A Not so Obvious Picture at the Grand Rapids Home for Veterans

Bob Goddard

In early August, a disturbing news story broke about the Grand Rapids Home for Veterans, my old workplace.  After an investigation by the State of Michigan’s Attorney General’s office, eleven former employees – all direct care workers – were charged with falsifying medical records. The caregivers charted that they had checked on members (the Veterans Home refers to the residents living there as members) while surveillance video shows that these checks were not done. In Michigan, falsifying medical records by a health care provider is a felony, punishable by up to four years in prison and a fine of up to $5000.

The investigation followed a scathing February 2016 report by the Michigan Auditor General. According to that report, the home failed to properly investigate allegations of abuse and neglect, took too long to fill prescriptions and operated with inadequate staffing levels. Both the Attorney General’s investigation and the audit came almost three years after the State privatized the entire direct care workforce at the home, thus replacing a dedicated, stable direct care workforce with contract workers from a demonstrably unreliable agency, J2S.

The eleven workers charged by Attorney General’s office were employed by J2S. That company was replaced by two other contract agencies last year after J2S repeatedly fell short of adequately staffing the facility.

As we have come to expect in media coverage of anything related to long term care, the local media treatment of this story displayed a superficial understanding of how a long term care facility operates and relied on sensational wording to make the story more compelling. In the process, the reporting presented a misleading picture of how caregivers go about their work. While reporters expressed outrage over the quality of care at the home, they seemed clueless regarding what it takes to make good care happen. I think it would be useful to correct this and offer a different perspective.

In one report following the announcement of the felony charges against the caregivers, a local TV reporter assured viewers that the Attorney General’s investigation “paints a pretty obvious picture of the situation” and concluded that bringing the charges does two things: “it holds people accountable for what they did,” and second, “I can guarantee you tonight at the home for veterans they’re going to be doing their member checks.”

The assumption in that last statement is that fear is a necessary and effective motivator in providing good care. This is a common fallacy among observers unfamiliar with the nature and practice of caregiving. You cannot get genuine compassion and caring from fear.

Yes, as our visibly self-satisfied watchdog reporter suggested, I’m guessing “those member checks” were indeed “being done tonight,” but as I will explain below, that form of diligence has little do with the actual quality of care at the home.

The media reports and statements from the Attorney General gave the impression that these hourly checks were at the heart of what caregivers do. They are not. In fact, the hourly checks are superimposed over normal care routines. In a typical institutional setting, each caregiver is assigned a group, usually ten or more residents depending on the shift, unit and facility, and is charged with completing a whole series tasks including assisting with the residents’ personal hygiene, bathing, grooming, dressing, toileting, bowel care, skin care, turning positioning, transferring, ambulating, transport, serving meals and feeding patients, offering fresh water and snacks, take vital signs, make beds, keep the residents’ room clean, answer calls lights and respond to requests, record intake and output information, observe and report changes in residents’ physical and mental condition. And of course, document these activities via flowsheets and other similar forms. The location sheet is one of these forms.

It’s important to understand that given the direct care staffing levels in a typical long term care facility, and this certainly includes the Grand Rapids Home for Veterans, assigned caregiver workloads are rarely possible to complete – not to the standards set forth by regulators, facility policy, and customary nursing practices, let alone family and public expectations.  This means caregivers are constantly engaged in a form of care triage, made necessary because no one above them in the Long Term Care hierarchy, including policy makers and legislators, seem able to provide the resources necessary to do the job according to standards. Either they lack adequate awareness of the problem or are simply not willing to make the hard choices. By default, this is left to the direct care worker.

Given the inadequacies of the system, the best a caregiver can do is to arrange these various tasks in some order that makes the most sense for everyone in the group, taking into account the unit’s mealtimes and other facility routines. While a good caregiver tries to plan ahead, working with human beings means that unexpected needs routinely arise and no can anticipate everything.  Each shift becomes a unique time puzzle that the caregiver must solve if the residents are going to receive the best care he or she can provide. But the puzzle is dynamic, the “pieces” change according to the immediate needs and expectations of residents, coworkers and management. The caregiver must continually adapt his or her time organization to ever changing circumstances and priorities. In essence, the caregiver spends the shift involved in perpetual problem solving with ethical implications.

At the Veteran’s Home, the check sheets are kept behind the nurses station while the majority of care is conducted in the members’ bedrooms and bathing areas. So, to properly document the checks consistently in a timely manner requires this absurdity: the already overwhelmed direct care worker must pause care and walk away from the members for whom she is providing care for the purpose of putting her initials on a sheet of paper that indicates she knows the location of the members she was just with. This may provide the facility with documentary evidence and meet an institutional need, but it does not necessarily address the needs of the members.

If we are truly concerned about the quality of care for our veterans, the real question is not whether or not the checks were properly documented, but what the caregivers were actually doing when they indicated they made the checks. Were they in the shower room with a member or making sure an unsteady member wasn’t tumbling off a commode or perhaps transporting a member to a therapy appointment? Were they in the middle of assisting a member with his meal or helping a coworker transfer a 350 pound man from his bed to his wheelchair? Were they responding to a member’s urgent request for help? Were they redirecting a confused member for the tenth time in the last five minutes? Were they assisting another caregiver who was trying to manage a combative member? Were they comforting a member who was experiencing some kind emotional turmoil? Were they on their way to nurses’ station to get the location checks clipboard when they noticed a call light? Were they with a sick member, maybe dealing with copious amounts of diarrhea or vomit? Were they cleaning up a spill that presented a fall hazard? Were they speaking with the family of a member regarding their loved ones’ care and status? Were they holding a dying member in their arms? Or perhaps they were engaged in a member’s post-mortem care.

I will leave it to the Attorney General and media reporters to decide to which of these activities caregivers ought to interrupt so that they might properly document the checks – and presumably stay out of prison.

Let’s be clear, if the workers were sitting behind the desk or off the unit or otherwise not engaged with the members when these checks were supposed to be made, then our sympathy and support for them evaporates. Not because they didn’t make the checks properly, but because they weren’t with the members and on task. Even in bad work environments, caregivers are ethically and morally obligated to the use the time and resources that they do have to do the best they can for the residents.

Of course, it could be argued that the hourly checks provide a more systematic way of accounting for the members’ location and condition. Regular checks ensure that no one gets forgotten.  It seems obvious, right?

However, when you start to look at how caregivers actually gather information and keep tabs on the members in their group, the hourly checks take secondary importance. Caregivers are routinely provided with a “cheat sheet,” a one or two page list of all the members in their assigned group. The cheat sheet includes basic care information for each member. The caregivers carry these sheets with them and will refer to them throughout the shift. Even caregivers who are familiar with the members in their group will often use the cheat sheet as an aid to help organize their time and, of course, to help make sure no one is forgotten.

Given the real needs of the members, the fact that the checks are hourly is completely arbitrary. The reality is that some members don’t need to be checked that often and some leave the grounds for long periods – as is their right, it’s a home not a prison. Other members may need to be checked even more frequently depending on their particular physical and mental status.  A lot can happen in 59 minutes and the hourly checks can no way guarantee the safety and well-being of all members. The best way to keep members safe and their immediate needs met is to have well informed, well supported, on-task caregivers. And by well-informed, we mean caregivers who are thoroughly familiar with the members – not just with their current medical status, but who they are as individuals, their daily needs, preferences, and habits.

By threatening caregivers with prison sentences and the like, we can make them jump through hoops and give the appearance that good care is being done, but we should wonder what is actually being missed while they’re putting on this show for us. As our watchdog reporter implied, fear will elicit a sure response. But with fear, the issue becomes not about the real quality of your work and how those in your care are experiencing it, it’s about how you think it’s being perceived by those who can punish you. Under siege, our actions are informed not by our sense of right and wrong nor even by common sense, but by the assessments and attitudes of those who are judging us. When those assessments and attitudes are based on faulty perceptions – which is often the case in long term care and certainly the case here – our priorities become skewed and we add yet another obstacle to good care.

Fear won’t take caregivers into the places where genuine compassion and caring will go. As a motivator, it’s a weak and insufficient substitute for the truly powerful motivations that result in the best care possible. On the other side of those closed doors and privacy curtains where caregivers engage members and actual care takes place, you really want people who are inspired by the better angels of their nature.

The quality of care in any long term care facility is directly tied to the facility’s investment in the caregivers who provide it. Paying direct care workers good wages with decent benefits not only helps attract and retain workers, but it also gives them the means to adequately provide for themselves and their families. Many caregivers have no choice but to work a lot of overtime or find second jobs just to make ends meet. The work itself is physically and emotionally demanding, and when you add the stress of double shifts and long hours, the result is a caregiver workforce perpetually on the edge burnout. You can’t get the best possible care on a consistent basis from workers who are physically exhausted and emotionally drained.

It should be no mystery why J2S had such difficulty staffing the place and why even now one of the current contract agencies continues to have problems. The shortage of caregivers has become a nation-wide crisis and annual turnover rates for direct care workers typically run between fifty and sixty percent. Prior to the State’s privatization of the direct care workers, the Grand Rapids Home for Veterans was immune to this crisis.

The cost of losing that stable direct care workforce cannot be overestimated. Caregivers who are unfamiliar with the members in their care groups cannot possibly provide the same level of care as those who have had long standing relationships. But we continue to routinely throw these workers into chaotic situations and expect them to perform a high level. Usually they feel fortunate just to get through the shift with no major disasters. Or investigations.

While a sense of duty and a good work ethic are necessary in providing adequate care, there is no substitute for the personal relationship that develops between the caregiver and resident. This bond is the single most powerful motivator in providing excellent care. In environments where these relationships are encouraged to develop and flourish, workers become more caregivers, they become advocates.

If the caregiver has a moral obligation to do the best for his or her residents despite difficult circumstances, then those above us in the hierarchy and those on the outside who seek to influence the activity of caregivers have an equally compelling moral obligation to understand the consequences of that influence. This requires a basic awareness of the real challenges faced by caregivers and insight into what really motivates them. From what I’ve seen, both the Attorney General and the local watchdog reporters have failed to demonstrate that awareness and insight.

  

57 thoughts on “A Not so Obvious Picture at the Grand Rapids Home for Veterans

    1. donna

      Wow. Bob this is such an important post as you can see from all the replies. I hope you’ve also sent it to the Grand Rapids papers and members of the Congressional Veterans’ committees. And to other organizations. The issue of staff shortages isn’t just a VA home issue, as you realize. Caregivers in virtually every long-term care home in the country are dealing with this, and residents are suffering the consequences. This is or should be a call to arms for all caregivers. Everyone who replied to thoughtfully to your essay will, I hope, think about “What next?”

      Reply
      1. Bob Goddard Post author

        Thank you, Donna. Staff shortages are indeed endemic in LTC, even “fully staffed” facilities often have difficulty providing excellent care on a consistent basis. There are places that do it, but you can bet they’ve invested a lot in their caregivers, know what motivates them, and support them every way they can

        Reply
    2. Bob Goddard Post author

      Appreciate your support Lawrence. We’ll do our best not to get lost in that wind! In fact, we’ll be speaking at the annual Green House Project conference in November

      Reply
  1. Anonymous

    Well said. Everyone who watched those sensationalized news reports should also read this article. Understanding of a long term care worker’s job gives another perspective to the situation. One sided news reports do not tell the whole story.

    Reply
    1. Bob Goddard Post author

      I’m really glad that you feel it paints a more accurate picture. It’s good to hear from those who actually do the work

      Reply
  2. Anonymous

    Have a lot of respect for these caregivers because I have walked in their shoes. Also some of these families expect private duty care for their loved ones which leave others short-changed. Really appreciate the families that really knows what is involved in caring for their family members.

    Reply
    1. Bob Goddard Post author

      Yes, families that have a good relationship with the caregiver can be so, so helpful. The information and support we get from them can be invaluable. It’s really nice when we work together for the same purpose. I’ve been on both sides of this and can tell you that when you see a strong bond between a caregiver and your loved one, it means everything

      Reply
  3. Anonymous

    Very well said and I felt your compassion throughout this piece. We don’t have enough professionals looking into the science of this work; Especially in long term care. We take for granted the acuity of patient care and the skill it requires for a workload of 20 – 30 patients. Do we compromise checks for quality of care. The standard in any health care environment is to check residents every 2 hours. If you are understaffed it may take you an hour to perform quality rounds.
    Our legislators and politicians need to really look at the fact that most of these caregivers work 2-3 jobs to support their family. They leave one job and go directly to another or even work their days off from one job at another job,
    Unless you have actually lived lifectgsg edh you will never truly understand. The government officials fail to realize that the employers of these workers are not Aleah’s providing affordable health care to these employees; which adds an additional burden to society.
    These same parents that work these multiple jobs are not home with their children which cause other societal problems that no one wants to investigate.
    This is a vicious cycle tgF always points thecgjbger but never seeks resolution to the foundational problem of stability,
    Thank you for this piece.

    Reply
    1. Bob Goddard Post author

      A lot of good points in your comment. I particularly appreciate your statement about not enough professionals looking into the science of the work. The good news is that this is starting to change with the efforts of organizations such as the Paraprofessional Healthcare Institute (PHI), The Greenhouse Project and the Pioneer Network.

      Reply
  4. Former LPN at GRHV

    Excellent Bob! If the caregivers are to be prosecuted, those who made the situation should also be prosecuted!

    Reply
    1. Bob Goddard Post author

      Thank you! And I agree that the lawmakers who allowed this situation to happen at GRHV should be held accountable

      Reply
  5. Jan Read

    This was so well written and tells a bigger picture of what a caregiver does in a so called routine day!! Management also has some accountability in this situation for they need to come out on the nursing units more often and actually job shadow with a caregiver to realize one person cannot adequately provide care for 10-13 members and pass it up the chain of command!! Maybe the senators and congressmen need to sped a day on a unit instead of quick walk through. These veterans a are humans and deserve respect!!

    Reply
    1. Bob Goddard Post author

      Thank you, Jan. Yes, I’ve always thought that management and supervisors should have greater involvement in the details of the daily care routine. That’s not an opinion shared by everyone, by any means! And I remember several supervisors in my time at GRHV who really did have a handle on what was going on. They also tended to be the most supportive

      Reply
    1. Bob Goddard Post author

      And thank you for taking the time to read it. Giving voice to the caregiver’s perspective is why I started this blog

      Reply
  6. Deb White

    Way to go Bob. Could not have said it better. Question is.. Will the bigwigs understand this side if the equation or even care?

    Reply
    1. Bob Goddard Post author

      Thank you, Deb. I think it takes many voices to truly present this side of the equation. And even more to get something done

      Reply
  7. Ronna

    Caregivers are the ones nurses depend on to be alerted to physical and emotional changes to report to the care team including physicians and family. Before the caregivers were privatized, I as a former nurse manager can say the state employees were invested with the veterans, going above and beyond. They knew their habits and quirks and brought them little things from the outside that made their day. I am proud to have worked with these caregivers. They were the best!

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  8. Linda S.

    I worked at the GRHV for J2S. J2S would push us caregivers to burnout. Although I was core staff on a unit they still pulled me to a unit I was not familiar with. How do you care for and give good quality care to members you’ve never worked with? J2S liked to use intimidation for just about anything. A per diem caregiver was taken off the schedule until she committed to certain days and made to work a permanent schedule. The manager stated That the prn status was taken away 6 months prior to this, but the caregiver was never told til tge day she was taken off the schedule.Often caregivers were moved to 3 different units in an 8 hour shift. Caregivers that walked off the job in the middle of the shift we able to come back the next week without discipline. J2S treated their caregivers like dirt no respect whatsoever! If they didn’t like you in the office it was known. Now caregivers that still worked for J2S didn’t even know they went out of business and are still owed a check. I think the owners of J2S should also be investigated!

    Reply
    1. Bob Goddard Post author

      I really appreciate your comment, Linda. When I said we routinely throw caregivers into chaotic situations, this is the kind of thing I was talking about

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    2. Sue

      OMG U r so rite j2s treated their CENA like cramp they talked crazy to u lied on them to cover their own ass messed with ur schedule promised double time to ya and not pay ya for it i have even seen a office personally get physical with staff and still have a job i never could understand how they was even able to get. The contract for the VA home my check was never rite they had their favorites and u was just out of luck if u wasnt liked by the scheduledr who was workin its sad cause with out us aides they was screwed. So it wasnt hard to see they didnt give a dam about our VETERANS all they wanted was money. Greedy bastards

      Reply
  9. Anonymous

    State caregivers were committed and compassionate career employees. For most of us it was our one and only job. The pay and benefits afforded us this. What a huge difference this makes. Some critics often said we were over paid. It’s so far from the truth. The majority of CNAs are simply not paid enough. The work they do is some of the hardest work there is. It is also work not anyone can do or should do. It’s not only physically draining but emotionally as well. If and when I or one of my loved ones get to the point of needing longterm care I want someone who is there for the career and not someone who needs to leave early to get to their next job

    Reply
    1. Bob Goddard Post author

      This: “Some critics often said we were over paid. It’s so far from the truth. The majority of CNAs are simply not paid enough.” Exactly! Actually, I think your entire comment was spot on.

      Reply
    1. Bob Goddard Post author

      I believe there is such a thing as “good” anxiety for a caregiver. The kind that keeps you on your toes, out of concern for the safety and well-being of the resident. But fear created by threatening people results in something altogether different

      Reply
  10. Melissa

    Very well written you got it right this time, coming from a former caregiver at the veterans home and former J2S employee

    Reply
  11. GRHV Rn

    Once again, the bureaucrats & media choose to blame the underdog in a situation that they themselves have created through poor choices & budget cuts, instead of correcting the situation and taking responsibility for their dirty deeds. Direct care workers are the most underpaid & underrecognized profession in the industry. Having worked every position from Nurses’ Aid to Director of Nursing over a 35+ year nursing career, and having first hand knowledge of this situation, I know that there were better ways to accomplish their goals while still maintaining the quality of care that the State Resident Care Aides were able to provide. Instead of trying to work with what they had, they chose to ignore the recommendations of the Home’s Nursing Management and proceed with budget cuts & privatization; with the end result exactly as predicted. Now, they focus on a management tool that is not even a part of the medical record, and then charge them with a crime for trying to do their best. This is another example of wasting tax dollars & projecting blame rather than accepting responsibility for bad decisions.

    Reply
        1. Bob Goddard Post author

          Ah. Just when I thought I had everything figured out! Back in the days when Florida had oranges. Did you know that the orange crop in Florida is getting wiped out by a thing called “greening disease?” They really don’t know what to do about it.

          Reply
  12. minstrel

    Wow, Bob, in the very best sense you’ve opened the lid on a can of worms and let the rot out and the light in. It’s what all of us caregivers should be doing when we’re denied the resources we need to provide the care residents deserve. We cannot continue to cover for an inadequate system. It’s not only the VA homes that are poorly staffed; it’s virtually every long-term care community, whether Medicaid-supported or private pay. You’ve sounded a great call to ‘arms,’ not only for veterans bur for residents of all LTC homes. I hope you sent this to the area newspaper, Bob, and the other media. And to the members of the Congressional committees dealing with veterans. Thank you for all that you put into this. You can see the impact you’ve made. What’s next??

    Reply
    1. Bob Goddard Post author

      Minstrel, this can of worms has been open for some time now. I’m actually late to the discussion. As always, I appreciate your insight and support

      Reply
  13. Anonymous

    As a care giver it gets rough when the employer tries to keep you busy as much as possible with tedious tasks just so you look productive and serve no purpose, and when you do not have time to complete those tasks because something was going on you are punished 110%.

    Reply
    1. Bob Goddard Post author

      Yes, I always guarded my time the best I could from any of the nonsense. After all, the time they take from us doesn’t actually belong to us. It belongs to the people in our care.

      Reply
  14. David Bailey

    I just want to add a comment here even though I am the news reporter being criticized in it. I just would like you all to remember that the workers were not charged for not checking the rooms. The employees were charged for signing off that they did check the rooms when they didn’t (falsifying medical records). There’s much more to the story and I am not saying any of them are guilty. I am not here to judge. I just want to state the facts as they are.

    Reply
    1. Bob Goddard Post author

      Thank you for the clarification, David. Yes, there is more to the story and no doubt there is more to come. We’ll continue to follow the coverage with keen interest.

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    2. Anonymous

      One fact that has been missed here is that the document you are referring to was a data collection tool, and is not any part of a medical record. I’m just pointing out that charging them with falsifying a medical record was probably not the best way to hold them accountable since the document is not in any medical record.

      Reply
  15. Anonymous

    Sadly the current caregivers are not receiving any credit here. It doesn’t matter rather they are state employees are contractors, the fact is the current CENA’s are providing fantastic quality loving care. They come to work everyday and treat each member with professionalism, compassion, and love. Shame on those who say only great care comes from state employees.

    Reply
    1. Bob Goddard Post author

      Yes, there are excellent caregivers who work for agencies. I worked with many agency workers over the years, people I know and respect. I learned from them and became a better caregiver because of it. Some of them were eventually hired by the State. But the bigger issue here is haven’t we given the current workers a kind of a hard row to hoe? The work is demanding enough without the additional burdens of continuing staffing problems.

      Reply
  16. Anonymous

    Thank you Bob. Love it. I love all your blogs but this one is the best. Love it. Wish everyone was as compassionate as you.

    Reply
  17. Pam Bruining

    Bob that was so well written and you where of course right on with all of the care. Thank you for writing that.

    Reply

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