Neglect Meets Advocacy

I can’t say I ever enjoyed doing incident investigations through all the years I spent in safety. That said, the investigations were much easier for me to stomach that providing direct care. I’m fine with seeing my own blood, give me a piece of duct tape and we’re good to go, but I might just pass out if I see much of anyone else’s blood. The problem with incident investigation is that, almost always, someone was injured. One of the seeds I pulled from that experience was a keen ability to analyze data for behavioral trends and root causes. That was incredibly useful through many of the care plan conversations we had with the staff and nursing director we were paying a fortune to see to Granny’s safety and wellbeing.

After a quick study of those twenty-plus falls in right at ninety days, I realized that more than seventy-five percent of them had occurred between 10p and 6a. Coincidentally, there were only three staff members covering twenty-two residents during that time. Technically, that fell within the state regulation. The bait-and-switch came with eleven residents being in one building and eleven being in another - with more than 100 feet separating the buildings - leaving just one to meet the needs of eleven elderly complete-care patients at any given moment. In theory, a second person was available but that assumed they weren’t tied up with something else and that they were even paying attention.

We politely raised this concern in one of the care plan meetings and were told our only option was to hire someone on our own to provide any additional service Granny may need. Knowing the covering guidelines and learning about the unreported falls led us to insist on a face-to-face conversation with the organization’s CEO, someone Cindy had worked with for years earlier in their careers. After a brief check-the-box listening session, the CEO said they wouldn’t be able to add more staffing “even if they wanted to,” citing a shortage of workers with that skill set. 

Here’s a bit of perspective: from late 2017 to early 2020, we were paying nearly $12,000 per month for Granny to live there and be cared for. And there were ten other residents in that same building. Do the math and help me understand how tough it could be to add another $12-14/hour employee (that was the average wage for that role at the time). The fact that we chose to bring this to the CEO civilly rather than file a formal complaint (based on staffing and unreported falls) wasn’t appreciated at all. On so many occasions leading up to that, that same CEO told us how easy Granny was to care for. I guess that $12k/month was nice when there wasn’t much work tied to it. I pointed that out when I realized we were being brushed off, saying that apparently the easy quarter million they had already been paid hadn’t earned much collateral when any real attention was necessary.

I can’t think of a time in my entire career where I wasn’t willing to work my guts out to help an organization I had any kind of relationship with. In fact, we had hosted a fundraising event for THIS organization just a few years prior to when all this unfolded. But like the scenario earlier in our careers where the jackass was sexually harassing ladies who were uncomfortable standing up to him on their own, there was no option where I was willing to stand for that crap happening to Granny. In the original Roadhouse movie, Patrick Swayze said “Be nice, until it’s time not to be nice.” That time came as our conversation with the CEO wrapped up.

Caregiving conflicts test sympathy and courage; discovering harm to a vulnerable person forces a choice between comfort and moral action. I was absolutely not looking for that fight, but I wasn’t willing to back down from it either. And that brought family strain, institutional pushback, and professional risk, all of which we’ll start working through next. Before that, think of a time you witnessed (or even suspected) neglect or mistreatment of someone vulnerable. What blind spot in loyalty or institutional trust did it expose? For us, having such a strong and test foundation built on our core values made all the difference.