were in place.

We found that my wife was dry at most of the checks at 10:00 pm and again at 12:00 am. These were dryness checks made at night.

Toileting was defined as placing the person on the toilet; and leaving them there for the time they needed to toilet. My wife comes from a family that has a small library in their bathrooms. Toileting needs 10 to 20 minutes.

To rush this invites a fight and a wet pull-up shortly after it is put on. Getting up in the morning takes about 15 minutes; combined the two is 25-30 minutes. Skilled and experienced caregivers leave our apartment after a few minutes to work on another resident for 10 to 25 minutes.

Curiously, all of this variation seems to have little to do with my wife’s abdominal skin condition. What does have an effect is what happens during the daytime toileting, that is not captured by the Arlo video clip camera in our apartment; that I am learning to use when the monarch butterflies return in the spring.

From the 13^th to the 15^th of December her abdominal skin condition was consistently GOOD and after the 23^rd of December totally CLEAR. The dermatologist determination that the infection was over by the 11^th of December was correct. Separating yeast and wetness irritation is another story summarized in the next post.  

Correct Nystatin Application

July 28 to December 11 covers five months. The battle is over (the burning, itching and scratching).

Cleaned skin break bleeding
at both ends when found
under right breast

That afternoon on a hot
July day

We started with leftover Nystatin cream that worked the past two summers.  No response. Got a new prescription. No response.

Next the powder formulation was used with some response and then with variable response. Nine caregivers were available each day, three per shift, to apply the Nystatin at bedtime and in the morning.

In hindsight we could see a failure of treatment related to each 13-day supply bottle. There was not enough powder to treat under two breasts and in the tummy fold. This allowed the tummy fold area to grow even larger to the far side of her body on both sides. An order for a 52-day powder supply ended the shortage. [11:22 today text. Yesterday’s new cream prescription by the dermatologist is ready at Schnucks Pharmacy.]

A caregiver came in one evening during the first weeks of treatment, took a look and announced: “This looks so good there is no need to make an application”, and left. She also deviated from the protocol all the other caregivers followed for the duration of the battle. We then knew of two ways the every 12-hour treatment was being broken. (A third one we found: the need to set a uniform time rather than flow with the workload.)

As the weeks passed, I looked for alternate treatments and what could be used to prevent a new infection. Success always seemed not too far away.

The application site must be dry. Wash, rinse off the soap, and dry with a third washcloth. Even using individual washclothes for each breast and the tummy fold made little progress.

I then found a very small electric fan. Mini Rechargeable Folded Fan

Mini Rechargeable Folded Fan

Dry is dry. But DRY is air dry. The medication does not cling or form little balls but remains a very fine powder during application. We could now see a proper application.

We now had a winning set of rules: (How this all came about is a long story.)

1.   Wash with a no-rinse self-sudsing disposable washcloth (no soap).

2.   Dry with a washcloth.

3.   Air dry with the fan.

4.   Make application, with fully exposed skin with Margaret on her bed, to the effected area and some of the surrounding skin.

5.   Have one person observe that the above was actually done across the three shifts (me).

6.   Set a uniform time to apply at 8:00 am and 8:00 pm.

A meeting on the 15^thof November approved these rules for the last try before we called in a dermatologist. Later, Monday 3^rdof December was the decision date to call it over. Monday AM it looked great. Monday PM the left breast was about as bad as it had been! Tuesday AM it was all clear again.

We went ahead with new rules for an additional week:

1.   Clean with rinse-free disposable washcloth.

2.   Wipe with dry washcloth.

3.   Liberally dust with Zeasorb.

We got an appointment with a dermatologist. She called our work done on the upper body, however, during the past few weeks the rash appeared in the groin area. “Continue your preventative measures on the upper body.”

She gave us new rules for the groin area: (Starting today 12 December.)

1.   Clean with rinse-free disposable washcloth.

2.   Wipe with dry washcloth.

3.   Apply and rub in a THIN layer of Nystatin Cream.

4.   Dry with fan.

5.   Dust with Zeasorb. 

A thick layer of Nystatin Cream in the spring resulted in a sweaty gooey mess and no results.

We also needed to learn how to liberally apply Zeasorb properly. Each caregiver had her own way of doing this that in general, was to invert the container and shake vertically. Erica held the container on its side and shook horizontally about six inches above the affected area.

The first method produces an uneven distribution with clumps. The second creates a small snow shower that evenly covers the affected area and around the area. For someone new, this takes a bit of practice.

Our prediction is to have the infection over by New Year; a lot shorter than five months. Winter weather reduces getting an infection but did not prevent it from spreading. A change in the management of incontinence ware the past few weeks seems important here.

A new toileting and changing schedule was in our clean laundry cart. Everything to optimize the effects of Nystatin are now in place.

One day later. We were all surprised to see Margaret’s skin looking normal in all areas. What now must be called false positive blushes of red, that appear one day and vanish the next, can be caused by her clothing when she sleeps in a chair, and by pull-ups that were not changed soon enough.

Nystatin works, but only if the stringent conditions are met for a person who easily sweats during a very hot season.

[Three days later. We are so close to the end that I do not plan to write a second post on this topic, however the recent  bizarre developments will need to be added when they can be put in proper perspective. I also need to get the fan resized and running.]

Physical Fitness Instructors

Yesterday I spent a half hour with our fitness instructor, Brandon. He has picked out a few residents to work with on their special problems. We have graduated from the exercise class appropriate for beginners, which is attracting few new ones.

I think he wants us to be models for other residents to follow; residents who do not see fitness as necessary in an environment where everything is done for you. You need to be active to age well over time and then to die quickly.

About a year ago I found myself walking down the hall, placing each foot directly in front of its former location, shifting my weight from one leg to the other, rather than placing one foot ahead of the other, Indian fashion, as I had been told at less then 10 years of age. It just happened. I was not even thinking about walking. This was the result of a number of exercises in a fitness class.

But there was more to it than just walking. To hold the pelvic girdle in place so as not to waddle, as one of our city cousins did, to our amusement, requires strong muscles in the lower abdomen. That has taken me a year to acquire.

In the past six months, I have experienced walking correctly. I have two exercises that place my shoulders in the correct position. I can recalibrate by just facing a wall in about three minutes. The problem is I must be very conscious of each step.

Yesterday that changed. I knew that I have been crouching, walking with my legs bent a bit. There were several exercises leading up to yesterday, related to the knees and everything attached there to.

Yesterday we worked with ankle weights. It is like the big mud boots we wore as little kids. Repeating the first step, in the same exercise, without weights, let my feet fly into the air, to my surprise.

I could see again my solo flight. “Watch out. It will get up fast.” And it did. Instead of lumbering into the air, the little fabric covered aircraft leaped off the runway and up to the altitude needed to leave the airport traffic pattern shortly after clearing the end of the runway. You never forget looking back to turn left and seeing no one in the back seat.

This time it was my knees that were different. “Look at me. Stand there. Look to your left in the mirrors.” I was standing perfectly straight without being ware of it. My legs were straight. My back was in alignment. It felt good.

I noticed my knees felt different. They still do. They are unlocked. They feel like gimbals that can move in all directions instead of rusty hinges. My lower legs are almost weightless.

My new 13 inch MacBook Pro, computer, that I just finished a few hours ago transferring my old machine into, is also helping. It is positioned at the correct eye location with a $20 keyboard on the desk.     

Success requires practice with both mental and physical memory. Individual parts make up the one final performance when under the direction of skilled managers. Things must be done so they build on one another and with such effort as to not over-do. “If it hurts, stop.”

Each person needs to learn what feels right when doing things right. Only then can you benefit the most from instruction. Just mimicking the motions does not cut it.

Our bodies are surprisingly pliable even at 88 years of age. Therefore many exercises must adapt to the ever-changing body. The fitness instructor determines your current state and monitors your exercises to build on that base. This is different from doing more of the same thing to follow body development.

The lack of instant success, rather than long term incremental gain, is one reason residents avoid fitness programs, When the process is so seemingly easy it raises doubts that, “Doing this” seems imposable to have a desired benefit.

Twice now I have experienced a new me: walking and standing correctly. I discovered it happening. I did not see a gradual development.

Now to finish what is left of my back pain that can be managed collectively by a melody of chiropractic (monthly), physical therapy (finished), fitness exercises (daily),and  mediation, tai chi, and yoga (weekly). We will see what another year’s application and practice brings at Provision Living at Columbia.

Memory Care Patio Monitoring

The ambulance people had a short discussion among themselves as Margaret was being checked in to the emergency room. They finally wrote down, “Unobserved fall in unsupervised area”. This left the fall and the time in question. We will never know the cause of the fall: stroke, heart fibrillation, tripping and tumbling when stepping onto an unidentified sloping surface, and/or dementia.  

Cruising Solo in Late July

Cutting Across the Lower Path Loop

Upper Loop Foliage Trimmed to Reveal
 the Grass Fall Site Which is Not Visible
at the Base of the Fence at the Far End

 
What we do know is the area was not being monitored like the interior of the building; after more than one assisted living resident became lost, or trapped in a stairwell. The foliage hid the sloped area between the upper figure-eight loop of the walking path and the fence from view from inside and outside the building. This lush third-year growth was also of concern as it was extending into the sidewalk. Two people looking at the foliage found Margaret.

Corrective action came quickly. “Be sure this door stays locked. We don’t want someone to get out there (pause) and get hurt.” Two weeks later the foliage was trimmed back to give an unblocked view of the sloped area in question. I am unaware of any staffing changes or changes in the timing of periodic monitoring of each resident (Margaret was checked on about every 10-20 minutes when using her walker).

My experience in the last two months with an Arlo motion-triggered video clip camera suggests one correction for monitoring the memory care patio area other than having a walking guard stationed there as at a swimming pool. (I am practicing using the Arlo camera so that next spring we can make video clips of monarch caterpillars and anything else we find of interest in the 1.5 acre Provision Living Monarch Butterfly Sanctuary). Cameras must be mounted high enough to see down to the base of the fence. There is little need to add to current monitoring if the sloped area were leveled or restricted.

Sloped Lawn

My wife was found lying flat on the ground, 30 Aug 2018, with her right shoulder raised against the iron bar fence (around the memory care patio area) and with her head held straight up by a vertical bar embedded in her forehead; resulting in her body resting at about a 45 degree angle to the fence, heading west away from the patio door. There was no motion and little fresh blood flow. “Don’t touch her; see her neck.”  I was called to the scene.

The Fence

The Slope

The emergency room attendant chuckled, “I know this lady. She grinds her teeth.” Her head and neck were viewed extensively.  Ten stitches were followed by one more to stop bleeding. “Her right shoulder is hurting her. You are not leaving until it is X-rayed" (Her right hand was X-rayed a month later in preparation for therapy).

She was up in a wheelchair Friday, four days after the fall on Monday. After the third glass of cranberry juice hit the floor, we realized she had no control over the fingers on both hands. She was not aware of this either. Her fingers functioned as a club; rather than stretching out in a normal reaching motion.

Monday, a week after the fall, the left hand started waking up, one finger at a time for the next few days. By a month she had taught herself to be left-handed when dining and had the strength to lift a full glass of water. The right hand puzzled her. She feels and rubs it with her left hand.

On our second trip to Peak Sport and Spine, for occupational therapy, we were informed that they would only get paid if satisfactory progress were being made. Fortunately we had been shown how to use an exercise ball, to keep my wife’s fingers limber, on the first session. At two months, now with my three exercise periods a day, the first two fingers have a good grip, the third is erratic, and the little finger is still limp. The fingers appear larger and cooler than on the left hand.

Now that Peak has rejected my wife as a good fit for their facility (too noisy and distracting for her dementia to make progress), I have asked our doctor to request an out of network provider order for the company installed on the third floor; that recently opened an area in the west end of our first floor memory care wing. (The company no longer takes private pay, which cost me less than the deductable last January!) I am getting the feeling that “progress” is more self-healing than therapy. Sheer determination on Margaret's part to feed herself may be the most important.

First Successful Use of Right Hand to Use a Fork Yesterday, 3 Nov 2018

Margaret and I have been very lucky when it comes to falls. This is the first one that put a dent into her health. We dined with a couple, during our first year; that were not lucky. One fell backward in their apartment, striking her head on the edge of an end table and broke her neck; he passed a month after she did, after she spend months in the hospital.

Last week the 3:00 pm exercise class went for a walk on the park trail. Where the trail started down, the instructor cautioned each one to watch their step. He again cautioned each one on reaching the sharper decline on the street, “Shorten your step.” He walked backward, to the side, and ahead of the lead person in preparation for anyone who may start to trip or fall.

As the rest of the group went back inside, he took me to the bank on the south side of the park and demonstrated several times what takes place when you are walking on a flat surface and on a sloped surface. We walked up the slope using the longest steps we could use; then down with short steps. To overstep downhill sends you tumbling. This is fun for little kids.

I could now see Margaret falling down the sloped lawn from the figure-eight walkway to the fence. One knee hit the ground as she tumbled into the fence. Her right shoulder took part of the impact. Her head struck with such force as to cause a concussion but not a broken neck.

This is the second time, in thee years, I am aware of a resident uncontrollably tumbling into the fence. This should be enough evidence to justify the expense of leveling the lawn (in this area) or establishing a barrier to effectively keep residents off such a sloped surface. This attractive sloping landscape design feature does not seem to exist in courtyards surrounded by buildings and solid walls.

Loss of a Spouse

This morning, I attended a for-men-only two-hour presentation by Sam Timbrook, a Life Coach and local minister, who started “The Connection”; a non-profit ministry with those in grief. www.samtimbrook.com 

“Sometimes we do not realize we are in grief.” Stress, grief, and depression can have similar effects but are not the same.

It was caregiver stress that put my wife and me into Provision Living at Columbia. In two days our world was transformed from two people living in a house with Home Instead helpers coming for three hours a time, three times a week into a community of hugging, caring people. That hugging took a bit of getting use to.

It came in handy as my wife lost her ability to speak. A hug in the morning, from our caregivers, on my way to breakfast, sort of set the day right. I had no idea how long she would live or what state of life she would have. We did nothing with the monarch butterflies that first year. Call it depression.

Several times during the presentation I had those total body feelings I now know come from grief. My voice changes and tears are not far away. But what am I grieving? What have I lost?

My wife is recovering from a concussion a month ago. I do not feel guilty having a good time attending the Osher class for seniors at the MU Extension with the only other man now in the fitness classes. Grief involves a loss.

Last year I worked with two employees on my Osher tobacco smoke exposure project. They were both huggers.  One was the Director of the facility and the other my first caregiver smoker, about half way, on her way to becoming a non-smoker. 

Almost 50 years ago we had the Vice President of Northwest Missouri State CollegeUniversity ready to clear the tobacco smoke out of classroom buildings. It did not happen. Instead, he took another job out East.

This time, one was fired, corporate style, and the other vanished. Residents were keenly aware of the mysterious loss of the daily hugs and cheery greetings.

One response to this state of affairs at the presentation was, “When managers lean too much on the side of the residents, corporations may not like this."

I still do not understand how talking with others about a loss helps one to get through it; but it does. A person needs to be aware that the loss will never go away and at the most unexpected times those pangs can strike again. It is part of being a human being.

Reference: LOSS of a SPOUSE by Grief Share, www.griefshare.org, 64 pages. 

Addendum two days later:

"The state of affairs" I have learned was a difference in judgment between different levels. The individual fired is working in a similar position at another company in town. It happens. 

In fact Columbia plays "musical chairs" with health care personnel as new facilities and home care companies open. It hurts to loose. There is no shortage of jobs. There is a shortage of workers. 

Memory Care Incontinence Management

Current marketing of incontinence products is “discrete” and “private”. The ultimate is a bed pad that is colored so it is difficult to see if it is “wet and embarrassing.” “Reduced leaks” was interpreted as an infrequent event; not every morning. “Keep your loved one dry” referred to the person rather than the bed.

Maggie and I took about a year to break through this barrier. Sum six factors descended upon us at about the same time. (-1-) MoliCare Mobile Extra, 915848, was redesigned as MoliCare Premium. The product is odor free (negative 5.5 pH) with a morning and evening change (915834, X-Large, $1.61 each online, 56 count).

(-2-) A change of the Provision Living at Columbia Executive Director, the Director of Nursing, and night Charge Nurses was accompanied with a change (-3-) from MoliCare pull ups, to Attends Advanced Underwear, Classical Super Plus Design, (APP0740, X-Large, heavy absorption, $0.75 each in house, 14 count), pull up, and Attends Stretch (DDSLXL, L/XL, severe absorption, $0.46 each in house, 24 count) brief.

I returned to our apartment from breakfast to a stench I can easily remember when we were looking for a nursing home for my Mom. The odor stayed in the room for several hours.

Attends does not have a pH control to eliminate odor. Change Attends more frequently to eliminate odor.

Water on Surface of MoliCare

Attends Bursting

Attends keeps the patient drier than MoliCare when pressure is placed on saturated areas. It took some time for caretakers to adjust to Attends bursting when pressure was applied to a fully soaked pull up. Change more frequently.

(-4-) So we then went from one pull up, to a pull up when the resident was out of bed, to a brief when in bed. A brief is much easier to put on in bed than a pull up and it cost much less ($0.46 brief and $0.75 pull up with Attends).

Unfortunately this did not keep the bedding dry. We experimented with over $100 worth of the best items in stores in Columbia, MO, and on the Internet; even a $2.00 each item from France that never seemed to fit right and also failed the “sit up and turn” test.

All items failed the “sit up and turn” test when getting out of bed. A bed pad is an essential item in an incontinence management system. It takes at least four, as three can be in the laundry at one time; and six when things do not go as expected.

Damaged Depend as a Tabbed Brief

We found Depend Adjustable Underwear (19184, L/X-Large, maximum absorption, $0.75 each online, 16 and 48 count) comparable to Attends. This item is novel in that it comes as a pull up for out of bed application, but can be converted to a tabbed brief, by opening from a difficult to find spot, for in bed application. It takes some practice to find the spot and apply the tabs without destroying the garment.

(-5-) An incontinence management system is then composed of a pull up for out of bed application, a tabbed brief for in bed application, and a large bed pad (in box under head of bed). Three-hour bed checks keep Maggie and the bed dry. There is no odor problem.

[The pull ups, $0.75, and briefs, $0.46, are placed side by side in the bathroom to prevent the closest one being used, and to promote restocking before each one runs out, rather than waiting to restock after the last one is used.]

(-6-) Along with the changes in personnel and incontinence items came a concussion with eleven stitches and the partial loss of use of her fingers on both hands. She was bedridden for three days and then up in a wheelchair. No more trips to the bathroom at night.

The cost of the incontinence management system, to a resident, changed from two changes at $3.21 per day with MoliCare pull ups (with toileting), to four changes at $2.40 per day, and six changes at $3.60 per day with Attends. The bed has been dry for over a month with Attends.

MoliCare, Attends and Depend all seem to fit Maggie. This is important. Poor fitting increases leaking and can injure the skin (especially with double briefing). It can also aggravate the skin rash Maggie has battled all summer. The Attends stretch brief has superior tabs and fit.

My opinion is a large washable bed pad, with the lowest cost pull up and brief, that prevents an overflow of the bed pad, is the optimum condition. I do not see a diaper cover being practical at night. Frequent toileting reduces the need for a diaper cover during the day.

Thank you to all the caregivers who took part in our investigation.

Smoking Management Freedom Team

I have worked my way through tobacco control state laws, city ordinances, and company policies (there is no national law). All of these controls depend heavily upon self-compliance. And they work fairly well.

Consistent violators are reported, and shamed into compliance, by the rest of the endangered community. A peculiar behavior I have observed is that the bluff and bluster of an addicted smoker disappears after the community sets the effective date for the end of smoke exposure in some manner.

There is an explanation for this change in behavior. Over half of smokers living in multi-unit housing vote for tobacco smoke free exposure.

The often-quoted “70% of smokers wanting to quit” shows here. They see an environment free of smoke as an important aid in quitting. The smell of tobacco smoke is a powerful trigger.

So it turns out that the last grouping I need to consider is also the foundation for tobacco control compliance; that group is not just smokers. It is everyone in the community.

A group larger than five, needs to be divided into functional teams. Each team needs to have at least one smoker interested in managing his/her addiction.

The teams need names. This provides a sense of accountability for prizes without needing to publish names. (Many smokers feel rejected and isolated. It is important to feel part of a positive supportive team. This is the main function of a team.)

Suggested times for teams to celebrate:

1. Each member's first smoke free day, first week, first month.

3. Entire site first smoke free day, first week, first month.

Team prizes are important and should be significant (equal to $60 per month per employee reported at one company in town). The new non-smoker is the star, but as in all sports, it is the team that wins, that earns recognition for their support. [Consider traveling trophies between participating sites.]

Promote the formation of freedom teams. Then each member calls 1-800-LUNGUSA for a free copy of their “Freedom from Smoking” self-help workbooks, that guide the team to success. (it takes about a week for delivery).

[Also contact the local city/county health department and CDC 1-800-QUIT-NOW (1-800-784-8669) for free 2-week alternative nicotine supplies.] 

Viral bylaw: After becoming comfortable with my own nicotine management or becoming a non-smoker, I will assist in at least one more team, at this location or at another location.     

New Over the Counter Safe Nicotine Sources

Frequent Sales in a Competitive Market 

         

A New State Tobacco Control Law

The term “Tobacco Control” comes from the days of “Alcohol, Tobacco and Fire Arms. The emphasis was on controlling tax revenue.

A new law must be based on “tobacco smoke exposure”; a recently recognized public health problem of great importance, and continue with addiction as a serious illness.

Education has been the most successful tool in controlling the use of tobacco (1).

Well to do, educated, and tobacco knowledgeable people have self-regulated their exposure down to no tobacco smoke by living in totally tobacco free condominiums and multi-unit housing (2). This is comparable to the self-regulated single family occupants at all socio-economic levels (3).

Heavily regulated hospitals have now arrived at the “tobacco free” status that includes not hiring people who are addicted to nicotine; that they obtain from smoke or from alternative nicotine sources (4). The air is clear for employee and patient. [Hospitals (health care) have given themselves the same status (in Missouri law) as health promoters (American Lung Association, for example), by charging for smoking cessation consultations.]

Private pay, less regulated, assisted living and memory care, sites have not arrived at the “tobacco free” or “exposure free” status in Missouri (5). They are only “smoke free” workplaces (6). The public regards them as “free of smoke”.

Here is the problem: The low wage workers are drawn from lower socio-economic levels where up to 50% are heavily addicted to nicotine (7).  

Here is the result: A caregiver, needing to adjust blood nicotine levels, can step out of a “smoke free” area to smoke, and step back in. Within a minute the next resident could have just as well have been smoking too, but now from the third hand tobacco smoke released from hair, clothes, and body.

Transitional competitive market solution (0-90 days): Hire smokers who are given to understand that nicotine addiction is a serious illness that affects everyone exposed. No tobacco or smoke are allowed on the property. They must take part in an effective smoking cessation program directed by a qualified person to manage their addiction while at work, and to set a low stress quit date. The job is conditional until nicotine addiction is under control.

Fully funded and updated tobacco control law solution (2-5 years): The enemy is a profit-seeking cult (8) that holds onto 70% of its members (9) by addiction (10). Pass company non-smoker health insurance benefits into paychecks. Fund tobacco initiation and smoking cessation programs at the CDC recommended level. Encourage effective “exposure free” company policies (11) and city ordinances (12) that can support an effective state law.

For details please see: https://residentialcarefortwo.blogspot.com.

A Transition Tobacco-free Policy

The “Sample Tobacco-free Workplace Policy” is dated 2013. This is in the era of “tobacco free” property. The property placed a shield around “smoke free” areas. Thirdhand tobacco smoke (THS) had not risen to the regulatory level of public consciousness.

Areas and properties remain in place. THS is left behind or carried about with people. THS penetrates the assumed safe “tobacco free” property.

The terms 100%, tobacco, smoke, and free have been combined in several ways to distinguish advances in, and reasons for, tobacco control beyond a source of taxes. Tobacco free, tobacco-free, and tobaccofree have generally referred to workplaces, restaurants, and bars. They may apply to assisted living and memory care as a “workplace”, and more recently, to “multi-unit housing”.

Tobacco-free in 2013 did not include THS. The American Lung Association (ALA) policy uses “complete” (without THS). I am using “complete” with THS rather than “Final” or some other term signifying the end for a need for new names.

Line and a half spacing is used to increase readability. A clean one page draft policy is located at the end of this post in text and in an image. New, Original, and Deleted. Provision Living has been inserted for EMPLOYER and ORGANIZATION NAME as this is where my wife and I live in Columbia, MO.

I have learned that effective tobacco control legislation starts from the bottom up. I have also obtained many meaningful insights into how assisted living and memory care actually operate in the past 2.5 years. This is a good place to start.

Sample Provision Living Tobacco-free Workplace Policy

A tobacco-free environment An environment free of tobacco smoke helps create a safe and healthy living and workplace. Smoking, and secondhand and thirdhand smoke are known to cause serious lung diseases, heart disease, heart attacks, strokes and cancer. [Provision Living] recognizes the hazards caused by tobacco use and exposure to secondhand and thirdhand tobacco smoke. Our policy to provide an environment for all employees, residents, and visitors was established to keep a safe and healthy workplace environment; an ideal environment to break out of any nicotine addiction. This policy covers the smoking of any tobacco product and the use of oral tobacco products, “spit” tobacco and e-cigarettes, and it applies to both employees, residents, and non-employee visitors of Provision Living.

Definitions

Smoker: A person so ill (nicotine addicted) that a nicotine adjustment must be made during the time spent on the property.

Smoke free: an area in which there is no smoking, but which secondhand tobacco smoke can drift into. A “smoke free” sign signifies smoking somewhere.

Secondhand tobacco smoke: the smoke that is inhaled by non-smokers, is deposited everywhere, and can be carried about on hair, clothes and bodies as thirdhand tobacco smoke (THS) where it can become re-airborne in restricted areas.

Tobacco-free: a property onto which no tobacco nicotine materials can be brought, but which thirdhand tobacco smoke can be carried into.

THS Level 1: New hires using non-toxic nicotine replacements, as needed, to adjust nicotine levels during their shift (before arriving until after leaving the property).

THS Level 2: After quitting or 30 days, using non-toxic replacements, as needed, to adjust nicotine levels all 24 hours of the day. [Protects worker, workplace, and family; reduces sick call ins.]

Smoker free: All occupants (employees and residents) living and working on the property no longer smoke. [The ultimate goal of any smoking cessation program.] In time, this status may be included in "tobacco-free", plus the effective date.

Stealth smoking: A facility is presented to the public as an environment free of tobacco smoke and free of tobacco control signs, when in fact, smoking is occurring and may even be accommodated. We found this a common practice in assisted living facilities in MO and TX. It is one reason we selected Provision Living at Columbia.

Policies

OPTION 1 – COMPLETE TOBACCO-FREE POLICY

No use of tobacco products including cigarettes and “spit tobacco” or e-cigarettes is permitted within the facilities or on the property of [Provision Living] at any time.

OPTION2 – COMPLETE TOBACCO-FREE  IN DESIGNATED OUTDOOR AREAS ONLY POLICY

No use of tobacco products including cigarettes and “spit tobacco” or e-cigarettes is permitted within the facilities or on the property of [Provision Living] at any time. No third hand tobacco smoke (THS) is permitted after probationary period.

THS is managed at three levels on the property: THS 1 (on shift), THS 2 (24 hours), and Smoker Free (no smokers) to accommodate hiring smokers into a caring, radiant person, family type community that is mindful, of the stress involved in continuing and in curing an addictive illness, and the freedom and benefit of being cured: a new non-smoker. At no time is smoke generated on the property.

Procedure

1. Employees will be informed of the [Provision Living] Tobacco-free Policy through signs posted throughout properties owned and operated by [EMPLOYER] including company owned vehicles during regular staff meetings prior to 30 days of being effective.

[Smoking signs in an environment free of tobacco smoke are a constant reminder for those quitting to think about smoking as well as smokers getting ready to quit. These people need to feel how good it is to be free from smoke for 9 hours.]

2. Visitors will be informed of the [Provision Living] 100% Tobacco-free Policy by their hosts, the meeting invite and email correspondence and signs posted throughout the properties owned and operated by [ORGANIZATION NAME].

[The old tradition of asking permission to smoke is reviving again. A free lozenge is available for visitors needing to adjust their nicotine levels. Stealth smokers often act embarrassed when encountered.]

3. Provision Living will help employees who want to quit smoking by helping them prepare to quit, set a quit date, and access recommended smoking cessation programs and materials. This includes a Freedom Team of never smokers, former smokers, new hire quitting smokers and smoking cessation counselors. (Visit www.lung.org/stop-smoking for more information.)

4. Any violations of this policy will be handled through the standard disciplinary procedure.

____________________________________        ________________________

 SIGNATURE CEO or PRESIDENT                          DATE  

American Lung Association 2013 (fits on one page)

One Page Image

Draft                      Provision Living Tobacco-free Policy                Draft

An environment free of tobacco smoke helps create a safe and healthy living and work place. Smoking, secondhand and third hand smoke are known to cause serious lung diseases, heart disease, heart attacks, strokes and cancer. Provision Living recognizes the hazards caused by tobacco use and exposure to secondhand and third hand tobacco smoke. Our policy to provide an environment for all employees, residents, and visitors was established to keep a safe and healthy workplace environment; an ideal environment to break out of any nicotine addiction. This policy covers the smoking of any tobacco product and the use of oral tobacco products, “spit” tobacco and e-cigarettes, and it applies to employees, residents, and non-employee visitors of Provision Living.

Policies

OPTION 1 – TOBACCO-FREE POLICY

No use of tobacco products including cigarettes and “spit tobacco” or e-cigarettes is permitted within the facilities or on the property of Provision Living at any time.

OPTION2 – COMPLETE TOBACCO-FREE POLICY

No use of tobacco products including cigarettes and “spit tobacco” or e-cigarettes is permitted within the facilities or on the property of Provision Living at any time. No third hand tobacco smoke (THS) is permitted after probationary period.

THS is managed at three levels on the property: THS 1 (during shift), THS 2 (24 hours), and Smoker Free (no smokers), to accommodate hiring smokers into a caring, radiant person, family type community that is mindful, of the stress involved in continuing and in curing an addictive illness, and the freedom and benefit of being cured: a new non-smoker. At no time is smoke generated on the property.

Procedure

1. Employees will be informed of the Provision Living Tobacco-free Policy during regular staff meetings prior to 30 days of being effective.

2. Visitors will be informed of the Provision Living Tobacco-free Policy by their hosts, the meeting invite and email correspondence.

3. Provision Living will help employees prepare to quit, to set a quit date, and to access recommended smoking cessation programs and materials. This includes a Freedom Team of never smokers, former smokers, new hire quitting smokers and smoking cessation counselors. (Visit www.lung.org/stop-smoking for more information.)

4. Any violations of this policy will be handled through the standard disciplinary procedure.

____________________________________        ________________________

 SIGNATURE CEO or PRESIDENT                          DATE  

                                           American Lung Association 2013, edited 25 May 2018