Category Archives: Abuse and Neglect

Broken System vs Personal Responsiblity

Sunflower  May

In compliance with HIPAA, all resident names and identifying details have been altered or removed.

If there’s a story of my career in health care, it’s probably: Nothing happens the easy way, or when I have time to deal with it. Take right now, for instance.
Mr. K has a reputation for being a jokester; he loves to laugh and he loves to make others laugh. The aides are his best audience as we always appreciate a bit of levity. Unfortunately, Mr. K doesn’t so much speak as he does mumble. It’s hard to understand him…especially when he’s cracked up laughing at his own joke. I know from experience that if I keep just repeating that I can’t understand him, his joy will vanish like his independence. So, I lean down and put my face right next to his mouth, in order to catch the words of what I am assuming is a killer joke. When he repeats himself yet again, I don’t take in his words. I can’t; I’m a bit distracted.
His breath is so foul, it smells like something died in it.

I didn’t brush his teeth this morning. I haven’t brushed his teeth all week. As I gag, I ask myself “How did this happen?”

Oral care is often the last part of personal care to be done, and by the time I get to it, I’ve been in the room for fifteen minutes already and ten other call lights are going off. It seems like a quick task, so it’s easy to say “I’ll get to it in a moment,”…and then never actually find time for that moment. When you’re scrambling just to change your people, making the time to do oral care is hard. Adding another five minutes to each resident’s personal care time, when you have ten residents and you’re already running behind…yeah, that adds up quick. Sometimes it is literally a choice between brushing Mr. K’s teeth or changing Mrs. L’s brief before she soaks through her pants. In other words: when you only have ten minutes, what is the most effective way to use them? Most often, we choose the big problems to tackle, the things that have an immediate impact on our residents’ quality of life.
The other problem is that we get so used to dealing with emergencies, crunch-times and hard decisions. We get so used to cutting corners just to survive the day that we form habits around the emergencies. The little things that we had to drop during the crisis? We forget to pick them back up. We get used to not brushing teeth.

The problem of oral care is the problem of this broken system of long-term care, narrowed to razor-thin focus: too few aides taking care of too many residents. We have a system that punishes the aides who take the time to provide good care, and then punishes them again for providing mediocre care. And yet, for all that is true, Mr. K’s mouth still smells like something died in it. I am still his aide…do the flaws of the system really absolve me of my personal responsibility? Being a CNA is, in so many ways, to be forever caught in the moment of drowning: my best isn’t good enough and yet my best is always required.

I laugh, like I got the joke. “Good one, Mr. K! Tell you what, while you think of another one, I’m going to brush your teeth, ok?”

Empathy vs Apathy

Sunflower  May

In compliance with HIPAA, all names and identifying details have been altered or removed to protect patient privacy.

Can I ask you something?” a newbie CNA asks me…in that tone of voice that usually means “Trouble this way”. We’re assisting Mrs. A to eat her lunch, although “assist” doesn’t quite seem like the right word when all she can do on her own is open her mouth. 

“Um,” I say, “sure.”

“That one aide. Why is she like this? How do you get to point where you just don’t care? Why does she act like giving these people your very best is a waste of time?”

“Well,” I sigh. “There’s a lot of stress that goes with being a CNA, and a lot of the time you don’t seem to be making a difference…”

He picks up the spoon, loads it up with mashed potatoes and gently gives it to Mrs. A. “There,” he says, “I just made a hell of a lot of difference for her.”

I almost come out of my seat. “Promise me you’ll stick with this,” I say fervently. “You’re right. Every little bit we do makes the world of difference…but sometimes it’s hard to remember that when you’re frustrated, over-worked and, well, when nobody else sees the good you do. And for that one aide, well, sometimes it’s easier to shut off the part of you that can feel, to spare you from feeling despair. Some aides learn how not to care to survive this broken system ”

“You didn’t,” he says indignantly. “I won’t.”

“Remember that promise,” I say gently, “but also remember this: deciding to be a good aide is not a battle you will ever leave behind you. It’s a choice you will have to keep making every single shift, to do your best even when it seems pointless, to keep being kind even when your efforts seem as terminal as your resident.”

“Is that what makes a bad aide then?” He asks. “Deciding that your best isn’t required? Choosing apathy over empathy?”


What is the good of small acts of kindness done for a person who will shortly be dead? Isn’t it a waste of time and talent? Isn’t your struggle to be kind as terminal as the disease killing your resident? One day soon, your resident will lie cold in a bed and there will be nobody left to remember how you put off your break so you could fluff her pillow. Nobody saw you give a good bed bath to Mr. T instead of just running a wet wash cloth over him. So what’s the point of trying? Why put yourself through the agony of giving good care in a system that is not set up for small acts of compassion?

Nobody wants to admit to having these feelings. Who wants to stand up and proclaim to the world that you wonder if somebody’s grandparent was worth the effort?
So instead of acknowledging these doubts, you repress them. You decide that you’re going to be a good caregiver, not like those bad ones who seem to act only on your worst thoughts. So you take your doubts and you shove them down, bury them deep, you say that you’ll never be like those CNAs…but idealism and good intentions will only carry you so far. Eventually, you will reach the place where everything exists in extremes and to feel at all is to be in pain. In that place, it easier to just shut it off, to distance yourself from that which causes you pain.
In this case, what causes you pain is the same thing that causes you doubts.
How do you handle the stress of constantly never being good enough? When you are constantly given more work than you can do and when you see your residents suffering because of it…what can you do?
Becoming a jaded CNA is not a single decision you make; there’s no switch you flip between “good CNA” and “bad CNA”. It is instead a series of small compromises. It’s slowly learning how to shut off the connection between you and the resident, until that resident seems more like work than a person. It’s getting to the place where your worst thoughts are the only ones you can hear. That’s when you become the thing you swore to never be.
This is how you surrender your compassion…because it hurt too much to care. Empathy hurts and apathy is appealing.
So, to all new CNAs, don’t go in blind. Being a CNA is like holding your heart to a cheese-grater. To feel is to feel pain. You will doubt whether you’re actually doing any good, and any difference you make will seem to die with your resident.
When these doubts came, face them. Look them straight in the eye and do not despair.
Doubts do not define you; a feeling that came over you during the struggle does not make you a bad person. But a feeling you buried deep in the bedrock of your soul, left to fester until it poisoned all the feelings that came after it…that one might, in ways you never expected. Sometimes, they chain you in such a way that you will never get free. The only way to break the chains is to acknowledge that they are there.
Remember that empathy hurts, but apathy doesn’t…because apathy means you don’t feel anything. Not pain and not joy. You can’t have one without the other, not in life and especially not in Long-Term Care.

And most of all, do not forget the other person in the room. Never forget the silent observer to the tiny acts of compassion, to all the sacrifices and struggles to carve out room for good care.
Do not forget yourself. 

“I’m Just Doin’ My Job”





One of my all-time favorite movie lines was spoken by Paul Newman in Cool Hand Luke.  Luke, the non-conforming prisoner in a tough southern prison, refuses to accept the prison’s status quo.  His conduct is a cascade of rebelliousness, until finally the warden orders Luke to “the box.”  The box is a small tin-roofed building, the size of an outhouse, under the blazing sun in the middle of the hot, dry prison yard.  After Luke spends twenty-four punishing hours in the box, the guard releases him.  As he does he says, “Sorry Luke, I’m just doin’ my job.  Ya got to appreciate that.”  Luke replies,  “Nah, callin’ it your job don’t make it right, Boss.”   

Calling it our job doesn’t make things right.  Among the most pernicious problems in long-termcare homes is staffing shortages.  With a census of 25 to 35 residents or patients needing skilled nursing and/or dementia care, there might be only three to five aides scheduled to work a shift.  (Then there are the last-minute call-outs).  If the aide is lucky, very lucky, she may have only five or six persons to care for.  The more frequent reality is having seven to ten persons needing care.  Remember that cacophony of call bells that May wrote about?  Blame it on short-staffing.  And the resident pleading for you to take her to the toilet?  Oops, it’s already too late…  The resident teetering perilously as we rush to prevent a fall? … And the time you lifted a non-ambulatory person by yourself because there was no one around to help?  What about those wheelchair bound residents who haven’t been taken out to feel the fresh air in weeks?  The hits just keep on comin’.   And we keep right on keepin’ on, because it’s our job; right?   

No, it isn’t.  We simply can’t do our jobs as CNAs adequately when we’re so understaffed.  What most determines the quality of care is the staff-to-resident ratios (‘duh’).  I challenge anyone to find an aide who disagrees with this.   Yes, staff need to be trained in good care practices.  Yes, we need to have certain supplies available (soap, towels, functioning hospital beds, appealing food, etc.).  But the key to quality care, to person-centered care is PERSONS.  Staff.  

We continue to work in short-staffed conditions we know violate our residents’ right to good care.  (See for a description of rights of persons in nursing homes.)  If we ‘complain’ to management about short staffing (and that’s how it’s viewed, as a petty complaint), we’re told sweetly that the staffing levels meet the state requirements.  And that’s probably true, because industry lobbyists have made sure that state regulators don’t burden the long-term-care industry with costly staffing requirements.

We complain about these deplorable conditions all the time.  As CNAs we’re mandated reporters of abuse.  (I guess we’d better not think about that one too much!)  But we tolerate abuse that residents endure as a result of understaffing.  Abuse isn’t just about physical or sexual assault.  It’s also about neglect and emotional abuse.  If I neglect a call bell for so long that a resident is left to soil himself and remain in his soiled condition for hours, that is abuse.  If I say to a resident who asks to be taken to the toilet, “Janie, I just put a clean Depends on you; I can’t get you back into the Hoyer lift and take you to the toilet, you have a diaper on, you can use that,” that is abuse.  Abuse is ridiculing a resident who cries for her mother all afternoon; scolding a resident who spills her drink all over the floor; ignoring the call bell of a resident who constantly asks to be taken to the toilet minutes after the last toilet trip, because we know she ‘doesn’t really have to go.’  Well, she needs something and it’s our job as aides to find out what.  “But I don’t have time for all that.  I have seven other residents to get to.  I’m just doin’ my job.”  

So what can we do?  Unlike the workers of the 1920’s and ’30’s, we can’t go on strike to win better working conditions.  We’re caring for the sick and the frail, not assembling cars.  But if we can’t leave the floor for a sit-down strike, we can use our cell phones as weapons in the revolution for better care.  Call your county or state abuse hotline every time aides have more than six residents to care for on a shift.  (And don’t count the LPN or Medication Aide in your ratio if she isn’t providing care, even if management does.)  The state regulators aren’t always thrilled to receive reports of abuse because they are short-staffed too, and don’t have the means to investigate all complaints properly.  They don’t always to a good job, for the same reasons we don’t always: because they’re understaffed and a little intimidated by their bosses.  

Revolution isn’t about violence and nastiness. (Remember Gandhi and Mandela and Rosa Parks.)  It’s about patient persistence and never giving up as long as change is needed.  It means taking that first step.  Maybe our first step will be a phone call.  

The mistakes we make


“They had a responsibility to care for your loved one.”

There’s only one coherent thought in my head, and that’s “Damn commercial”.
I’d turn it off, but then I’d have to a) get up off this floor and b) come out of this bathroom. And I just don’t have the energy, or the willpower to do these things. It’s crowded enough without opening the door and letting the world in; just me and my mistake. Perhaps I’m overreacting; people say I’m good at that.
“Everyone makes mistakes.”
“You’re only human.”
“Even the best fall down sometimes.”

All true, of course. All absolutely true. Perfection is impossible.
But I’m a CNA. My mistakes are marked on my residents’ quality of life. A skin tear if I’m not careful; a fall if I’m not paying attention; an error in front of a surveyor if I’m not collected. So many things to go wrong, so many mistakes to make. It’s all well and good to say “learn from your mistakes”, but the truth is, long term care isn’t known for its mercy. We really can’t be: our profession is the knife edge between care and neglect, advocacy and abuse. Mistakes can’t be tolerated. It’s the residents that matter.
“Your loved ones deserve better,” the narrator booms on. “Make them pay!”
Is that what I’m afraid of? That someday I’ll make a mistake in front of the wrong person and get sued? That someone will file a complaint? That I’ll get accused of abuse? That I’ll lose my certification?
I drop my head to my hands. Right now, I’m afraid of two things: that I’ll start crying and that someone’s going to need this bathroom before I’m ready to leave. This isn’t exactly a great place for a breakdown…but I guess you really can’t choose the moment you’re going to snap. Because if I could, I wouldn’t have chosen the moment right before an ambulance-chasing lawyer commercial came on. My problem with it isn’t that it exists…just that it played at the exact moment I pulled an inadequately tucked hoyeir pad out from underneath a resident. One of the straps got caught on her arm and opened a large skin tear.
And now that same commercial is playing again. I feel like it’s following me, taunting me. See how the mighty have fallen; this “good aide” who prides herself on her “conscientiousness” got in a rush and hurt a resident. Oh, great. Here I go again…

No. I get up and splash cold water on my face. There’s a CNA looking back at me from the mirror….I can tell because she’s exhausted but determined to carry on. It’s that or quit, after all; maybe it’s pride, but I am more than the mistakes I make.
So I caused a skin tear. A big, nasty one. Yes, I did the right thing and told the nurse straight away without trying to conceal anything. Yes, her family is very upset. Yes, I overheard two coworkers talking about me and my “big mess up”. Yes, I messed up. Yes, I was in a hurry because we’re short and I’m tired because I’ve been working over a lot. And yes, there’s that damned commercial playing again.
Big whoop. There’s still a lot to do and my residents still need me to help them…Lord knows they aren’t going to change and transfer themselves without more injuries. The truth is, my residents’ quality of care is greatly dependent on my frame of mind; my wellbeing connected to theirs.
Time to calm down and get back to work.

An Obligation to Testify




A quick review of CNA related Facebook pages will show that no group of people get more upset over media reports of court cases involving caregiver abuse of nursing home residents than other caregivers. After expressing their shock and disgust, caregivers will often add that they have no problem reporting other staff members who mistreat residents.  There is nothing in these comments to suggest that both the strong emotion and the claim are anything but genuine.

Not all forms of abuse are equally severe.  When determining charges and sentencing, the legal system itself takes into consideration such things as the intent of the accused, the severity of a crime and – important for our purposes here – how the victim experienced it. Obviously, some acts are particularly heinous and deserve harsher sentences.

Caregivers are obligated both morally and legally not only to report incidents of abuse that they’ve witness, but to intervene on behalf of the victim.  Silence and inaction are forms of collusion and zero tolerance is the standard policy. Zero tolerance means that the relative severity of mistreatment cannot be used to relieve long-term care staff of the responsibility to intervene and report.

How a resident experiences our interactions with them is a primary consideration. As caregivers we may not intend to mistreat, but if we fail to give reasonable and adequate attention to how a resident perceives any given interaction, we could be guilty of a form neglect or abuse.  Perhaps not a severe or overt form, but under zero tolerance it is a violation and we are required to intervene and report.

The quality of life for residents in a long-term care setting depends on much more than how they experience their interactions with their direct caregivers. While the factors that determine their quality of life are diverse and complex, there is at least one universal standard that should be applied in all situations: how does the resident experience it?

No one is more aware of how residents experience life in a nursing home than their caregivers. Direct care workers accompany residents through that experience on a daily basis.  They see and feel the impact of when the system is working  – and when it fails. They are familiar with the flaws of long-term care in a way no one else can be: in intimate detail and within the context of the lives of the people in their care.  No quality assessment tool or inspection protocol can adequately replace that unique perspective.

This is a perspective that informs the worker of how things such as inadequate staffing levels, an unstable work force and insufficient or inappropriate regulation negatively affect residents. Because of the way residents experience that impact, it is nothing less than a systemic form of abuse and neglect.

While systemic forms of mistreatment are not intentional or overt, under zero tolerance do we not as witnesses have a moral obligation to report them like any other form of abuse?

If so, the question then becomes how do we respond to this obligation? How and to whom do we report?