During an annual visit of State Department of Health surveyors to the nursing home where Mother lives, I said to one of the surveyors, "I don't know whether to laugh or cry or throw up when I watch the dog and pony show the administration puts on for your benefit." The surveyor said they know that what happens in a nursing home when they are there does not reflect what happens during the rest of the year, but they are required to report only what they see.

That evening, the dining room was overrun by administrators who, with a rare exception to prove the rule, are out of there at four o'clock on the dot when the surveyors are otherwise occupied. Family members were amused, as were aides and nurses. One aide approached Mother's table, holding a tray in a position assumed by a high-tone waiter, and asked in an affected voice, "Did someone order a bug-a?"

Many stories have surfaced that fall into the wonder-of-it-all category, but there is hardly world enough and time to present the discrepancies between the state-inspired dog and pony show and everyday life at the nursing home. Most people are inclined to dress up for company, but what happened at the nursing home is the equivalent of a couple inviting neighbors over for a cookout and appearing at the door dressed for opening night at the opera.

There was no gradual return to the norm. The surveyors left at 3:00 P.M. on Thursday. At 3:30, the administrator was seen leaving the building. Other administrators followed suit. The dining room was not overrun by staff that evening. Friday evening, the situation was even worse. The dining room was filled with residents, but there was no staff member present except a woman from housekeeping who was talking on the telephone by the door. The length of the call would indicate that business was not her intent and her position, facing the foyer, would indicate that she was not there to monitor the residents.

The kitchen staff pushed four carts loaded with trays into the dining room. There they stood, clear and present evidence that the surveyors had gone. I was reminded of a statement made in one of Flannery O'Connor's stories about a grandmother, who had not led an exemplary life, who was accosted on the road by an element of the criminal community. The criminal, holding a gun to the grandmother's head, said, "She would have been a good woman if it had been somebody there to shoot her every minute of her life."

One of the ladies, from her vantage point at a table in the corner of the dining room, monitors failures of attention to residents, prefacing her remarks, delivered in a carrying voice, with "Honey! Honey!" Friday evening, she yelled, "Honey! Honey! This lady needs attention. This lady needs attention," referring to a lady who sits at her table. There was, of course, no member of the staff there to give attention, except the woman on the phone who was, in any event, prevented by regulations to go beyond the parameters of her job description. When the lady in question stood up, clearly discomfited, the lady who was distressed by her situation threw subtlety to the wind and yelled, "She did number two! She did number two!" 

At that point, a charge nurse walked into the dining room. When I asked her if she would call for help, that a lady in the back of the room was in dire need of assistance, she didn't answer, but kept walking to the kitchen counter to take care of whatever business that had brought her there. 

The lady who had done number two addressed the situation in the only way she knew how, which resulted in her hands being covered with excrement, which she flung to her right and to her left as she walked up the aisle between two rows of tables where residents waited to be served their evening meal. That was too much for me. Where was the dignity that is the catchword of the administrator? I circled around and approached the lady from behind, took her arm and led her down the hall until I found an aide.

As I left the dining room, I saw the lady who had raised the alarm waving a bib and heard her yelling to the nurse, "Take this and clean up that stuff," which the nurse didn't do, doing honor to her job description. The woman from housekeeping, whose job description was at that point pertinent, was still talking on the phone when I returned to the dining room.

A few days after the surveyors left, I told the ward clerk that one of the ladies had smeared excrement on her body and on the bed covers. There followed a prolonged discussion at the nurses' station concerning what protocol dictated in reference to what should be done about the lady's condition during the evening meal. The ward clerk told me and two aides, who had been summoned for this high-level conference, that she had been given three different instructions about what should be done when a resident needed attention concerning basic body functions during a meal. The first instruction was that nothing was to be done until the meal had been served to and eaten by all the residents. Since three meals take a considerable amount of time each day, this means that there are several hours when the most basic needs of residents are ignored. The second instruction was that an aide could attend to the resident's needs if the ward clerk could catch her attention as she walked toward the serving cart on the hall, but not if she had picked up a tray before the ward clerk saw her. At that point, the surreal was upon me. The third instruction was to be followed only when surveyors were there. CNAs would continue with whatever "feeding" assignment they had been given and an LPN would be called to attend to the needs of the resident. That was what the surveyors saw, immediate attention to the residents, not what I see every other day of the year, residents waiting and waiting to go to the bathroom, to be cleaned up, or to be given any other help they may need during "feeding."

Actually the surveyors don't see everything that happens when they are there. One of the ladies, whose problems are physical, not mental, told me about something that happened while the surveyors were in the building. She asked the charge nurse on her hall for antibiotics to address a fast-developing cold and sore throat. When the nurse returned with her verdict, she told the lady that her doctor said she couldn't be given antibiotics unless she had a temperature. "How do you know," the lady asked her, "that I don't have a temperature? You didn't take it. In fact, my temperature, my vital signs, haven't been taken in over a week." The nurse was nonplused. After all, most of her patients are in no condition to remember when their temperature was taken. Even so, the nurse didn't take the lady's temperature. In fact, she did nothing. The weekend nurse did do something, but by that time, the lady was unable to talk.

During that time I had a serious concern about Mother's care or lack thereof, as I often do. For obvious reasons, I don't feel free to discuss Mother's condition. My point is that she was not given the attention that she should have been given. Those things need not have happened to the lady I mentioned or to Mother if, as the weekend nurse told me, the staff hadn't been preoccupied with impressing the surveyors. 

My belief that the surveyors didn't see the failure of care that was going on under their noses was reinforced by the fact that failure of care was not reflected in their report. What they saw was the building teeming with staff, one-on-one in full flower, and bonhomie in all its glory. Not surprisingly, but maddeningly, the nursing home received a most favorable report. While that report was being "earned," I was worried to distraction about Mother, the lady I mentioned was neglected to the point that she couldn't talk, and Mother was stumbling up and down the hall, at risk of yet another fall.

Family members were insulted and dismayed by what we witnessed during the time the surveyors were in the nursing home, but the administrators were overjoyed.  They threw a pizza party for the staff to thank them for their help in putting one over on the surveyors.

What the surveyors knew but could do nothing about or, worse still, chose not to do anything about was that what they saw was prompted by their presence, by their holding a metaphorical gun to the head of the administrator. When they left, that gun was tucked in its holster. Then failure of care resumed. Neglect resumed. Abuse resumed. The administrators knew that they had a year to do precisely what they pleased. The State Health Department needs to figure out a way to keep that metaphorical gun pointed at the head of the administrator every day of the year.