No doubt by now everyone has read and/or heard about Colleen, the nurse who Brookdale Senior Livingrefused to do CPR on an 87-year-old woman who collapsed in the dining room of Glenwood Gardens, a Brookdale Senior Living facility located in Bakersfield, CA. The elderly woman later died at a local hospital.

The partial transcript of the 911 call is almost unbelievable, especially in the nurse’sGlenwood Gardens - Brookdale Senior Living - Bakersfield, California refusal, with her boss concurring with her refusal, to let the dispatcher talk someone – anyone – else through doing CPR – saying it was against company policy – to aid the elderly woman, who was barely breathing.

After reading this story, I contacted a friend of mine who is the director of nursing at the Brookdale Senior Living facility where my mom lived until she came home to live with me until her death. I asked if this was really company policy. She confirmed that it was.

Even though my mom had a DNR, so this would not have applied to her, I told my nurse friend that I didn’t remember anyone telling us that during the admissions process, since that would be something that should be clearly stated at the outset for people considering a Brookdale Senior Living facility as a choice for themselves or a family member.

She said she had brought that up to the admissions person there who basically said that telling people wasn’t required because it was explicitly stated in the mountain of paperwork that was signed and given at the time of admission. I admitted I hadn’t read every word of mine because my sister and I asked all the important questions we needed answers to during the admissions process, but that I didn’t think that was a responsible answer, because that, for a lot of people, would be a deciding factor in determining living arrangements.

I then asked my nurse friend what she would have done. She said she didn’t care what the legal issues were because this was a moral and ethical issue and she would have broken the company policy and put her employment in jeopardy to do the CPR. She made an interesting statement about how she would not be able to live with her conscience if she could help someone and didn’t. She also reminded me that in nursing school, she took The Florence Nightingale Pledge, which is similar to the Hippocratic Oath that doctors take, which includes the intent of doing no harm to those in their care. 

So what does this have to do with quintessential leadership or the lack of quintessential leadership? Everything.

We’ll start with the nurse because it’s the easier of the two to clearly see a lack of quintessential leadership. As a nurse, she took the same pledge my friend did. The welfare of that 87-year-old lady – even if any efforts at CPR didn’t, in the end, save her life – should have been her only concern. The dispatcher gave her an opportunity to let somebody else do CPR and the nurse refused everything. She lost – or maybe never had – the vision of what being a nurse means. At the very least, her nursing license should be immediately and permanently voided in all 50 states.

Brookdale Senior Living is also being operated and run by unquintessential leadership. That this policy is in place at all, in assisted living facilities, is not only absurd, but reprehensible and irresponsible. But the company’s unquintessential leadership goes far beyond this one incident.

It is important to take a big-picture look at this company – and all others like it – to see what their priorities are (I know a lot about Brookdale Senior Living, which is why I am singling them out, but it would be naive to say they are the only senior community company that has these policies and operating models). While seniors and their families are encouraged to believe that these companies care about them and put “our residents first,” that is, in fact, not the truth. What these companies care about most is profit (the monthly charges, for the bare minimum of services, start around $5000 in the south, so it makes sense that it’s much higher in other parts of the country) and no legal liability. If the residents happen to fall in the mix pleasantly, that’s okay, but if they don’t, then the company comes first.

The lack of honesty and the greed and self-interests of the companies are all unquintessial leadership traits. So, buyer beware, which quintessential leaders don’t have to worry about, applies to anyone considering one of these facilities.

Brookdale Senior Living lacks quintessential leadership in many areas beyond this, based on my experience with them and subsequent first-hand knowledge that I have had of their activities. They have policies in place that don’t protect the residents, the interests of the residents, and the families of the residents. And the puzzling part of this is that some of these policies leave them wide open for lawsuits, if someone wanted to pursue them.

In my mom’s case, while she was living there – and this precipitated (among other things affecting her health that I had discussed and been promised over and over would be done and never were), after Mama emphatically told me she wanted to live with me and didn’t want to go back there, Mama coming home to live with me until her death in August of last year – she had a very bad fall in the middle of the night.

(I don’t know what happened in Mama’s brain during the month between her diagnosis with vascular dementia and the hospitalization in a geriatric psychiatric facility after a couple of the most bizarre weeks of her life and my twin sister’s and my lives, but the first thing I noticed on my first visit with her there was that she was suddenly turning around counter-clockwise. Because of that, she would lose her balance. That became her way of turning her body, and as the diseases – Lewy Body dementia was also present – worsened and her balance in general got worse, she was more prone to falling.)

The problem – and quintessential leadership failure – was that I didn’t hear about the fall until 8:30 the next morning when I called Mama to tell her I was on my way (I was there every day, often for hours at a time, just to keep an eye on things and make sure she was okay) and she told me she’d fallen and her ankle was hurting badly. I was livid as she told me that a CNA had come in and found her on the floor, asked her if she was okay, and when Mama said she was, lifted her up and put her back in bed.

The unquintessential leadership in this scenario abounds. The first is asking someone, who, by the way, had a serious hearing loss and did not have her hearing aids on, with dementias and Alzheimer’s Disease to accurately assess her condition. The second was not calling EMS to take her to the emergency room to check for broken bones (fortunately, she didn’t break anything, but she had a serious ankle sprain), then call me to tell me to go to the ER. The third was the CNA moving her without confirmation that nothing was broken.

I got calmed down enough to go in and talk with the director of nursing, because I had explicitly said early on that if anything happened to Mama, I wanted to know immediately, no matter what time of the day or night it was. It was in the record and it wasn’t done. I got a lot of excuses about why the CNA didn’t call – also unquintessential leadership – but finally the director of nursing agreed that she should have and told me she’d get mobile x-rays done just to make sure Mama was okay.

I ended up spending almost two weeks pretty much living there with Mama to ensure she was healing and safe (I understood that it was assisted living, so I couldn’t expect someone other than me to be there 24/7).

About a week after that, I went in early one morning – several people had been in and out of the room and Mama had gone to breakfast, so a lot of people had an opportunity to observe her – and I immediately noticed she was having a really hard time breathing. The fact that no one else saw it or said anything to me about it was unquintessential leadership. I got her to the doctor and the determination was either pneumonia or the beginnings of congestive heart failure.

The doctor treated it as pneumonia since the chest x-ray seemed to indicate that, but it was in fact congestive heart failure, which landed Mama in the hospital a week after that (she’d been staying with me that week and I grew more concerned as I saw her breathing getting more and more labored). It was after that hospitalization that Mama came to live with me for good.

I didn’t blame all of Mama’s issues with high blood pressure and congestive heart failure on the Brookdale Senior Living facility. It wasn’t all their fault. However, the lack of quintessential leadership at the facility definitely contributed to Mama’s condition.

Her doctor had ordered a very strict diet to try to deal with blood pressure and weight and I had talked to everyone there for about a year trying to ensure that the diet was followed.

Everybody from the top down gave me lip-service that they would follow the doctor’s orders, but no one followed up and no one ensured it was done. I saw time and again, with my own eyes, that it wasn’t being done. Each time I brought it to the attention of those in leadership positions there, I heard blame and then the same old promises, which were never kept.

That was unquintessential leadership on so many levels.

But the most unquintessential leadership story that I heard about this particular facility was recounted to me (and I will not recount the details here to protect the person, who is a good friend, who told me in excruciating details one of the most horrific stories I think I’ve ever heard in my life) months later and it is damning evidence that Brookdale Senior Living is under unquintessential leadership from the very top down.

This story involved a serious medical emergency with a resident – whom Mama and I both knew and who was vivacious, healthy, and said to me every time she saw me, “I just love your little mama” – brought on by a criminal act by another resident, that occurred on a Sunday morning. The registered nurse was asked to call 911, but instead of calling 911, the RN started trying to call the executive director and the director of nursing. Finally, because the RN wouldn’t call 911, one of the staff members did.

The resident with the serious medical emergency was transported to the hospital, where she died a week later. The staff member told 911 what had happened, but immediately the RN started disputing her story. The executive director finally came in and the cover-up of what actually happened began in earnest. The staff member was put on notice because she’d “broken the chain of command,” which she had not, but the RN, who was at the top of the chain of command, didn’t do what she should have done, which was to have called 911, and then called facility leadership to let them know what happened.

The family was lied to about what happened and the circumstances under which it happened. No action was taken against the resident who committed the criminal act, which jeopardized every other resident still there. And eventually the staff member who did the right thing was fired for insubordination.

You might wonder why and what all this has to do with us as quintessential leaders. The answer is “everything!” This is both a strong caution for those of us who are now the quintessential leaders who are entrusted with our aging parents’ care and for those of us who are striving to be quintessential leaders in every aspect of our lives.

This is what unquintessential leadership looks like in action, with specifics that have broad application throughout our professional, personal, and spiritual lives. As quintessential leaders, we have the responsibility to ensure we are not following in the footsteps of the examples given above. Please be sure to read an excellent companion blog article to this one entitled “Quintessential Selfishness.”

That requires us to have the commitment, the determination, and the courage to do the right thing all the time, no matter what the personal cost is to us. It requires us to have an immovable and unshakable moral and ethical foundation that is the basis of everything we are, we do, we say, and we think. It requires all the components of Building Trust and Being Trustworthy to be an active and living part of our very beings all the time.

It’s prudent to look in the mirror quite frequently and make sure we are the quintessential leaders we say we are and are striving to become better at. Too often, we can all get lazy or complacent and believe, as Paul Simon so eloquently wrote, “that we’re gliding down the highway when, in fact, we’re slip slidin’ away.” 

  1. […] a follow-up to last week’s post on CPR and quintessential leadership regarding the action of a Brookdale Senior Living nurse refusing to do CPR on 87-year-old Lorraine […]


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