Please HELP and be detailed as possible.

You are Director of Assisted Living for Autumn Park and Ms. Mildred Puce, a new resident, has been taking advantage of the facilities resources, displaying inappropriate behavior towards personnel, and threatening to sue the company for alleged violations of the American's with Disabilities Act (ADA) and go to the media claiming mistreatment of persons with handicaps. You've received caregiver complaints alleging poor treatment from Ms. Puce which she denies. A few of the caregivers have decided to resign their position rather than continue to work with Ms. Puce. Ms. Puce has also lodged a number of complaints to management and even spoken with her attorney. Mr. Brad Douglas, Executive Director of Autumn Park, has had discussions with the State of California's Community Care Licensing Agent and it was mutually agreed that the level of care that Ms. Puce requires exceeds that typically provided at a Continuous Care Retirement Community (CCRC). Autumn Park can provide the care Ms. Puce needs, but not to her unique expectations. Mr. Douglas is planning to present a number of options to Ms. Puce for her consideration. You would like to make certain that the options Mr. Douglas is initially considering will, in fact, address the concerns expressed by Ms. Puce and the employees. To this end, you know it's important to figure out what is motivating Ms. Puce and the caregivers. After all, if you understand their motivation, it may explain the decisions and behaviors you've witnesses.

After carefully reading the case entitled: Autumn Park in which the Executive Director and the Director of Assisted Living in a community for independent and assisted living must resolve a disagreement as to the appropriate level of care for a difficult resident (Provided Below) please develop plan for how to go about assessing these stakeholders' motivation.

Instructor note: This isn't a plan to address the issues. It's plan to assess the motivation of all the people involved in resident's care. You are to developing an action plan using a table format that includes information such as:

• what is to be done
• why it will be done
• when it will be done
• how it will be done
• who will do what

HERE IS THE CASE! IMAGES BELOW!

Autumn Park

Cara Thomason Embry and Robert C. Myrtle

The executive director and the director of assisted living in a community for independent and assisted living must resolve a disagreement as to the appropriate level of care for a difficult resident.

25 Autumn Park Cara Thomason Embry University of Southern California, Anaheim, CA Robert C. Myrtle University of Southern California, Los Angeles, CA Brad Douglas, Executive Director of Autumn Park, was tired and frustrated as he once again looked at the resident file of Mildred Puce. Douglas was preparing for the afternoon meeting with Puce and Hannah Meeks, a registered nurse and Director of Assisted Living at Autumn Park. Douglas supported the company's principles, values, and beliefs on how to deal with resident issues and problems, yet everything he is doing with Puce goes against them (see Figure 25.1).THE HISTORY OF AUTUMN PARK Autumn Park is one of thirteen properties owned and managed by Abbot Retirement Communities (ARC), which owns and manages high-quality, full-service rental retirement communities nationwide that offer independent living, assisted living. and dementia care. Most are continuing care retirement communities (CCRCs). Regulated by the state, CCRCs offer long-term continuing care services by contract that includes housing and residential services. usually for a resident's life time. ARC is passionate about enhancing the lives of seniors and is committed to delivering exemplary service with integrity. dignity, and compassion. Statement of Poincipleo. Vaiueo. and Beliefs We are committed to exemplary service delivered with integrity, dignity. and compassion. Our communities for seniors are distinguished by warm, secure, and friendly environments. We will enhance each resident's lifestyle by: - Responding immediately to residents' needs and concerns. - Oering highquality. creatively designed programs. - Encouraging independence. - Promoting a sense of community and friendship. We the staff are committed to: Teamwork Being professional Open communication Fostering a learning environment Continuous improvement Profitability We live by a standard at conduct that encompasses honesty. accountabil ity. personal development, and a passion for excellence. Figure 25.1. These principles. values. and beliefs are referenced whenever important decisions are made at Autumn Park. ARC is a family-owned company founded in 2001. The President and CEO, Anthony Abbot. was given a retirement property by his family as an investment. The original plan was to manage the property and improve its appearance and services. and then resell it. Abbot became so interested in managing the property he decided to keep it and expand the business. Abbot had a vision to grow ARC as a unique company dedicated to meeting the changing needs of residents and their families. He wanted to create a working environment in which associates are appreciated and inspired to develop as individuals and in which strengths and abilities are nurtured and rewarded. He wanted to own a company of high-quality retirement communities and services delivered with warmth and friendliness. He was committed to responsible growth. operational excellence. and superior financial results. He did not want the largest company in the industry; just the best. In 2013. Abbot and his executive team wanted to develop a property from the ground up. Abbot wanted to build a high-end retirement community. The properties he had acquired previously were all middle- to high-end properties, in appearance and price. Abbot was able to meet with the county development planning department for a new, planned city in Southern California. They found a central location for the facility and bought the land. Contemporaneously, ARC moved its corporate office from North Carolina to Southern 475 C alifornia. Figure 25.2. Autumn Park Continuum Care Retirement Community. ARC broke ground for Autumn Park in 2013, with an anticipated opening in March 2014 (Figure 25.2). Autumn Park is a community for independent and assisted living residents, with an additional facility for dementia care. The goal for Autumn Park was to have no more than 40% of residents in assisted living. BACKGROUND OF MILDRED PUCE In September 2013, Mildred Puce visited the house trailer that was the marketing office for Autumn Park while it was being built. After several visits with the marketing team about what Autumn Park could provide her, she gave her deposit in November. Puce already lived at another continuing care retirement community (CCR'C), yet she was attracted to Autumn Park's centralized location. It would be near shops, restaurants, churches, and grocery stores. Autumn Park offered what she has now, plus access to more services. Autumn Park's marketing team sought to ll their new property as soon as possible. They took applications and deposits from anyone who was interested and seemed to meet their admission requirements. But, Puce was diHerent. She is younger than 60, lives in another CCRC, and uses a motorized wheelchair because multiple sclerosis limits function to only her head and left arm. Autumn Park accepted her deposit on condition that they would be able to obtain an exception letter from the state because she was under the age requirement to live in a CCRC. In addition, she had special needs and required a Vera body lift, which might limit her ability to live independently (Figure 25 .3). Circumstances delayed Autumn Park's opening to July 2014. In March 2014, Autumn Park received a doctor's order that Puce needed a Vera lift to get into and out of bed, and to the toilet. The orders also stated she could operate the Vera lift with little assistance. She used a motorized chair because of her disability and, therefore, needed a handicapped-access apartment. Figure 25.3. Vera Lift. The life enrichment assistant coordinator of the CCRC in which she lived also wrote a letter to Autumn 477 Park saying how wonderful a resident Puce was and how sorry they are that she is leaving them. In May 2014, Autumn Park received another order from Puce's doctor that stated she could self administer her Interferon Beta injections. The physician disclosed all her disabilities for the clinical staff to examine and consider in their assessment. The marketing department collected the information, but did not share it with the clinical staffto assess at that time. ARC's policy was to complete an applicant's admission assessment prior to accepting a potential resident's application. The assessment is based on observations of, and conversation with the resident, as well as a physician's assessment of the resident's medications, diagnoses, disabilities, and abilities (see Figure 25.4). If the clinical staff determines that Autumn Park cannot meet the needs identied, the application will not be approved. Consistent with state requirements, ARC's policy states that, following initial assessment, the resident must be reassessed 30 days after movein. Puce's assessment prior to admission indicated she required 10 minutes for bathing and showering, 15 minutes for grooming, and 15 minutes for assistance in transfers. This indicated that her care required Level 1, assisted living care. This was in contrast to her personal assessment that she was fully capable of taking care of herself, as well as her two cats. Autumn Park opened July 1, 2014. During the first month, the executive director resigned and the director of assisted living was dismissed. Corporate brought in regional directors to fill in. By the end of August, Brad Douglas was hired as the new Executive Director of Autumn Park and Hannah Meeks was Autumn Park's new Director of Assisted Living. At the end of August, 2 months after her admission, Meeks reassessed Puce as a Level III assisted living resident. She was taking 45 minutes of caregivers' time for her showers, which are given three times per week. Also, caregivers spent 20 minutes daily helping Puce with oral care. It was also determined that caregivers were spending an extra 1530 minutes with Puce each time she used the bathroom. Much of that time was spent helping her in and out of her Vera lift. It also t0ol-r caregivers 20 minutes to transfer Puce into and out ofbed, which they did once each per day. Each apartment at Autumn Park has two emergency call cords {ecords): one in the bedroom and one in the bathroom. The ecords are to be pulled only in emergencies. A pulled ecord shows on a computer screen at the front desk and the receptionist texts a caregiver to go to that room. A resident who wants nonemergency help calls the front desk, and the receptionist texts a caregiver to respond. Ecalls are considered emergencies and take priority over phone calls. Puce was, however, abusing the process by pulling her ecord every 30 minutes for caregivers to help with nonemergencies, such as taking out trash, turning on lights, or feeding her cats. Instructions for Level of Care Assessment Bathing/Showering: . 20 minutes-Resident requires daily bathing/showering due to inconti- nence 10 minutes-Requires total assistance, substantial assistance, or standby assistance during bathing/showering including help in and out, supervi- sion/assistance with washing, shampooing, toweling, dressing, and so forth; bath/shower 3x/week; assist with dressing daily . 5 minutes-Resident requires verbal reminders, clothes laid out, bathing items prepared, some assistance with buttons, zipper, and so forth . 2 minutes-Resident requires minimal assistance, including reminders and follow-up Staff member does not need to be present during bathing and dressing . 0 minutes-Independent Oral Care: . 10 minutes-Total assistance or standby assistance with and/or reminders for oral care including care of dentures, partials, and so forth . 5 minutes-Reminder and setup only . 2 minutes-Reminders only and follow-up check daily . 0 minutes-Independent Grooming: (includes hair care, shaving, and makeup application) 15 minutes-Total assistance or standby assistance daily 7 minutes-Reminders, setup, and follow-up only 0 minutes-Independent Toileting/Incontinence: 50 minutes-Assistance and/or reminders to resident to use the bath- room every 2-3 hours; assistance with protective undergarments, assis- tance with removing and/or reapplying clothing; changing bed as needed . 25 minutes-Reminders and directing only and/or frequent accidents (more than 1x/week) . 10 minutes-Assist with cleanup of occasional accidents . 0 minutes-Independent Medication Management: 20 minutes-Total medication administration (4 plus x a day/dosing or more than 6 medications a day) . 15 minutes-Supervision of medication administration (3x a day/dosing or 3-6 different medications a day) . 10 minutes-Supervision of medication administration (2x a day/dosing or less than 3 medications per day) . 5 minutes-Weekly medications setup only, or supervision of medication administration for P.R.N.s only 0 minutes-Independent Mental Status/Behaviors: . 60 minutes-Disoriented, requires 24-hour supervision and monitoring; occasional redirection- 3O minutesDisoriented, frequent reminders needed. but some direction or redirection required or depression requiring constant encouragement and frequent individual socialization - 20 minutesMild disorientation. occasional behavior problems. needs reminders daily or depression requiring daily encouragement - 10 minutesMild disorientation, no behavior problems, follows routines or some depression requiring occasional encouragement 0 minutesIndependent TransferaiAmbulation: ~ 10 minutesAlways assist with transfers; pushing wheelchair to meals. activities, or standby assistance for ambulation with walker - 5 minutesOccasional assistance for wheelchair transport to meals, activities. or standby assistance for ambulation with walker - 0 minutesIndependent Other Treatments: - Other treatments, including follow-up of therapies, dressing changes. customary care, Unna boots. whirlpool treatments. application of ointments, blood sugar, frequent vital signs, or treatment. Record estimatedfectual time per day to perform treatment. This includes weights or vital signs, more than once a month, daily bed change due to incontinence, and so forth. Legend: 045 Minutes of cars per day is Level I 4690 Minutes of care per day is Level II 91135 Minutes of care per day is Level III Greater than 135 minutes per day might require Alzheimer's care or nursing care. Each additional 40 minutes will be billed as an additional level. Figu: 25.4. Level ofcare assessment criteria at Autumn Park. Douglas, Autumn Park's new executive director, and Meeks also noted that Puce was abusing her use of Autumn Park's transportation. Autumn Park owns a wheelchair accessible bus that carries 20 residents and is used for scheduled outings and other residents' activities. Autumn Park also owns a Lincoln Town Car for doctor's visits and unscheduled errands. One hundred and forty residents share these two vehicles. Puce's handicaps limit her to using the bus. Disregarding its use for scheduled activities and groups of residents, she demanded the bus take her to doctor's visits as needed. Puce complained constantly that caregivers don't understand her Vera lift and don't understand English. She continually pulled the e-cord. When Autumn Park increased her fees due to the time spent on her, she and her attorney claimed discrimination under the federal Americans with Disabilities Act saying that Autumn Park raised only her rate and no other resident's. When Autumn Park showed her the minutes used for her care, she insisted they were not correct. She dictated to Meeks which caregivers she wanted to care for her. Such a request is considered private duty care in Autumn Park. which necessitates a rate increase. Puce again claimed Autumn Park was discriminating against her and threatened to sue. In November 2014, which was 5 months after Puce was admitted to Autumn Park1 Meeks discovered that the letter describing Puce's health status and disabilities had not been sent to the state. Douglas and Meeks prepared the letter asking the state to decide if Puce would receive an exception to the regulation prohibiting someone younger than 60 from living in a CCRC. If, as Douglas and Meeks hoped, the exception were not granted, the state would no longer allow her to live at Autumn Park. To their dismay, the exception was approved by the state. This meant Puce could remain at Autumn Park. Also in November, Autumn Park began a 30-day period to record the minutes spent on Puce's care. She was to keep a record and the caregivers were to keep a separate record of the minutes they spent with her. It was discovered that Puce manipulated the caregivers as they documented the minutes used in her care. Puce denied the accusations that she manipulated the caregivers in their documentation of her care. Due to the dispute on how to record and how the minutes reected care, Puce and Autumn Park redid the evaluation in January 2015. Also, in January, a letter was sent to all residents at Autumn Park stating there was a change in the fee structure for assisted living. Instead of $400 for Level I, and $300 for Levels 11 and II], it would be $500 for each additional level ofcare. In March 2015, a third evaluation of the minutes of care used for Puce was conducted. Puce continued to assert that the minutes documented were not a true reection of the care she was being given. Once again Puce manipulated the caregivers; many came forward to describe it to Meeks. Also, several caregivers wanted to resign because they no longer wanted to care for Puce. They claimed she was verbally abusive and yelled at them. Puce denied she ever raised her voice to a caregiver or spoke to them in a derogatory way. She said caregivers must have interpreted her requests incorrectly. Also, in only 5 months, three caregivers made workers' compensation claims because they hurt their backs caring for her. Puce continued to demand that only certain caregivers care for her, and now she wanted no male caregivers giving her showers. By this time, Douglas and Meeks were very frustrated with Puce. They wanted her out of Autumn Park, but didn't know how to evict her without being sued or causing negative publicity. Douglas decided to visit the executive director of the CCRC Puce lived in prior to coming to Autumn Park. The executive director agreed with Douglas about how difficult and manipulative Puce was. She also told Douglas that, \"once we got her 30-day move-out notice we were jumping up and down in the halls. We wrote glowing letters about her just to make certain that Autumn Park would take her.\" Douglas was at a loss as to what to do about Puce. In May 2015, Autumn Park talked to the state ombudsman1 about the difficulties they were having with Puce. Her demands on Autumn Park and her caregivers were causing a great deal of stress. The ombudsman agreed that Puce is a difficult resident. In June 2013, Puce complained to the state ombudsman that her privacy rights were being violated because a male staff member was assigned to help her take a shower. The ombudsman called the state licensing authority, which sent an official to Autumn Park to speak to Douglas and Meeks about Puce. The official reviewed Puce's file. It documented the skill level they provided and showed that Puce needed an even higher level. By this time, Puce had severe edema in her legs because of poor circulation. The edema caused her legs to weigh about 50 pounds each. This increased the risk of caregivers being injured repositioning her legs in her wheelchair or when operating her Vera lift. If the edema persisted, her skin would break down, causing open, weeping wounds. If this happened, she would have to be hospitalized. California regulations require a residential care facility to give residents 30-day notice to move out if the facility feels it can no longer provide the care a resident needs. Also, state regulations allow a facility to refuse a former resident's request to return to it if, after hospitalization, the facility determines it cannot provide the care the resident requires. The regulations state that a resident in such a facility must have skilled health professionals take care of any open wound, skin tears, or pressure ulcers. Hospitalization may be needed to receive such care, or the facility may have an exception from the state that a home health nurse will care for the resident until the wound heals. As Douglas revietved Puce's le, he felt his hands were tied. If Autumn Park gives Puce notice, she will sue Autumn Park under the Americans with Disabilities Act. Puce also threatened to call the local media about Autumn Park's treatment of a handicapped resident. Therefore, Douglas had made certain he told the state licensing official Autumn Park can care for Puce, but not to her unique expectations. Puce needed custodial care not skilled nursing care. Yet, Puce was a victim of her own circumstances since she could not afford the onetoone care. Community care licensing agents had evaluated Puee. They agreed that Puce was not appropriate for a CCRC and needed a higher level of care. Douglas also thought about what the ARC corporate staff had told him. They stated that anything is better than negative publicity about Autumn Park or its parent, ARC. \"Do what it takes to provide her care; avoid a lawsuit and negative publicity at all costs." At the meeting with Puce, Douglas plans to offer her three options: 1. Get the level of care she needs from sources such as home health 2. Move to a facility with more skilled care 3. Get 12 hours of onetoone care daily at a cost of $7,000 a month