Published on:

Assisted Living Communities That Do Not Offer The Skilled Nursing Level of Care Cannot Necessarily Care For Your Loved One Through The End Of Life

As I have mentioned in the past, the lines between the levels of care provided by long-term care communities have become very blurred. As the number of assisted living communities providing specialized memory care seems to increase every week, here are some of the things you need to look out for if you are contemplating moving a loved one to one of them:

Last month, I was hired by a family to advocate for their grandfather who had recently turned 100 years old. He was living in an assisted living community that specialized in memory care. Please note that the level of care offered was assisted living only and did not include a third higher level of care, i.e., skilled nursing. When he entered the community a year ago, he had been totally ambulatory and able to take care of all of his activities of daily living with cueing. Shortly after he entered, the community physician decided to take him off of all of his memory-related medications (without the consent of the family), because the doctor felt the medications were adversely affecting the patient’s kidneys. The grandfather went into withdrawal and ended up in a wheel chair needing total assistance with all activities of daily living.

In addition, the absence of using one of the dementia medications made the grandfather combative. The staff at the community claimed that he was at times in need of a three-person assist. Normally, a two-person assist and beyond indicates that person should be in a nursing home. The staff requested that the family look elsewhere for a new community for their grandfather. The staff also requested that the family hire a private caregiver to assist Grampa with his activities of daily living and prevent him from getting out of bed. The cost of his care in assisted living was $8,300 a month, just as much as a nursing home, plus the cost of a caregiver. Since the grandfather was already 100 years old, the grandchildren did not want to move him. Upon the request of the grandchildren, I was asked to attend the quarterly care plan meeting (attended by the Administrator and representatives of dietary maintenance, social work and nursing). Here is what happened:

The first issue that was discussed was Grampa’s combativeness. In the presence of the community’s nurse practitioner, the question arose as to why he could not be put back on a very low dosage of the dementia medication in order to reduce his combativeness. The nurse practitioner replied that a low dose was not going to hurt his kidneys and arranged to have him placed back on the meds. A simple suggestion led to problem solved!

​When I questioned whether the community was perhaps understaffed to meet the acuity of its residents, the reply was, “Oh no, we are staffed according to state regulations.” When I probed further, I found out that, out of the 43 residents living at the community, 25% were effectively at a level 5 of care, with the level 1 being the lowest. When I asked where the remaining residents fell with regard to level of care, the Director of Nursing said, “I think between 3-4.” (Keep in mind, this facility did not officially truly offer even a third higher level of care, i.e., skilled nursing and beyond.) In addition, I found out that the bulk of the effectively level 5 residents were under hospice care, meaning the caregivers from the hospice company would relieve the regular staff members of some of their duties. Thus, the regular staff would be free to help with other things. When I questioned the administration about the extra help hospice care provided, they insisted it didn’t help.

​I found out that the community had been without an Activity Director for 3 months, which is inexcusable for a memory care community. The residents need mental stimulation.

​When I left the quarterly care planning meeting in the company of my client, the granddaughter, to meet the grandfather, I saw the staff members waiting 15 minutes early for a customary 3PM meeting and they were laughing and talking. For an assisted living community that had taken on residents with serious and, over time, compunding needs, such idleness was a clue and cause for concern.

​The grandfather was sitting in a library with 10 other residents, and 7 of them had private caregivers, presumably at a cost well over and above what the senior and his or her family might have anticipated at time of admission. The residents were all wheel chair bound and could be in potential need of future skilled nursing care. The absence of that third level of care at the community could mean another emotional move for the senior and family down the road.
So, when an Admissions Director tells you, “We can take care of your loved one from admission to the end of life,” beware of what I have shared above.