When the strongest start to fail.

One of the saddest things as a nurse, is seeing the proud, strong, independent, become more confused, dependent and weaker. Sometimes nothing can be done to "fix" the problem, Symptoms can (and should) be managed. Emotional support is a necessary part of the picture.
The family should be supported. Sometimes they lash out at staff, not because staff has done anything wrong, but, because they (the family) are feeling angry, helpless and just not dealing well with the guilt, stress, etc. that they are feeling. It is a time to be patient with the family, without letting them disrupt the nursing floor.
Hospice, although not essential in a skilled nursing setting (for actual care), can make the difference with emotional support and advice with symptom management. Sometimes a doctor is more willing to treat pain, nausea and other symptoms more aggressively when hospice is involved.
Staff do become emotionally involved with people they take care of day after day. They grieve, too, as a patient becomes weaker, losing their battle with chronic illness and an aging body.
It is a hard time for all.
It is a time to support each other, and to be kind to all involved.

Depression

Depression is the most undiagnosed ailment of the elderly population. (Don't take my word for it - do a search online for depression in the elderly.)
It isn't always expressed as sadness.
Sometimes you will see anger and/or irritability.
Some people don't eat. Others want to eat all the time.
Some people sleep more - others, less.
Some people withdraw from the people around them. Others have an unending list of ailments and complaints.
There are simple tests that can be done to determine signs and symptoms of depression. Staff observations are often crucial.
It is expected, that there will be a period of adjustment in a new setting, like a nursing home. But, when the mood affects quality of life, there are interventions needed.
Moving into a nursing home means there are new things added to the losses that we all have in our lives - loss of autonomy, privacy, giving up your home, your belongings, the pattern of your life. Sometimes it means giving up a beloved pet.
It may require someone like a licensed clinical social worker coming in to listen to your loved one. Sometimes medication is needed. Some doctors order a psychiatric consult (that doesn't mean their patient is crazy).
The important thing is to find the right combination of interventions, and help the resident feel better, and more in control of their lives.
It doesn't mean the nursing home is the wrong place to be. It means your family member needs help and support to cope.
Depression is not a "normal" part of aging.

Pain

Pain can be expressed in many ways, not just verbally.
If someone grimaces or is protective of a body part (called guarding) this is a symptom of pain.
Irritability, changes in mood and/or behavior also can indicate pain symptoms.
If you are in pain, do you want to eat? Interact in your usual manner?
If someone shows discomfort when repositioned, they were probably in pain before the repositioning.
Look at the whole person, not just the words they say. Families are often taken aback when pain management (sometimes just Tylenol scheduled at regular times) is started. Some people feel that it is "unnecessary".
But, ask yourself this - is life good when you are in pain, even a low level of it?
No one should deal with constant aches and pains. It is not "just a part of getting older".

Making the nursing home a real home

What makes someone (like your mom or dad) feel at home when they aren't "home" ?
A nice cover for the bed (make it something that you will have no trouble cleaning if you do their laundry) in a warm, but light material (fleece seems to be very popular these days) is a start. The facility will provide a bedspread, but, it will be about as individual as a hotel bedspread. Your parent can have their own.
Is there an afghan that they liked to use at home?
What about family pictures? A favorite picture? One of the most memorable I've seen was the romantic kiss of a pair of newlyweds. They were married many years, and the bride, now widowed, still grew misty when discussing that happy moment. It gave her a chance to share a happy memory and gave me a glimpse of a happy marriage, and the woman she had been when younger.
The facility pillows are, well, institutional. I always travel with my own pillow, and maybe your loved one has a preference, also.
A warm, easy to put on robe, sweaters, lap robes. Warm socks are always great!
A popular item in the nursing home these days is the new flat screen TVs. The facility probably has size and weight restrictions, so check before buying one. Keep in mind that even in a private room, space is limited. A remote control is a must, so that mom (or dad) can control the TV. It is there for their benefit, not the staff's. If you find it tuned in to shows your family doesn't watch, ask them who tuned in to the program. If they need help tuning in to THEIR favorite programs, let the RNAC (Registered Nurse Assessment Coordinator), Unit Manager, Social Services, and other staff know what their wishes are.
Residents are encouraged to wear their own clothing. Everything should be clearly labeled, even if you are doing the laundry. Facilities usually offer a labeling service. Firmly attached labels like you can purchase for summer camp, etc. are also good. The labeling must be where it isn't visible on the outside of the garment when being worn, for dignity reasons.
Velcro, snaps and other alterations can make most clothing easier to put on. Elastic waistbands help, too.
Expensive jewelry can be lost (or stolen).
Cash and other tempting items of value should be limited. Discuss this with admissions and/or social services. Facilities have stern policies about theft, but, there will be alot of people in and out of the room.
Eyeglasses and dentures should be engraved.
If your parent has a habit of hiding their hearing aide under their pillow, it is wise to share this information with staff. Too many hearing aides end up in the laundry, when a bed is stripped. Dentures, wrapped in a napkin on a tray can end up in the garbage. Staff are trained to watch for these items, but even with vigilance, things get lost or damaged.
Think about what makes your loved one comfortable, ask them what they would like and be realistic about durability and space restrictions. Their room is their home, and should look like it is.

Falls

No one wants your family member to fall.
Having said that, unfortunately, people do fall. What can be done? Interventions (ways to prevent a fall) are as varied as the members of the IDT (interdisciplinary team). Confusion is a big cause. A simple, treatable UTI (urinary tract infection) can dramatically increase confusion in the elderly.
A mat on the floor can prevent injury when someone rolls out of bed. But, the benefit must outweigh the risk if your family member might trip on it when walking.
Siderails can actually cause more injury, so they are not used as often as they once were. They do not keep someone safely in bed.
Alarms are sometimes used to alert staff when a resident is forgetful about requesting assistance and is at risk for falling. They are disturbing to some people, and may not always be appropriate.
Sometimes body pillows or bolsters help a resident understand the boundaries of the bed.
Dycem (a slip resistant material) can help someone not slip off their pressure redistribution cushion ( also called a gel cushion, foam cushion, etc. depending on the type).
Toileting schedules help not only continence (staying clean and dry) but, can help a resident not feel as anxious about getting to the bathroom in time (which is sometimes the reason individuals give when asked why they tried to go into the bathroom without asking for, or waiting for help). Identifying a person's pattern for toileting needs is a big part of the process. You can help with the process if you know that your parent (or other loved one) always goes in the bathroom right after meals, during the night, etc.
Is there a time of day that your loved one is more likely to be restless, or has fallen in the past?
A team approach (and you are a part of that team), a knowledge of a resident's habits, meeting basic needs are all a part of.
A pharmacist reviews your family member's medications, to watch for possible drug interactions.
These are only a few of the many interventions that may be used.

Restraints

There was a time, when I first went into nursing, that we used restraints (aka lap buddies, posey restraints, etc.) on pretty much anyone who fell, tried to get up without assistance, climbed out of bed, etc. in a nursing home. But, fortunately, the regulations and views changed over the years and we started to try to find better ways of keeping people safe. Why? Because restraints aren't really safe. First of all, they aggravate people more than calm them. Imagine someone putting a cloth belt on you, and telling you that you had to wait for assistance to do anything you wanted (like go to the bathroom). Then, imagine waiting, and then waiting some more.
You start to feel claustrophobic from not being able to move very much, and you pull at it. Then, you try to slide under it (or climb over it). What if you get partway out and get stuck? Or choke yourself? Or fall with even more force than you would have, because you've been fighting the restraint so hard?
Now, imagine that you can't always tell someone what you want (or need), so they treat your behavior with a medication, so that you quit trying to climb over or under the restraint.
Now you're groggy, more confused, and everyone is doing this TO KEEP YOU SAFE.
Sounds awful, doesn't it?
Most long term care facilities/nursing homes, don't have restraints anymore, or a very few. Staff tries to be more vigilant. Medications are reviewed (and reduced) more. Clever interventions like regular TOILETING (imagine that) actually reduced the number of falls and injuries.
Which is why, if you saw them tie your parent to the bed, in the hospital, you won't see it in a nursing home (or rarely).

The Blame Game

The quickest way not to get anywhere productive, is playing the blame game. It may be one nurse blaming another, or "it was an agency person", or "it was the other shift". Give me a staff person any day, who looks you straight in the eye and says "I'm so sorry. What can we do, to make things better?".
So instead of looking for the culprit responsible for whatever has raised your ire, which accomplishes little, let the nursing (or housekeeping, or maintenance, or whomever) take their own internal measures by :
A) Making sure the right person knows there is a problem. How do you know who the right person is? When in doubt, tell the Unit Manager (or Nursing Supervisor). Not to worry - if another department goofed, they know who to refer it to.
B) Let them know exactly what (when, etc.) the problem is, why it is a problem, etc.
C) Now, at this point, it is not out of line to ask "what are you going to do, to make sure it doesn't happen again?"
D) A telephone call the next weekday to the person in charge (of the unit, or the facility) is not only a good thing, but, will make sure you get follow-up.
What can I tell you won't (and shouldn't) happen. One staff member should not identify another staff member or shift as "responsible". Disciplinary actions should not be discussed with you.
What should be? The problem should be clearly identified. The corrective action should be in place. The appropriate staff/discipline should know what is expected of them.
Who is responsible to make sure that happens? The person in authority who you went to in the first place, their boss, and various other levels of the power structure. Social Services (the Social Worker) and Nursing (the Unit Manager, Supervisor) should be involved.
What does the blame game (yelling, etc.) accomplish? Usually very little other than people not hearing your message, only your noise. They won't think you are more involved, more supportive, or more loving.
Being polite, firm and tenacious always works.
Your family member deserves good care.