Phone conversation with Renee (SNF Activities Director), Mon 6/9/2014

I need to write this stuff down, call occurred while I was in the car

Conversation with Kris Hermanson 6/6/2014 around 3pm

Notes from my call with Kris Hermanson – for Andrew & Christine; Kris, feel free to correct.

Notes on conversation 6/6/14

MOM WAS ADMITTED TO SNF!!

-          We’re seeing issues increase, getting dressed is now a problem

-          Has been gradual,

-          Had a long talk, always had a terrible sense of direction

-          Gets lost on campus, needs to get redirected a lot, sometimes doesn’t recognize her surroundings

-          Sometimes presents very clearly sometimes gets lost

Preliminary : very good candidate for memory.

How did transition go?

-          Better than you would think

-          She wasn’t happy, explained that campus was too big for her right now

-          But she’s not being hysterical, she has friends here

-          We also have about 4 residents here who will be going to memory assist

-          She will have her own apt, much smaller, more of a studio – larger is more confusing

-          Right now AL is too big for her.  She did well for a while but it’s getting much worse

-          Doesn’t seem to be fighting the roommate issue

-          Doing the transition very easy, getting her acclimated, not going to close AL at this point

-          We will be having care conference in a couple of weeks

-          Convenience vs SNF, KH: she will be a risk to herself and those around her

-          Because of the elopement, because of the need to keep her safe

-          When memory assist is available, then functional assessment.  SNF is a stopgap.

-          Many residents use SNF as stopgap

My reaction – seems like a strong response to the elopement

KH: I did my homework

-          There’s been a lot of concern about mom being lost

-          It’s not the one incident, that was the icing on the cake

-          Now she needs the caregivers, because she’s impulsive

-          It’s really not strong handed, it’s the only alternative we have

-          She has friends and has familiarity

-          Will blossom in there hopefully

Memory Assist unit: Supposed to be mid-august, realistically September 1

-          Hold an assisted living unit, not sure

-          Have proper care conference

-          If it looks like she’s acclimating, can start a level of care change

-          SNF is used as a stopgap, not unusual

-          Probably in a couple of weeks, and then Rene Hayward will call to set up (director of social services)

-          Mom in conference

-          We can talk after that about a level of care move.

-          We can work with you

-          Level of care is assisted living if she is in memory assist

Mom’s phone number 707 537 4277.

Call with Dr Antenucci, 6/6/2014 around 230pm

Dr Antenucci, call 6/6/2014

I saw your mom Wed 6/4, because had gotten a call about being on the highway.

Saw her, had long talk, she was crying a bit, saying she didn’t realize getting old would be so bad.

Overall, the problem comes down to:

-          Understands that she’s having more grouble taking care of yourself

-          Hard with subtle losses in her faculties

-          Getting lost for instance, difficulty

-          Mini mental status exam – 20/30. 

-          Everyone loses dates, but didn’t know year, day.  Didn’t have recall.

Part of test is 3 commands, take paper, fold in half, put on floor – that’s a key.

Most get that, Mom didn’t, has problems with acute retention of information.

After seeing that, and being back and forth with her, definitely seeing the decline

That’s why I’m agreeing with placement.

She does not need skilled nursing, but needs constant supervision.

Based on these issues, she will make good decisions most of the time.

But someone needs to be there to keep an eye on that.

Rick - Expressed my concerns

Dr A:

-          Would be great if she was in a situation with care

-          There are no other needs causing her to be locked down

-          We wouldn’t want her to get lost, get hit by car, etc.

-          Agrees that it’s better to have a safe environment w/o skilled care

-          Needs someone to help her make the best decisions

-          Might be the easiest thing to do is to lock them down in SNF

-          Other than monitoring no acute issues

My email June 2: Bruni Dulaney, 6/2/2014

From: Rick Dulaney
Sent: Monday, June 02, 2014 2:38 PM
To: Sela Nissenbaum (snissenbaum@jtm-esc.org); Kris Hermanson (khermanson@jtm-esc.org)
Cc: Andrew Dulaney (andrewdulaney@comcast.net); Christine Dulaney (ckdulaney@gmail.com)
Subject: Bruni Dulaney, 6/2/2014

Good morning,

I’m writing regarding my mother, Bruni Dulaney.  There was some discussion on Saturday about moving my mom to the skilled nursing facility, although I couldn't tell if that was considered as a permanent move or not.  That conversation was based on what Sela saw as an “elopement” and my mother saw otherwise, after my mom left the square dance on Friday night.

I have some questions and some thoughts.  I’ve copied Kris Hermanson based on my conversation with Sela; hopefully that’s correct, since my notes weren’t perfect.  I’ve also copied my brother Andrew and my wife Christine.

First, having spent some time in SNF at SLV and other places, I do not believe my mother belongs in SNF.  She does not need skilled nursing, since her main needs are help managing her medications and help with daily activities, which she gets in assisted living.  Although the SLV SNF unit is the nicest I’ve ever seen, moving to SNF would clearly be a negative factor in her quality of life.  My mother also does not want to move to SNF.  What she may need is more oversight of her comings and goings.

Second, it seems to me that requiring 24-hour caregivers is a very strong response.  She spends most of the day in the "L" unit and takes many of her meals there.  Having a person shadowing her even while she's sleeping or watching TV seems like overkill.  My mother has been in the "L" unit for five or six months, and has had this one episode.  Sela mentioned that my mother sometimes gets disoriented on shorter trips around the campus, but she still takes herself to visit people in SNF and to the main dining facilities and bistro areas.  Those activities are very important to her quality of life, and my experience of her is that she "trains" well.

Third, there may be options other than 24-hour caregivers.  Is there a procedure for checking in and out of the "L" unit?  When the building first opened, there was a sign-out book, but it was kind of out of the way and I don't know if was a rule or an idea – but it seems like there should be clear procedures for the conditions when she leaves and some expectation of where she is and when she'll be back.  If those exist now, please let me know and I can reinforce them with my mom.  Another item is that the first building she moved into ("K") had a counter next to the door so that SLV staff knew when people were coming or going.  This seems like a worthwhile thing to have in this situation.

In general, my mom's health condition seems to be complex.  One the one hand, when I speak with her, she is generally very lucid and able to describe her recent experiences very well. This was the case on Saturday.  Other times she has trouble with things like locating her glasses/checkbook/purse/remote control/etc.  My mom often seems very irritated about day-to-day issues, but she also interacts positively with other residents, according to Sela.  I receive periodic updates from Sela in which it seems that my mom is often angry and confused. In general, it does seem that my mother fixates on things that she can no longer do, and things she feels she is prevented from doing, and generally sees the glass half empty.

When I described one of my recent conversations with my mother to a friend, he pointed out that these were classic symptoms of depression and she should possibly be evaluated for that.  I had an email exchange with Sela about that a few weeks ago, and I do feel that should be part of the way forward.

When Beth and Sela first proposed moving my mom to assisted living, there was an idea that she could be appropriate for a memory management building.  I think Sela said that this unit is now scheduled to open in August, although it sounds like the construction has lasted a lot longer than anyone expected and this schedule also might slip.  I'd be happy to discuss whether my mom is appropriate for such a unit.

When I spoke with Beth a couple of months ago, she was going to request and send me a copy of my mother's lifecare agreement.  That seemed easier than trying to find my mom's copy.  I haven't gotten that yet, and understand that Beth just left, so perhaps someone else could help me there.  I feel somewhat uninformed about lifecare and her coverage.  If I need to contact someone else about that, please let me know who.

I believe we are all on the same page about moving her health insurance from Kaiser to SLV.  Although I'm not exactly sure yet what’s involved there, I’ll reach out to Kaiser for advice and forms.

With regard to 24-hour caregivers, my mom cannot afford that really at any level. My mom asked me to take over her finances in 2013, and it's been a bit of a struggle.  She has an extremely small income from social security, and is spending down her remaining assets.  At current levels, she should be OK for a few more years.  But if caregivers are say $20/hour, that's $480 per day or $14-15,000 per month -- at that rate, she'll be out of money in weeks or months.  So we'll need to discuss and resolve that before she incurs additional caregiving costs.

I look for your guidance on how to go forward.  A couple of specific items are that I will contact Kaiser about changing insurance coverage, and I would appreciate from SLV a copy of my mother’s agreement.  Beyond that, however, I would like to have an approach in place that maintains her quality of life, that balances the oversight necessary for her safety, and that addresses her possible depression.

I’m always available by email, or on my cell (301-250-0698).  You may also text my cell, which is sometimes more useful if I’m in a situation where I can’t take a call.

Even though this situation and conversations are stressful, I would like to acknowledge again, as I have in conversation with Sela and others, how much I appreciate the SLV staff and community.

Thanks, Rick

Fri May 30: Mom "elopement"

I received a call Sat May 31: my mother had "eloped" the previous night.  Sela was very upset, as was my Mom.  After multiple hours on the phone, here's what I know:

• Mom went for customary after-dinner walk
• Saw friends at a square dance event being held in the new spa building
• Visited with them for a while
• When leaving, took the wrong exit, got confused by the construction
• Wound up walking along Montgomery Drive, where she was escorted back to L building by SLV employee

Sela reported that she felt my mom needed 24-hour caregivers to keep her from eloping again and should consider move to SNF.

From Sela May 3, 2014: Behavioral changes

Hi Rick,

I know it’s been a while but I wanted to let you know what has been happening. Health wise your mom is fine. We arranged for an appointment with Dr. Antenucci as part of our wellness check and her BP med, Atenolol was discontinued because she was not feeling well on it.  It is becoming more difficult for her to go to Kaiser with caregivers. She is very vocal and resentful and cannot understand how “we can all be against her when she is capable of going by herself.” We just stand our ground and gently explain the department’s need for safety.

As you know Mr. Segal is now a permanent resident in our skilled nursing unit which has very much upset your mom’s routine and also saddens her very much. I’m attributing her increased confusion and paranoia ( nurses and staff are all against her) to this event. Her apartment if left unattended by our staff, looks like her independent apt before she moved in. We are not allowed to move a thing or else she starts to yell at us. We try very hard not to be confrontational but just going about our day to day routine is perceived as we are (against her) and she becomes extremely agitated.

My staff really  likes Bruni very much and tries to diffuse the situation but  it is sometimes better to just let it go. I don’t think that there is any medication that will change this behavior it is just a progression of her cognitive decline. She still manages to take care of her  personal needs and has a steady gait when she walks. She was visiting Bob in Skilled Nursing almost everyday, which I felt gave her a purpose but she no longer does that.

My comments are in no way are ulterior  but  just informational as an update. Feel free to call or email at any time.

Thanks, Sela

Lots to update:

• in Nov 2013, Spring Lake Village felt my Mom could not handle herself independently, she needs to move to Assisted Living.
• Moved to K building (K-102) into an apartment she did not like
• I moved everything else into storage and gave away some stuff
• Then in Jan 2014 she moved into L-204, lovely 1BR overlooking the chapel
• Mom definitely unhappy with all details of her life, but in a good place overall