The day begins around 6 a.m. when the nurses and their assistants begin waking the sleeping residents.
For most of the 300 or so men and women who live at the Wisconsin Avenue Nursing Home, the day will hold no surprises. They have accustomed themselves to living in a world reduced largely to the distance from the room where they sleep and the place where they eat, to the community room on the first floor or the physical and occupational therapy rooms on the lower level.
One of 14 nursing homes in the District and 71 in the metropolitan area, the Wisconsin Avenue home falls somewhere in the middle in terms of quality and cost of care. Its eight-story tan brick building has a concrete patio next to the parking lot in the rear, but no lawns, no grounds. A few residents may venture a walk outside, but most of those who consider the nursing home their home will go no farther than the rear patio. They remain inside--secure in a tranquil world where their most basic needs are taken care of, even anticipated.
For the sons and daughters of those who live here, the nursing home is often a depressing statement on the reduction of a person's life. "No one wants to grow old to start with," the Wisconsin Avenue home's director, Jacob Mast said, musing on the thanklessness of the job he does. "No one wants to accept the growing old of people close to us." A once vital, active woman who is remembered as a loving mother now sits passively in a wheelchair. A former general who once commanded thousands of men now is bedridden.
The permanent resident, however, often has a different perspective on life. Some may complain of the "endless sameness" of their lives. Some still harbor ideas, fantasies in fact, of returning to the outside world. A few will complain of boredom. But many, perhaps most, seem to have accepted the limitations that living in an institution imposes. They have contracted their expectations to fit the new, narrower dimensions of their lives.
Vernon G. Alleyne, 69, is one of the healthiest and most mobile of the Wisconsin Avenue Nursing Home's residents. He goes out for walks frequently, downtown when he feels like it--about once or twice a week, he says--and to New York three times a year to see old friends.
Alleyne came to the United States from Barbados, W.I., 33 years ago. His English has the clipped quality of the Caribbean. He has worked as a longshoreman, tailor, shipping clerk, file clerk and a postal clerk.
He shares a room with another man, but spends little time there. A copy of Bertrand Russell's "A History of Western Philosophy" lies on a bedstand table. "He stimulates me," Alleyne explains. "I don't necessarily agree with everything he says."
Alleyne was married once, but he and his wife have parted, and he has no children. About three years ago he was mugged on Rhode Island Avenue, an event that had a profound effect on him because the thing he says he likes best about the nursing home, "at the top of the list, is security." He frankly admits to having been scared by the attack. "Security is more important than anything else," he says.
Beyond that, Alleyne is not wild about living in the nursing home. "I read," he says, describing his life. "I do quite a number of things because it's really boring. I deliver the mail because I used to work in the post office." He pauses to chuckle at his little joke. "Sometimes I'm really stimulated and sometimes I just kill time . . . Right now I feel myself established and I've adjusted to an m.o. I think is satisfactory."
The treatment he receives, is "comme ci, comme ca,, as they say in French." He refers, without elaborating, to the "insouciance, where some of the staff may have some problems in their private lives outside and they bring it in here."
He talks about leaving the nursing home, where he has lived for about a year and a half, and going to live with his two married sisters in Canada. Some problem he vaguely describes with immigration authorities at the border, however, is the reason why he stays. But it is not at all clear that he really wants to live outside the nursing home either. "If I had my druthers," he says, "I think I'd stay right here."
One of the comforts of living in a nursing home is that a person no longer has to be troubled with the minor errands and chores that complicate more independent lives. Housework is no longer a problem; meals are taken care of.
At 8 a.m., about 35 persons appear in the dining room for breakfast. They sit quietly at their tables, waiting for the breakfast they order to be brought to them. There is little conversation. The atmosphere is subdued. Breakfast is juice, eggs, toast, bacon, and coffee, tea or milk. Cold cereal is available.
"The biggest problem in a nursing home is monotony," says Carrie Lee Kinlaw, the home's chief dietitian. "You don't want it to be chicken every Thursday."
Hospitals, she adds, can get away with repeating menus week after week because the average hospital stay is only three days. But a nursing home has to find ways to encourage older persons to eat without forcing them. Kinlaw says she strives for the "element of surprise," and serves things like crepe suzettes and pizza, in addition to meat and potatoes.
Kinlaw, a stocky woman of 26, becomes animated, almost passionate, as she describes the problems of her job and the efforts she makes to do it well. Many of the residents, she points out, have suffered strokes, making it difficult for them to perform the daily tasks that younger persons take for granted, like cutting a piece of meat. So meat is served slivered or in a stew, making cutting unnecessary and the food easier to chew.
Kinlaw works out of an office that was once a large closet, measuring seven by nine feet. She sees herself as catering, literally and figuratively, to the most important concerns of the home's residents. "You've got your food, your bowel habits and your roommate, usually in that order," she says.
At mealtimes, she has to see to it that not only the residents who come to the dining room are fed, but also those in their rooms. The basic diets offered are broken down into six categories--regular, diebetic, bland, puree, low salt and low salt, diebetic. Cards for each resident are arranged by the floors they live on for those who take their meals in their rooms. The card indicates the basic diet of each resident, along with food preferences and dislikes. Trays move down a conveyor belt where four or five kitchen employes choose from among the dishes offered to meet the demands of a resident's diet and preferences or dislikes.
"I feel like we are making an effort here," she said. "I'm not ashamed of the food we serve here. We don't serve 'mystery meat.' We don't serve patties. We serve good quality meat . . . We have to be realistic. We do not serve sirloin steak. For one thing, they probably couldn't eat it.
"We don't always succeed," she adds candidly. "We have some lousy meals."
Mildred Havener, 72, is a native Washingtonian. A widow who lived in an apartment on Connecticut Avenue until about a year ago when she became ill, she found it difficult to care for herself and moved to the nursing home.
Now she lives in a single room on the first floor, where the healthiest, most independent patients live. Her room has a comfortable chair and a small desk she brought from her apartment. It also has a bed, another chair, two Japanese prints, a bone China dish from Bermuda and a photo of her deceased brother in his Navy uniform.
On days when the weather is good, she says, she tries to get outside, going for walks, or across the street to have her hair done. "I spend very little time in here her room ," she says. "I'm just around, sitting talking to people, taking walks. I enjoy being with people."
Mrs. Havener has a niece who visits her once a week and three or four friends who come to see her about once a month. In this respect, she is fortunate. Although visitors can come into the home throughout the day and evening, many of the residents rarely see a relative. One staff member describes with approval how some relatives come to the home for every meal, sitting with the resident while he or she eats. "Then you have the family member who comes in every six months and you get holy hell because they've got all this guilt built up," a staff member says. "That's the kind that gets on my nerves. It's our problem, the guilt is."
Art as Therapy
Besides physical therapy sessions for some 30 to 50 residents who are taught or helped to re-learn basic functions like dressing and feeding themselves, the home offers other forms of therapy as well.
In a basement room across the hall from the physical therapy room, some of the residents are drawing pictures. The art has a child-like, two dimensional quality to it. One of the residents, Kenneth Bruce, used to be a professional portrait painter, working in Hollywood and traveling abroad. "I made good money at it," he says, recalling his younger days, when he worked in Hollywood and knew several movie stars, including Grace Kelly.
He recalls a visit he made to Monaco after Kelly left Hollywood to marry Prince Rainier. He sent his card in to her. He had just wanted to say hello. "She came out to the gate," he says. " 'You're just the person I need,' she told me. She took me inside. She wanted a portrait of her husband and child. Set me up in a room in the palace so I could paint. That was my vacation." He laughs at the memory.
Bruce suffered a stroke several years ago that left his right side paralyzed. Now he spends much of his time in the nursing home's basement, painting with his left hand, mostly clowns, birds and flowers, but without the grace and subtlety that he once must have had. Asked to talk about the work he does now, he dismisses it. "I used to paint," he says.
The Cost of Care
The amount of attention a resident requires is a key factor in determining the cost of nursing home care, and a profit-making home such as Wisconsin Avenue tries to maintain a balance between quality care and economics.
The home is owned by Beverly Enterprises Inc., a chain that operates about 500 homes in 34 states. Wisconsin Avenue alone employs 285 employes on three shifts. In a cost-cutting move, it recently reduced the number of staff, but with immediate consequences for morale and, some said, care.
Several registered nurses, the professional heart of the nursing home, resigned in protest, and a subsequent visit by officials from the D.C. Office of Licensing and Certification determined that staffing levels on the home's skilled floor, where patients requiring the closest supervision are kept, were inadequate.
According to James T. Williams, executive vice president for operations of Beverly Enterprises' Eastern Division, the cutbacks were initially ordered in March because a drop in the nursing home's patient population, especially in the skilled care unit, had resulted in a loss of $37,000 in one month.
Williams said the cutbacks ordered, with his participation, amounted to an overreaction. "We made a mistake," Williams said. "We cut staff too quick and too much. The numbers looked realistic at the time." Williams said corrective measures have been taken and the District has ordered the nursing home to file weekly, rather than the usual quarterly, staffing reports to make sure that the care meets federal and city standards.
The cheapest rooms at Wisconsin Avenue cost a private patient $50 a day, which includes a semiprivate room, meals, personal laundry and a minimal level of nursing care. Residents needing more nursing care pay $55 a day for a semi-private room (about $20,000 annually) or $80 a day for a private room ($29,200).
The most expensive rooms, luxury private rooms that have a half-bath of their own, cost $100 a day. Medicaid, medical care for the indigent, pays $49.63 a day for intermediate care patients and $55 a day for skilled care, those needing the most attention.
In 1981, Medicare, medical care for the elderly, was paying $61.39 daily for skilled care patients, the only kind Medicare will pay for. Although it is widely believed that Medicare covers nursing home care, in fact the program covers only a limited number of days--100 percent of a certified patient's first 20 days and all but $32.50 per day up to 100 days in all--and then only under rather narrowly defined circumstances.
Throughout the day, there are scheduled activities attended by small groups of residents. At 2:30 p.m., 15 residents, two men and 13 women, gather in the community room for choir practice. They sing from song sheets that show the words in inch-high letters, while Greg Shelton, a senior at American University who works part time at the nursing home, leads and accompanies on the piano.
The first song they sing is "The Last Rose of Summer," the irony of the lyrics apparently lost to them:
"Tis the last rose of summer
Left blooming alone,
All her lovely companions
Are faded and gone . . . "
The overwhelming majority of residents have not come to choir practice. Many are dozing in their rooms or suffer from some form of senile dementia, so that they are partially or entirely out of touch with the world around them. In the day rooms on each floor of the nursing home a television plays constantly, showing an endless procession of talk shows, soap operas and game shows.
Since relatively few of the home's residents are involved in therapy or the activity of the moment, many of them can be found in the vicinity of a television. Television is a favorite instrument in many nursing homes, used in much the same way that overwhelmed parents use it to occupy a bored child.
This tedium may be more apparent than real, however, more in the perception of a younger outsider than in the eyes of the residents themselves. When asked whether they have enough to do, few complain. Augusta Machen, an 84-year-old resident who has been in the home for more than three years, says she likes the home "very much," likes the people there and finds it generally a "well organized place."
Immediately after dinner, which is a relatively light meal, a gospel session is held in the home's community room. The songs are led by church members who have come to the home to lead the singing and prayers. About 20 residents, mostly black, attend.
When the gospel hour is over, about 8:30 p.m., the residents go upstairs to prepare for bed. Some already are asleep. By 10 p.m., the corridors are relatively empty on all of the floors.
Occasionally, a resident is still found awake in the day room watching television. An 81-year-old woman is sitting in the day room on one of the home's upper floors.
Asked why the woman is not in bed, the floor nurse explains that if she is put to bed too early, she will awaken in the middle of the night. The woman's son wants her put to bed early, the nurse says, but the son has trouble comprehending what is happening to his mother.
"The doctor says she is getting excellent care," the nurse says. "Her son cannot accept that his mother is getting old. He also cannot accept that she is senile. There is no other word for it. He insists that she is just as alert as she was when he was a little boy." Although the son visits daily, the nurse says, his mother often fails to recognize him. Once she said, the son brought his mother a cake and gave it to her in the box. The mother proceeded to eat it without taking the paper off first. "She'll eat whatever you put in front of her, including the paper. That's how confused she is. He can't see that."
On another floor, the staff is anticipating the death of a woman in her 90s. As might be expected, death is not an unusual event in the nursing home. Roughly half of the home's residents finish their lives there. The woman's family has instructed that no heroic measures be taken to prolong her life. The staff tries to make her comfortable.
The corridors are quiet, save for an occasional resident who talks in his or her sleep. The nurses make rounds every two hours--at 1:30 a.m., 3:30 and 5:30.
When a patient on one of the home's two Medicaid floors becomes disruptive during the night, pulling down the light fixture on the wall behind his bed, he is given an injection to sedate him after the nurse checks with the man's doctor. An hour later, the man is dozing in his wheelchair, five feet from the nurses station. "He was just feeling his Cheerios, but I'm ready for him," she explains, showing a pair of heavy protective mittens and some restraints she can use to tie down his arms if necessary. "I'll only use these if necessary," she says.
On another floor, the nurse takes two visitors to the supply closet to show them new cotton diapers that the home has purchased for incontinent patients. The nursing home experimented with disposable diapers for a while, she says, but they turned out to be too expensive and had other problems. The cotton diapers look much like baby diapers, only much larger.
She also opens a box of liquid formula to show what is put into the feeding pumps used for patients who are fed through a tube inserted in their nose and then down their esophagus. All of this is explained matter-of-factly--the nurse apparently has accepted these problems of old age as being part not only of her job but of life as well.
Daisy Broughton, the night-time supervisor, explains that patients who are comatose have to be turned to prevent the formation of bedsores and contraction of pneumonia. Asked if she enjoys her work, she says she likes talking to the residents, hearing about what they did when they were young.
As it turns out, the woman in her 90s survived the night. She lingered and regained consciousness the next day, long enough to see her family before she died.
At 6 a.m. the cycle begins again. The nurses begin waking the residents, cleaning up those who need it, helping others out of bed and into their clothes, beginning another day.