Caring for Larger Residents: Preserving Dignity Without Sacrificing Safety

Dealing with resident rights, mobility, and hygiene in the bariatric population

INTERVIEW WITH BARBARA LANDY, NHA, AND DOTTY OLSEN-DEHON, OTR

Do you seem to get more referrals for extremely obese residents than the other long-term care facilities in your area get? If so, why is that?

Landy: Yes, based on conversations I’ve had with other administrators, we do. There are several reasons for this, I believe. First, we’re seen as an “expert facility” for managing younger residents, and many of the very large residents have been under 50 years of age. Another factor is that some of these residents have been on Medicaid, and some of the other nursing homes in the area don’t take Medicaid beneficiaries.

Also, providing care for bariatric clients can be much costlier than for other clients, so managing all their needs requires a greater financial commitment than some facilities are willing to make. Since we’re a healthcare taxing district facility, we have a special commitment to accepting those with unique and challenging needs. Finally, these people often have many complications, and we’re experienced with handling multisystem medical problems.

Over the past year, how many extremely obese residents have you cared for at your facility?

Landy: There have been roughly 10 residents or rehab clients we’ve cared for in the past year whose weight was a significant issue in their medical management and rehabilitation-in the 400 pounds or higher range. There were another 20 or more who were almost within that range.

It must be challenging at times to look out for residents’ rights and dignity when those residents are exceptionally large. Could you address that?

Landy: First, any population that’s made up of younger residents, as our bariatric population is, will present more of a challenge. If a nursing home is accustomed to older people and their rights issues, they’ll find that younger people bring with them a whole different set of issues. They’re much more demanding.

Regarding our bariatric population specifically, one issue that comes up is their right to have access to food that’s not on their diets. A resident’s physician evaluates that resident and might place her on an eating regimen, but compliance is really up to the resident. As her caregivers, we have to respect her right to choose to follow that diet or not. She might not. For example, she might go to vending machines to buy snacks, or she might ask staff to pick up food for her from outside the facility. Whether it’s good for her or not, it’s her right to ask. Also, some residents who are bedfast ask their families, church members, and friends to bring them food that isn’t on their diets-whether it’s high in calories, fat, sodium, or sugar, or just a larger volume of food than their doctors have recommended.

How do you deal with this?

Landy: By being extremely straightforward in care planning meetings. It’s important to explain why the physician has chosen the particular regimen he or she has chosen. Although we will support residents’ rights to choose, we certainly encourage them to adhere to their doctors’ recommendations and encourage their families to cooperate in this. And we praise them when they succeed. We do not, however, chastise them if they fall outside those recommendations.

Another issue that arises involving rights relates to residents’ mobility. Approximately 50% of the bariatric population is not terribly interested in leaving their surroundings. They are either bedfast or “chair-fast,” and they’re often resistant to socializing. We have to respect their right to either assemble with other residents or not. We endeavor to create milieus where all residents feel welcome and comfortable, such as the common dining room, but these residents often don’t want to eat communally. They prefer smaller groups or solo activities.

Residents also have a choice in the clothing they’ll wear. Quite often, bariatric residents have had long periods of prolonged inactivity and are not used to dressing. Many of them frequently feel warm, so they might not want to wear regular clothing as many other residents do. They might want to remain in their pajamas all day or wear thinner clothing than we’d like to see them wearing in public areas. We do encourage them to dress, but we can’t force them.

The last and the most difficult area of resident rights involves hygiene. Some residents are so extremely obese that caring for their own personal cleanliness needs is challenging for them; they can’t reach everywhere that needs washing because they’re so large or because they lack the range of motion or flexibility required. We offer them personal care, and many welcome it but some do not. We have to walk a fine line between their right to choose how often they’ll bathe or receive help bathing, and creating a problem for other residents.

What measures can you take to educate and encourage the residents who are reluctant to be helped with hygiene but can’t take care of their own cleanliness?

Landy: We have a staff psychologist and a social worker who address self-esteem issues. They also help clients and residents learn to deal with living disabled in an “abled” world. We also try to instill in them a sense of pride. Sometimes residents are embarrassed about being unable to take care of their own bathing and grooming and would rather not deal with this issue. We tell them it’s not their fault and that we just want them to have the opportunity to be as clean as their neighbors.

Olsen-DeHon: Even all the adaptive equipment does not allow some residents to bathe thoroughly. We’ve become fairly ingenious with strategies to allow them to be clean after toileting when their arms are too short. Unfortunately, those handles made for that purpose often aren’t easily manipulated. We’ve looked at adding flexible tubing to the ends, but this sometimes becomes a hygiene problem. We are continually adding to and reshaping products so they reach the desired position.

We also teach obese residents ways to stand so that they have a better reach, and we teach them to be more ambidextrous than they were before. It gives them an increased sense of pride when they learn alternative ways to care for themselves. Sometimes these are functional tasks they haven’t been able to do for years.

How do you deal with safety for staff who must move these extra-large residents?

Olsen-DeHon: Standard wheelchairs accommodate people weighing 250 pounds or less, and standard lifts can handle about 300 to 350 pounds. But we’re dealing with residents who weigh 400 to 600 pounds and more. There are many safety issues related to moving them from a bed to a commode or a shower gurney, or weighing them safely. Often a resident will say, “I want to stand by myself,” when he’s just gotten out of the hospital and hasn’t stood alone for several months. We have to explain that it’s unsafe, both for him and his caregivers.

Medical conditions-such as limited range of motion, high blood pressure, and diabetes-also influence these residents’ mobility. We also have to make sure a resident’s mental state is all right before we let him stand on his own.

I should also mention that when these individuals are receiving physical or occupational therapy, they have a much longer rehab road after a major-or sometimes even a minor-illness or injury than someone of average weight or size.

Their care also requires more equipment, more staff, and more staff training. For example, it can take as many as six people to help move a 600-lb resident from bed to a shower gurney using a lift; some operate the lift while others help guide the resident and, if he or she is new and in a state of high anxiety, someone is needed to verbally calm him or her down. Simpler, more routine transfers of larger residents with a lift still require at least two staff members.

What do you provide in the way of staff education, to ensure that all staff members are aware of these residents’ rights and how to protect them?

Landy: We have an annual in-service, and if a new resident poses new questions or presents new problems, we meet with the staff and explain how our actions reflect on residents’ rights.

Olsen-DeHon: This is a conversation we’re always having with staff. Staff ask those questions-and get them answered-on an ongoing basis.

Have there been many changes over the last few years in terms of equipment and products available to use in caring for the extremely obese?

Landy: When I first looked for a wheelchair that would accommodate a larger person, I could only find one vendor that supplied one that was wide and deep enough. This was around 1996, when I first realized our facility was getting more and more bariatric residents and clients referred here from hospitals. I searched the Internet for bariatric commodes, showers, walkers, canes, beds, and scales. I didn’t find much; it was quite a challenge back then. For example, I couldn’t find a scale that was wide enough to fit the bariatric wheelchairs, so I had to have one made in Canada and shipped to us.

What a difference seven years has made! I recently looked for extra-large wheelchairs and found at least three companies that provide them, as well as extra-large beds and other equipment. I also located a wonderful chair for transporting larger people that can fit into an ambulance.

We’ve come a long way toward serving this population. Before we had to have our staff shore up existing equipment somehow to accommodate our bariatric residents, or build something from scratch. Now, although bariatric equipment is rather costly, at least there are choices.

How expensive is this special equipment?

Landy: Beds are about $2,700 and up-that is, if the resident fits into a standard bariatric bed and doesn’t need one that’s custom-made. If someone weighs more than 500 pounds and is beyond a certain width, then a bed for that person becomes even more expensive.

I’ve seen wheelchairs that cost as much as $10,000. I understand why they’re more than standard chairs: They have to meet weight and usage requirements, have a certain turning radius, and feature sturdy tires that will roll without problems under the resident’s weight. The materials and seat structure must be strong enough. The same applies to lifts and slings.

Are residents in the bariatric population at increased risk of developing pressure ulcers?

Landy: For whatever reason, we haven’t noticed a higher risk. We have had bariatric residents arrive here with ulcers, and healing them was difficult. But they don’t appear to be more susceptible, and we take the same preventive precautions used for other residents. We’re in the habit of checking all our residents’ skin, of course, and we haven’t identified any particular problem with the extremely obese ones.

Are these residents at higher risk than the general population for certain diseases, such as diabetes?

Landy: Oddly enough, the incidence of diabetes in these residents at our facility has been fairly low. Some of them have had circulation or cardiac problems, but even those haven’t often occurred until the end of their lifespan. Many bariatric residents have complicated histories, with heart problems, seizures, and some mental health concerns but, overall, we don’t monitor them any differently than the general population.

I will say, though, that the CNAs are quite adept at sensing small changes in members of this population’s attitudes and feelings. They’ll be the first to tell you, “She’s not as interested in participating today. Please make sure nothing is wrong.” The CNAs are very vigilant with these residents.

Of course, we have the best CNAs in the world. They’re well seasoned-some with 30 years’ experience-and perceptive when it comes to something that might be wrong. They’re interested in our residents getting better and succeeding, and they’ll speak up if anything might interfere with that. This is the kind of caring attitude you see among people who have chosen, as a true calling, to work with the ill or disabled. One often hears the phrase “my resident,” followed by tales of improvements residents have made toward self-sufficiency. These nursing staff members are truly the most dedicated caregivers I have ever seen.

What’s the most challenging thing about caring for extremely obese residents and rehab clients?

Olsen-DeHon: On the physical/occupational therapy side, I think the biggest challenge is getting these people to take an active part in their own care and in letting us know how they’re progressing. Many of them previously did so poorly for so long that they’re used to being taken care of by others. It can be difficult to encourage them to shift into thinking it’s up to them if they’re going to get better.

This population is not likely to be out and active with the general population. We have to convey to them that they can meet goals and they can participate. We have to let them know that we can’t just give them a pill to make them become functional.

Our other primary challenge is maintaining the safety of both staff and residents. We have to make sure that the equipment staff are using for a given resident is rated for an adequate amount of weight and make sure staff are instructed in how to move residents so that no one gets hurt.

Landy: We have 11 different brands of lifts in our facility, because many items were donated or bought piece by piece over decades. To help us meet the safety challenge, each lift is clearly marked with its weight capacity and has a full-color, facility-made booklet attached. The booklets were created by facility maintenance staff and show in color photographs which slings can and cannot be used for each lift. This allows staff to select the correct lift and the correct sling for each resident based on the resident’s weight, physical abilities, and the equipment itself. It’s challenging to keep up with this, but it’s the area of the greatest amount of potential danger.

Other than the challenges we’ve mentioned, the bariatric population is no different from the rest of the residents. If they’re here for rehab, we want to see them get better and move on-either to their former level of independence or to some level of lesser assistance in assisted living or with family/friends. If they’re long-term residents, we want to see them become more independent. As is true of every other resident, we’re happy when they improve.

Besides having to purchase bariatric-sized equipment, have you needed to make any other adaptations to accommodate your extra-large residents?

Landy: We’ve chosen to put them all on same unit, for the sake of equipment sharing. This unit has extra-large commodes, and we had to widen the resident room and bathroom doors. In some cases, we had to open up some walls so that the rooms would be large enough for the beds and other equipment. I really recommend that to anyone who is planning to admit bariatric residents. NH