Nursing Homes and Care Homes Should Not Be For Abuse

Back when I left academics to start my private practice (this would have been around 1992), I filled in some vacant days at county mental health clinics until I could fill my private office schedule.

From the very first, I was exposed to mentally ill patients who lived in boarding homes.  Some of them were reasonable – I wouldn’t say any were good – but some were tragic situations and the residents were basically trapped.  They needed somebody to take care of them, and in many cases they were taken advantage of.

I just kind of tripped over this recent report of abuses in the board-and-care homes. The hard thing for me is that it is so easy to believe.  I am glad the video was not released to the public because I am certain that it would be the most popular “viral video” on the internet.

The number of people in any world — mine in particular — who get off on physical cruelty is beyond mind-boggling. Since we are dealing with “care homes” I will avoid diving into what family members do to each other. In California, private homes can be licensed for “non-medical custodial care.”  I have avoided setting foot in these facilities for a number of reasons, but let us say simply that the laws here permit the licensure of facilities as small as single family homes, with six guests or less living like a surrogate family, to bigger facilities that look for all the world like nursing homes.   The tinier facilities account for 90% of the lot, or about 8100 facilities.

The way most of them work, the residents sign over their monthly disability checks in exchange for food and lodging, and someone in the facility is charged with dispensing medications since the residents can’t always be responsible for remembering dosages and when to take them.

I still have a vivid memory of a woman I met while working as an outpatient psychiatrist at the VA in Las Vegas, who had a bit of a tussle with the local nursing board and announced to me one day she was moving over the border to California.  She had in her care four schizophrenics, and it was a lot easier to get licensed to run a custodial facility (also known as a “board and care home”) in the Golden State.

Now the California agency’s web page explains that we are dealing with a less “medicalized” standard of care than a nursing home.  Although people find it easy to rhapsodize on the advantages, which may well exist for the right patient (not everyone who cannot live alone is a psychiatric patient), a choice has been made, on some level for money. Are you beginning to notice a common thread throughout these troublesome topics?  It’s always about the money rather than the standard of care.

Once choices have been made that are relevant to cost, questions have to be raised.

The California department of health does as good a job as any and a better job than most.  This is one of the reasons why I chose this state as my home base, for I could be anywhere I wanted to if I were willing to take enough exams.

Now this agency has applications for accreditation for a number of levels of care — but not the board-and-cares, because they are too “low” on the totem pole of things, and are regulated by county offices.  So I have nothing in writing here, and if I did, I can promise you from experience in a dozen or more California counties that it would not be consistent.  But I have experienced these facilities in a number of ways.

There are employees  who are low level — not a lot of university degrees — but I have known a few who have real “people sense,” who are helpful to the impaired people in their charge, and love to keep them productive and smiling.  There are not many of these, as more and more people choose jobs for money and not for talent or pleasure or life purpose or anything else I can think of.

There are patients, often rejected by their families sometimes for good reason and sometimes for bad reason. These places are supposed to be “non-medicalized” so patients are supposed to monitor their own medications.  Most of the time, however, some kind of a listing is kept of the medications given.

The patients may have been rejected by their families.  They may want a chance at independence and not yet be the kind of patient you send out with a hotel reservation and a couple of travelers’ checks.

Such was my own brother of blessed memory.  I will never know exactly what kind of a medication error happened in that board and care, only that it started a downward spiral to the lithium toxicity that led to hospitalization, and emergency dialysis that led him to a pulmonary embolus and to his untimely and totally unnecessary death at a young age.

I have visited the house of a friend — a singer– who did a little work with my husband working on some new music for her.  I saw her children, as well as the mentally handicapped people for whom she cared, take the run of the house, and participate in family rituals like singing, and smile and be happy.  I remember particularly vividly the girl who was identified as a doctor’s daughter, because I thought, as she was singing, that her own parents could not have given her this kind of care, and something had probably been gained by the placement.

For now, the most intelligent thing I can say about people in this level of care is that when I was doing acute, inpatient psychiatry, the time most people got into trouble was when they moved from an intensive care unit to a “stepdown” unit – a place where the level of care was somewhat less.

It is clear when someone who has had an ulcer or surgery with blood loss is “stable.” There are vital signs and numbers and things that can be measured. There are no such measurements for the psychologically impaired, so it is especially often to check — and to check a heck of a lot.

I am reminded of a hospital where I served my surgical internship that serviced many Russian-Jewish emigrants.  I was surprised at first but later understood why family members moved into the hospital room and slept on cots. The family members would go to the nursing station in the middle of the night and ask for service.  They were used to an ill-monitored system, where they knew that the wheel that squeaked the loudest would get the grease, and they made one awful lot of noise.

A quick internet search shows a lot about elder abuse and nursing homes and lawyers who specialize in same.  It is harder to find information about board-and-cares, but we must say simply that the opportunities for abuse are many, especially because it is a part of the system with lower costs, and it seems, a bit less regulation.

But wait, there’s more.

Back to the LA tape, which nobody in the public has seen, but which allegedly shows sex and assaults.  On the one hand, these are things which absolutely should not happen when they represent a breach of personal rights.  But I feel strongly sexual satisfaction is a basic human right – as important as food and drink and shelter for one’s well-being.  A competent person should have sexual pleasure, as long as it is not so risky it will surely destroy them. I do not know the legality of informed consent, except that there was probably not one in the examples on the tape.

Ahh — life pre-AIDS.  I remember now with some affection the day I came to work in a French psychiatric hospital and found two patients (of opposite sexes) fornicating in a corner, joyously with squeals of delight.  That was how this medical student learned (a kind nurse did show me in the patient’s chart) that the woman was on oral contraception — and had been a victim of so much horrendous violence in her lifetime that she deserved any joy she could find.

Yeah – you might mutter about those French and their one-track minds.  I guess I’m more of a humanist and care about the human beings. Many years later, I was called upon to discuss sexually in the aged with the staff of a nursing home in the buckle of the Bible Belt.  I still remember how I shocked everyone by saying people did not need to be stopped if they happened to be masturbating alone and peacefully.But consensual sex among patients brought up all kinds of questions that could not be resolved at that moment, questions such as competency, which I had no choice but to leave with the lawyers.

At least people are asking the right questions.  They may not yet have found answers. But while this article comes from the Midwest, what on earth are the people in the Los Angeles surveillance video doing? Nothing.  As little as possible.  People abuse each other — responding to base instincts, or ignoring the social mandate to care for the disabled.  These things are just too easy. Social legislation is all we got.

These people should be slammed.