Supervision of Alzheimer’s Residents in Assistid Living Facilities

By Allan Vann, Huffington Post, February 15, 2016

I am incredibly fortunate to have my wife, Clare, residing in an excellent assisted living facility (ALF). Residents with Alzheimer’s disease (AD) and other forms of dementia are in a separate lock-down unit in a facility that has many caring aides and five or six hours of daily scheduled activities that engage her. However, despite the excellence of this ALF, I must remain an advocate to insure that Clare receives the proper care she should have each day.

As a retired elementary school principal, I view an ALF much like a public school in terms of its staffing structure. Each is a bureaucratic institution that depends upon strong leaders setting high standards and expectations for themselves and all who work there. In the best schools and ALFs, staff members work very hard to meet these high standards and expectations to help their clients succeed. Different criteria will be used to measure success for young students in schools and elderly dementia residents in ALFs, but school and ALF administrators have the same primary responsibility ... to keep their clients safe and to ensure that all staff members work hard each day to help their clients meet with success.

There is only one sure way for school administrators to know if staff members are fulfilling the organization’s mission properly and that is to actually observe them doing their jobs. In the best schools, administrators make frequent classroom observations to directly observe teaching and learning. Whenever teachers and students are in the school for instruction or activities, even if school sponsored activities are held in the evenings or on weekends, administrators should be present to supervise.

Unfortunately, the same degree of supervision is not found in many ALFs. Schools are open for about 180 days per year, whereas an ALF is open on all 365 days of the year. Unlike children and staff who are usually in school for anywhere from six to ten hours daily on each of those 180 days, ALF residents and aides are there 24/7 with several shifts of staff on each of those 365 days. ALF supervision problems arise because ALF unit directors cannot work 24/7. They may work 8, 10 or even 12 hours a day ... but that still leaves at least half a day when staff in the dementia unit are working without an administrator present to supervise. And, given that administrators receive two full days off each week, there is yet additional time when staff operates without onsite supervision.

ALFs may designate one of their aides to function as a “lead aide” when the full-time unit director is not there, much as a school may designate a teacher as the “lead teacher” in that subject. But part-time lead aides and teachers are, by definition (and often by union membership rules), aides and teachers ... not administrators who have been trained to supervise and evaluate staff. And whereas ALFs may have one or more administrators available somewhere else onsite in the facility, it is not the same as having an administrator onsite full-time in the dementia unit.

Despite Clare receiving excellent care for the most part, there have been “issues” that should never have happened in such an outstanding facility. With very few exceptions, “issues” I have had with Clare’s care have come at a time when no full-time unit director has been present in her unit. Issues with medication, meals, daily hygiene practices, clothing, etc. have continued to surface every so often.

Fortunately, whenever these issues have been brought to the attention of the unit director they were always handled properly. But I can only wonder how many other aspects of daily care have gone by the wayside when no full-time administrator has been there to supervise and observe, and when I’m not there to personally observe. Loved ones with AD are not usually aware of their lack of care, but if aides are not doing all they should then they need more training or should be terminated.

Perhaps when all or almost all of the dementia residents are asleep, there is no need to have a full-time administrator present. But there should be an administrator present from 7 a.m. until 3 p.m. to oversee aides helping residents with morning hygiene and dressing routines, serving meals at breakfast and lunch, and dispensing medication. A second administrator should be present from 3 p.m. until 11 p.m. to oversee aides providing evening meals and medication, and supervising hygiene routines and preparation for sleep with residents at bedtime.

It would cost additional money to provide another administrator. But the result would be improved daily care for residents as administrators supervise personnel and programs throughout the day. Staff members not fulfilling high standards and expectations would be more easily identified and then receive immediate additional training to improve ... or they would be fired.

AD caregivers who have chosen assisted living placements for their loved ones need to check to see what staff supervision is provided each day, morning through night. If no supervisor is present during morning and evening hours, caregivers should try to visit loved ones on different days and at different times to observe how their loved ones are cared for. Should less than outstanding care be observed, AD caregivers must then become advocates and meet with their loved one’s dementia unit administrator to remedy those situations.