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Caring for Larger Residents: Preserving Dignity Without Sacrificing Safety

November 1, 2003
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Interview with Barbara Landy, NHA, and Dotty Olsen-DeHon, OTR
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 In response to an article we published in our October 2002 issue ("Accommodating the Bariatric Resident" by Gary Lipperman and Gil Preira, page 82), Barbara Landy, administrator of the Edward J. Healey Rahabilitation and Nursing Center (formerly the Palm Beach County Home), in West Palm Beach, Florida, wrote: "I was beginning to feel that we were the only nursing home in the world who cared for this population." That piqued our interest, so Editor Linda Zinn phoned Ms. Landy to ask how many residents her facility cares for would be classified as "exceptionally obese." Her answer led to the following interview, allowing us-and in turn our readers-to glean from the expertise of Ms. Landy and her colleague, occupational therapist Dotty Olsen-DeHon.

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.