This is the thirty-fifth in a series of articles intended to demystify retirement living options.

You may assume that your loved one is getting all the expected care in assisted living or nursing/skilled nursing. But sometimes, quirky problems disrupt the established routines in the facility, and care can suffer as a result.

Isabel turned to the section on dental care in her mother Gretchen’s chart in the skilled nursing facility where Gretchen had been living for many years. Isabel had agreed with the in-house dentist’s recommendation that Gretchen have a check-up and get her teeth cleaned every three months. Gretchen had difficulty taking proper care of her teeth, but with the three-month check-ups, she had been doing well.

But Isabel was puzzled by the consultation request – the “work order” for a visit to the dentist. It showed that her mother was to have seen the dentist four months earlier, but it looked as if the appointment hadn’t happened. The appointment request had two handwritten notes on it: “Refused!” and “Try 1x more.”

Isabel asked the day nurse, “What does it mean when it says “refused” on this dental visit order? Did my mother refuse to open her mouth so that the dentist could work on her teeth?”

“Oh, no,” the nurse replied. “Your mother sometimes refuses to get in the elevator. We don’t know why. That note probably means that that was a day that she wouldn’t get in the elevator.”

The in-house dentist was located one floor down. Because the building was built on a hill, the nursing wing where Gretchen lived was on a floor with direct access to the outside, and the dentist’s office, even though it was a floor below, also was on a floor with an outside entrance. Isabel and the nurse discussed the fact that at the extreme, someone could always put Gretchen in a car and drive her around to the entrance near the dentist’s office.

But clearly, no one had thought to do that. They planned to take her on the elevator; when that didn’t work, they didn’t have a Plan B.

“Why does it say, ‘Try 1x more’ on here?” Isabel continued. “What does that mean – that if she refused to get on the elevator one more time, she would never get any more dental care for the rest of her life? That doesn’t make any sense!”

The nurse sighed. “Yes, you’re right.” Isabel could picture the scene: The aide who had accompanied her mother would have come back in and reported, “Gretchen won’t get on the elevator.” A busy nurse would have said vaguely, “Okay, we’ll try another time,” before turning away to deal with another little crisis.

“But,” Isabel said, “It doesn’t look like another appointment was ever scheduled. It’s been four months!”

When the unit secretary called to make a replacement appointment, she found that the lead-time was two months. So it would be nine months between appointments when it was supposed to be three. And if Isabel hadn’t spoken up, no one would have ever rescheduled.

She frowned – something else had just occurred to her: in the monthly bills she got from the nursing facility, there were always four or five charges for weekly appointments at the in-house hair salon – which was located on the bottom floor, just down the hall from the dentist.

Why were they able to take Gretchen downstairs to the hairdresser without fail – but unable to get her downstairs for health care?

None of it made any sense!

A senior executive at the facility made an unexpectedly candid admission: “You know, no one actually reads the charts. They don’t have time. They’re too busy taking care of patients.” The nurses, she explained, get their information about what’s happening in “Report,” the meeting between shifts, when the departing nurses explain to the arriving nurses what has happened in the last 8-12 hours and what they have to watch out for as a result.

A missed dental appointment wouldn’t have made any impression at all.

The next column will discuss some approaches to take to find out what is happening with your friend or relative, and how to address gaps and problems that you discover.

-- Next -- 116. Read the Medical Chart of Your Elderly Relative to Avert Mistakes