Why do nursing homes improperly medicate residents?

According to a recent study, each week 179,000 nursing home residents are given  antipsychotic even though the residents do NOT have diagnoses for which the drugs are approved. Often, these drugs are administered without informed consent. Unrelated to any underlying treatment, the medications are provided to make the resident docile. In today’s episode, nursing home lawyers Rob Schenk and Schenk Firm discuss in appropriate use of medication in nursing homes with Kelly Bagby, an attorney and Vice President of the AARP Foundation Litigation.

Schenk: Hello everyone, welcome back. My name is Rob Schenk.

Smith: And I’m Schenk Firm.

Schenk: And we are hosts for this episode of the Nursing Home Abuse Podcast. As this podcast goes to air, it’s February 25th, and generally, we like to at some point in the podcast talk about something topical. Usually it’s a holiday or like one of those special days. We try to find something nutty, something nutty to talk about.

Smith: Right. Okay.

Schenk: In terms of the special days.

Smith: Well I don’t know why you would use “nut” as a segue into the special day, because the special day is Pistachio Day. I don’t know if pistachios are nuts.

Schenk: That’s a good point. I guess it would be more difficult to say sometimes we get really legume-y with the days that we pick. Is that right? Is a pistachio a legume?

Smith: I don’t know.

Schenk: A pistachio is a nut.

Smith: I have no idea.

Schenk: It’s in a shell.

Smith: I don’t know that that’s how that works.

Schenk: I love pistachios.

Smith: You do, and anytime we go on a road trip, which we frequently have to drive all over the state to see clients, Rob will make sure that he brings a bag of unshelled pistachios so that he has something to constantly make a mess with.

Schenk: I mean I don’t know why you’re complaining about that. You love pistachios and that one time that I brought that gallon-sized container that had unshelled pistachios, it was like you hit the numbers, like you were so excited and you just downed it.

Smith: You mean shelled pistachios.

Schenk: Unshelled. Like they had the shell removed from them.

Smith: Oh.

Schenk: Are you saying by saying shelled pistachios, they don’t have shells?

Smith: Right, because shelled is not a verb, it’s a noun. It’s that their shells have been removed, so they’ve been shelled. No?

Schenk: No, sir.

Smith: It’s not like shucking an oyster. Like shuck is the verb.

Schenk: Well oysters don’t have shucks.

Smith: Right, and that’s why I’m saying, but I feel like if you shell a pistachio, you remove its shell.

Schenk: I guess the better analogy would be pitted dates. So a pitted date is one that still has the date pit in it.

Smith: No, I don’t think so. I think a pitted date would be one that had the pit removed.

Schenk: Gene, we’re going to have to get your – you’re going to have to be the tiebreaker on this one.

Smith: We’re going to have to come back to this one.

Schenk: Well that’s enough nonsense.

Smith: Okay.

Schenk: We need to get to get into what we’re talking about today.

Smith: Yeah.

Schenk: So the topic for today is the problem with overmedicating nursing home residents, and that happens for a variety of reasons in our experience. But to delve deeper into this topic, we are going to need some help. We have a special guest. Her name is Kelly Bagby and I saw Kelly Bagby speak, actually like many of our guests, at the National Consumer Voice Conference in 2018. Maybe we’ll see her again later this year. Well anyways, Will, who is Kelly Bagby and what’s she about?

Smith: She’s the vice president at AARP Foundation Litigation AFL managing the office’s work related to health, hunger, housing and human services. Kelly specializes in civil rights, disability rights, health law and other public interest areas with an emphasis on litigation. She’s been part of AFL’s health team since 2008. She has litigated a range of discrimination and public interest cases in both federal and state courts. Prior to joining the litigation branch of the AARP, she worked with the Office of Counsel for the Office of Inspector General, OIG, for the United States Department of Health and Human Services. From ’98 to 2004, Kelly was the litigation director at Disability Rights D.C. and worked with Disability Rights Maryland before that. So we’re dealing with an attorney here today who has a wide range of experiences in both federal and state courts and dealing with topics related to the care for the elderly. So we are very lucky to have Ms. Bagby here today.

Schenk: Ms. Bagby, welcome to the show.

Kelly: Thank you very much.

Schenk: All right, great. Well Kelly, Will and I were just talking about overmedication of residents, nursing home residents, particularly in the state of Georgia is a growing problem, so we’re really happy that you’ve been able to come onto the program to talk about this issue.

I guess one of the main things we want to get out of the way first is like in terms of overmedication, what are some of the more commonly overprescribed medicines that you’ve seen in your experience?

Which types of medications are commonly overprescribed in nursing homes?

Kelly: Yeah, actually if you don’t mind, I’m going to push back on the term overmedication because I think some of these medications should never be administered to certain people, so there’s no small amount of the medication that would be appropriate for them. Particularly with people with dementia, giving people with dementia certain kinds of what are known as antipsychotic drugs, drugs like Risperdal or Geodon or Abilify, those drugs are not intended to treat dementia and in fact can’t treat dementia. Those drugs carry FDA’s most dire warning, which is known as a black box warning, and it’s named because it has this big, old black box around the manufacturer’s box. And it’s the highest warning that the FDA requires, and that warning says, “These drugs can cause death when given to people with dementia.” And so no small amount is going to be appropriate in those circumstances. But it’s not so much about the over-prescription of these drugs, it’s any prescription of these drugs for people with certain kinds of conditions can be fatal.

So on top of the drugs I just mentioned, Risperdal, Geodon, Abilify, there’s a long list. You go to the FDA’s webpage and Google “black box drugs,” you can get the list of the name brands as well as generic brands so families can look up and see, “Well is this a drug that has a black box warning?”

On top of that, there’s another category of drugs usually given for seizures, drugs like Depakote, and those drugs are also commonly used to administer to people with dementia in nursing facilities, but all these drugs are given not to treat an illness when dementia is present. They’re there basically to chemically restrain the residents and to prevent them from having what might be normal behaviors for a person with dementia.

Smith: Right, so there’s an effect that we were talking about this another two podcasts ago. When I was in working nursing homes, they were using Haloperidol a lot, and then they started going to Risperdal and Seroquel, and I don’t know if sedate is the correct medical term, but it makes them more compliable. It’s a convenience for the staff because you may have somebody like Mr. Johnson who has dementia and he keeps going into other people’s rooms, so they kind of come up with a reason to keep giving him these drugs. But he doesn’t need it at all. He doesn’t have schizophrenia. There’s something else that needs to be done.

Why is improper medication a problem in nursing homes?

Kelly: That’s right. So you’re talking about the sedative benefits from their perspective, from the staff’s perspective.

Smith: Sedative, yes. But they are – and so that’s basically control of the resident for staff convenience rather than having adequate staffing to redirect Mr. Johnson to doing things that maybe are a distraction to him rather than sedating him.

But the really dangerous part of these drugs is that they – with some people, the impact can be within weeks that they begin to be unable to eat or drink and they start deteriorating. They start slumping in their chair. Their breathing becomes labored. They lose all interest. My clients have lost the ability to communicate and sit up and then they become at risk of aspirating food into their lungs. This can happen, with my clients anyways, this can happen in weeks of being administered the first prescription of these drugs. It can happen very, very quickly, especially when you’re talking about a vulnerable person who has other medical complications. The impact of the drugs is very swift with some people and irreversible.

Smith: Irreversible. I didn’t realize that. Yeah, and it sounds like they’re being used for, again, and I say this as somebody who worked in a nursing home, I’m not saying this for all people who work in nursing homes, but it’s because of staff laziness. It’s easier to have a sedated Mr. Johnson than it is to figure out why he may be going into other rooms or figuring out a different way of dealing with it. And it’s a shame.

Kelly: That’s right. There is a client that we have that we built a class action around one facility in California, and that one client is in for rehabilitation. She had broken her hip. The only purpose of her being in the nursing home was so she could rehab her hip after surgery. She was only in for three weeks, and during that time, they layered on increasing amounts of drugs. Their reasoning wasn’t that she was wandering or bothering anybody or yelling or any of those things. Their reasoning was she kept trying to get out of her wheelchair because she was uncomfortable because she just had hip surgery. And so every time she would shift and try to get out of her chair, they would layer on another drug. And when you looked across the week that she was there, she went from zero drugs for behavioral intervention to 11 drugs for behavioral intervention. And she died. Her daughter realized they were basically poisoning her with these drugs and withdrew her from the facility, but by then, the damage was already so advanced in her cognitive abilities and her immune system had become so depressed that when they put her back into basically an opioid kind of thing to get her off all the drugs that the nursing home had put her on, and they couldn’t. They couldn’t get her off. And she passed away.

Smith: And you mentioned opioids. We all know that that is a widely prescribed class of medicines in the American medical system overall, not just for the elderly, but are opioids an issue as well?

Are opioids a problem in nursing homes?

Kelly: Yes, especially for people who are not necessarily in nursing facilities, but people who are living in community settings and who are hopefully being supported in their own aging in place in their own homes. Sometimes if there’s a fall, they go to the emergency room, and it’s not even a bad fall, the doctors will give them a whole bottle of painkillers, and unbeknownst to the person who’s taking the drugs, they’re becoming addicted quickly. And so that becomes a real problem for a lot of people in community settings as well.

Smith: So in addition to the chemical restraint aspect of certain drugs, what are some other reasons that – what are some other overprescribed medicines that we’re looking at then?

Kelly: Well I think there’s a lot of use of drugs like Ativan, anti-anxiety drugs, which are sort of a temporary restraint. They’re not given on a daily basis, so if somebody’s feeling anxious and having worries or is acting peculiar, nursing homes will sometimes start giving them something like Ativan or Valium, but those drugs can also become a problem if not monitored and particularly if not evaluated in conjunction with the other types of drugs they’re taking. So looking at counterindications and how the drugs interact with each other and how they might cause problems that older people are more susceptible to, like constipation, which can lead to very serious side effects, dehydration, which can lead to very serious side effects and swallowing problems, which can also lead to aspiration.

So it all comes down to you need good oversight and monitoring and people evaluating and following up with what is happening with this person who’s taking these various medications? Are they having a normal or an abnormal reaction to them? And are we watching carefully with the way the drugs are interacting with each other? And more importantly, are there alternatives to these things? There are a lot of nonpharmacological interventions that should always be tried well before you start asking for your pharmacy’s assistance.

Smith: Well what kind of oversight is out there? I mean clearly individuals like yourself who are involved in litigation are doing what you can, but is there a lot of government oversight? Is there even an F-tag for overmedication?

Is there an F-Tag for inappropriate medication?

Kelly: There’s an F-tag for inappropriate medication, not for overmedication, but the F-tag doesn’t look at whether there’s actual harm, which is really a problem, because if you’re giving somebody medication, if I just handed you a bunch of pills that you don’t need right now, you would assume that’s actual harm for you. I mean that’s how we would normally evaluate somebody handing me a bunch of drugs that I don’t need to take. But in a nursing facility, there’s no such presumption. Their giving somebody drugs who are not appropriate for them medically is harmful, and that is a serious deficiency, I think, in our system.

Smith: And I want to correct myself on this too. I keep saying overmedication, but you’ve made the point, and it’s a very good one, that it isn’t really a matter of overmedication.

Schenk: Well in some instances. Some instances are inappropriate.

Smith: It’s totally inappropriate for somebody who’s going in for a three-week rehab be given medicine for schizophrenic just because it prevents her from getting out of the wheelchair.

Kelly: Right. Right.

Smith: There’s no amount that she should be getting. Yeah.

Kelly: If you think about if your kids went to school one day and your teacher, the teacher called you at the end of the day and said, “Yeah, so Mary was having some problems in school and she was disrupting the class, so in order to make my job easier, I gave her some Haldol.” That’s mad and uncontrolled behavior. But when you do it with a child, we are appropriately horrified, but we should be also appropriately horrified when it happens to an older person in a nursing home.

Smith: Yeah. No, absolutely. Go ahead, Rob.

Schenk: Kelly, you had mentioned earlier that from a nursing home standpoint, and I’m putting “benefits” in air quotes, but one of the benefits of inappropriate medication for residents is basically controlling their behavior. That seems to suggest that maybe there are some other “benefits” to inappropriate medication, maybe for example, preventing wandering or something, preventing falls. What are some other reasons why you’re seeing inappropriate medication?

Why does inappropriate medication in nursing homes occur?

Smith: Yeah, and it could even be, I know that in the world of mainstream medicine and the opioid crisis that there’s a lot of complaints that Big Pharma is involved in maybe pushing hydrocodone, Lortab and Oxycontin, all these different types of drugs. Is anything like that going on in the long-term care community? Or is it strictly just staff?

Schenk: Controlling behaviors?

Smith: Yeah.

Schenk: Staff just trying to be convenient.

Kelly: Well it depends on how much time you have. This is a long history of off-label promotion of these drugs in nursing facilities, and there’s been criminal prosecutions by the federal government, there’s been False Claims Act settlements to address, in the billions of dollars, to address the way that pharmacological manufacturers have pushed these drugs into, through kickoff schemes and various different ways, have just gotten this to be an acceptable culture where drugs are your first line of defense if you see a behavior, and that takes reeducation, I think, of doctors. It takes increased staffing in nursing facilities so that if you have enough staff to redirect the person who’s exhibiting wandering behaviors or whatever, all the staff has to do is say, “Mary, you don’t want to walk out of that door. Look over here. Let’s do something over here. Let’s read this book or look at this magazine, or let’s go paint a picture.”

And so facilities that have shifted away from such a medical model where pills are your first idea and have put in place more activity therapists and more people who are working on a day-to-day, hour-to-hour basis with people in dementia units, people with memory problems, those facilities can go without – they can eliminate the use of antipsychotic drugs completely and have, but you have to make a real culture change in the way you operate your nursing facility to be able to accomplish.

Schenk: Yeah, it sounds like the first line of defense is care plan meetings and putting the appropriate interventions that are specific to each resident in place.

Smith: Well it’s also interesting. We had met another individual at the National Consumer Voice conference, Diane Carter, who’s a nurse in Colorado, and she used to be with the American Association on Post Acute Care Nursing, and she was telling us – we were talking to her about chemical restraints and was telling us a story about one resident who kept going into people’s rooms and kept going into their drawers, and the staff figured out a non-medical intervention, which had to do with her history as a librarian, and they set up this sort of fake Dewey decimal system box to give her…

Schenk: With cards.

Smith: …with cards in it. It gave her something to do and that’s what she was looking for, but it was an interesting anecdote because it shows that there are other alternatives, or at least there should be an attempt at other alternatives before you turn to pills.

What are the alternatives to medication?

Kelly: Well sometimes I think it’s also just trying to figure out why the person’s behavior is what it is.

Smith: Exactly.

Kelly: Dr. Jonathan Evans, who was co-panelist at the Consumer Voice with me has been my expert in many of my cases, tells the story of one of the residents in his facility who kept pulling the fire alarm, just repeatedly, kept pulling the fire alarm day after day, and the facility said, “We’re going to have to kick her out. We can’t have her pulling the fire alarm all the time.”

So they all put their heads together, they’re sitting down like, “What are we going to do? Should we put her on med? I really don’t want to put her on meds.” And so finally, they look over at the fire alarm and there’s a sign above it that says “Pull.” So every time she’s walking by, she’s following directions. It says “Pull” so she pulls it. It required some deep thought by the treatment team to go, “Okay, wait a minute. What’s really happening here?” So they put up a sign that still says “Pull,” but it says, “Not you, Mildred.”

Schenk: Wow.

Kelly: That works, you know?

Smith: Yeah. But it is – I always thought about this when I was working on the floor. I was a CNA, but the LPNs above me, what a floor nurse, at least in our environment, what their main job is, is passing out medicine. That’s all that they have time to do. Every single resident has a myriad of different pills that they take, and it’s strange that we have that mindset where we would say, “Well of course they have pills to take. They’re older and they’re sick.” That’s not really the case though. A lot of those pills are given and probably shouldn’t be given. There probably are a lot of alternatives to just taking medicine all the time.

Kelly: It’s true – 20 percent of people in the nation’s nursing facilities have a diagnosis of dementia. So that’s a fifth of all people in nursing facilities for whom these drugs could be fatal. So you really have to take that into context and say, “All right, so that’s a fifth of the people whom we should be finding better choices, better alternative treatments for,” and really, they shouldn’t be the alternative. They should be the primary because drugs do not treat dementia. These are not treatments. These are 100 percent just chemical restraints for this population of people.

Schenk: Well Kelly, again, because our audience consists of mostly family members with loved ones in nursing homes, what are some of the signs, some of the telltale signs of inappropriate medications, medications being used as restraints so they can observe and know what’s going on.

What are the signs of inappropriate medication use in nursing homes?

Kelly: Well the main things that my clients have described to me are there something just starts to seem different. They seem withdrawn, which can happen to people when they go into a nursing home because especially if they’re coming from their own home and they’re going to a nursing home, they can become depressed, but it’s depression plus they’re losing interest in everything. They don’t want to talk. They don’t want to eat. They have to be reminded to drink water. Those kinds of things are very beginning signs, but when they start slumping over and they’re not really able to – like their spine isn’t really working for them and they’re slumped over all the time or they stop walking or they start shuffling or tremors, those are very important signs they should never ignore, because once you get those sorts of Parkinsonian symptoms where they’re moving their hands and feet a lot or they’re having twitches in their face, then those are warning signs, and people need to heed those carefully.

Schenk: And Kelly, can you kind of walk us through what the AARP Foundation Litigation Department does on a daily or yearly basis? Like what kinds of cases are you guys taking? Who are your typical defendants? Who are your typical clients?

What cases does the AARP Foundation Litigation Department take?

Kelly: We bring a host of cases. We’re basically like a small law firm housed within the AARP Foundation, so we bring on top of elder justice cases, elder abuse cases, we bring age discrimination cases in employment contexts and cases around consumer protection and a host of other things. But we also bring cases targeting nursing facilities who are mistreating or who are potentially abusing or neglecting our members or people who are similarly situated. We do that bringing – sometimes we’ve brought wrongful death cases, sometimes we’ve brought class action cases to try to address what are obviously systemic problems. And so we’ve done a number of cases in those areas.

We also bring cases all over the country to help give meaning to the civil rights of people in nursing homes to be able to live outside the nursing home, to try to get Medicaid to pay for long-term care services for them in community settings where they’re not isolated and not feeling like they’ve gone to a nursing home as the last place they’re going to live, that they can live full lives with dignity and in the community as well. So we have a very robust practice in all those areas.

Schenk: And so it seems like you’re taking on a lot of more systemic claims. You said class actions, not just maybe what would be considered like a one-off incident. You’re talking about structural problems with these nursing facilities.

Kelly: Yes. We try to pick big chains to sue so that we can hopefully push them to make broader systemic changes throughout their company, but we also are bringing staffing cases because we recognize that poor staffing is one of the reasons why people are inappropriately medicating people. We also have a case where a nursing facility resident was dumped into a hospital out of a nursing home and the facility refused to accept her back even after she had won an administrative decision to be returned. So that is another systemic, nationwide systemic problem that we’re trying to tackle through litigation and raise awareness with corporations that Nursing Home Reform Act means something and they can slight the law and think we’re all just going to go along.

Schenk: That’s right.

Smith: Now you guys, please correct me if I’m wrong on this, but the AARP is the only special interest group that has a litigation section. I know Consumer Voice doesn’t, right?

Kelly: No, they don’t, but we do a lot of work with Consumer Voice.

Smith: Of course, yeah.

Kelly: We partner with them on things, but Justice in Aging is also both a policy and an advocacy as well as a litigation unit.

Smith: We have Mr. Eric Carson on next week from Justice in Aging.

Kelly: Oh great.

Smith: But, you know, I’m giving you guys credit. It’s you and Justice in Aging. There’s not a lot of other people out there providing.

Schenk: With teeth. With legal teeth.

Smith: With legal teeth, yeah.

Schenk: I don’t know if that’s the right analogy.

Kelly: Yeah, well I think that the other organization that doesn’t just specialize in older folks is the National Health Law Project. They do a lot of litigation around Medicaid in particular, but we’ve partnered with them on broad systemic litigation, particularly on cases to get people out of nursing facilities.

Schenk: So what is your office look like? How many attorneys are in your litigation unit? How big is the operation?

Kelly: I think we have about 12 attorneys and then I’m actually one of the vice presidents, so I’m technically the manager, but I still help with building all the litigation. And the folks that do the nursing home work is probably about three or four of us.

Schenk: I see.

Kelly: And we partner with firms all over the country though, so that’s how we can really get a broad swath and it really helps to have a familiar name. It does help us to be able to attract good partners everywhere.

Smith: Yeah, I bet.

Schenk: And Kelly, so for our audience, which is mostly Georgia-based, if they suspect that their loved one is being inappropriately prescribed, given medicine, and it’s affected their health, and they want to get in contact with the AARP Foundation Litigation section, how can they reach out to you? How can they reach out to your staff?

Kelly: The first thing I would advise a family member who’s worried is to call an emergency meeting with the treatment team at the nursing facility because the number one thing you need to find out is what’s going on, what medications did they give their loved one and how long have they been administering these and are they monitoring the side effects. Why are they giving them? That’s the first thing I would say to anybody, before you go try to find legal assistance.

I would also urge the family to, second, notify the state of their concern if they find out their loved one was getting medication without informed consent. We haven’t really talked about informed consent, but that’s a big thing. This is usually a surprise to a family to find out that their loved one is getting any of these drugs, and so if that’s the case, they should notify the state that they didn’t authorize it and that they don’t believe their parent or their loved one authorized it, and why is this happening.

And then if they do decide they need legal assistance, they can certainly contact me at kbagby@aarp.org, and we will do what we can to – if we can’t represent the family, we will help assist them in finding help.

Smith: And you just mentioned something I want to touch on briefly, because we’ve been talking about inappropriate medicine, but just as a reminder, you don’t have to take any medicine you don’t want to. I went to the doctor the other day and they gave me something for – I can’t remember what it was, but as an adult human, I have the right to go, “I’m okay, I’ll do without it. Even though you’re suggesting it, I’ll exercise my right as a human and say no,” and family members or whomever is making the decision for the resident, whether it’s the resident or healthcare proxy, you have a right to not take medicine.

Kelly: You’re absolutely right. You need to be informed, however, so a part of the problem is, I mean, we heard examples at the Consumer Voice conference where people were having medications ground up and put into their food, so clearly you’re not going to be able to informed consent to that because you don’t even know they’re doing it.

Schenk: That’s right.

Kelly: But I think part of the problem is we have to insist upon admission, insisting upon admission that they want to know every single treatment that is being suggested, whether it’s occupational therapy or a drug treatment protocol. They need to be informed and there should be no administration of drug without that first informed consent being provided.

Smith: And I think, Rob, I think in the future, we need to use the phrase “medication abuses,” because number one, it’s not just overmedication. It’s also inappropriate medication and it’s medication that may be appropriate or it’s prescribed but there’s no informed consent. I know for a fact that I worked in places where there were individuals who were not necessarily cognitively aware, and they would just grind up anything, put it in the pudding and just give it to the person. And I don’t know any checks and balances on that going on at all.

Kelly: No. And one of the things we that we do in our cases is we make sure we call that what it is – that’s a battery. That’s you doing an unlawful touch on a person. And if you, if somebody gives me a drug without my knowledge, that’s a battery victimization. And it’s the same for nursing facility residents.

Schenk: Yeah.

Smith: Yeah, absolutely.

Schenk: Well Kelly, this has been very informative.

Smith: Yeah, we’ll have to have you back on at some point because there’s a lot…

Schenk: A lot of stuff to talk about.

Smith: …to talk about that you do, and we really appreciate the work that you do out there, fighting the good fight.

Kelly: Thank you. You guys too.

Smith: Absolutely. We really appreciate it. But thank you for coming on.

Schenk: Thank you so much, Kelly.

Kelly: All right, thank you both very much. Take care.

Schenk: All right.

Smith: You too. Bye, Kelly.

Kelly: Bye-bye.

Schenk: The National Consumer Voice is kind of like, you know how the professional – I don’t know why I’m speaking like I’m not from this planet – like Major League Baseball. They’re not just finding people from random places.

Smith: Oh right.

Schenk: The Cincinnati Reds have what’s called a farm team, which would be a Triple-A team that they have their prospects, or if they’ve got a guy who’s injured, they’ll send them down.

Smith: It’s always dudes that are talking about going to the show.

Schenk: Exactly. Exactly right. And when I was kid growing up in Nashville, Tennessee, we had a team that was called the Nashville Sounds, and the Nashville Sounds, for the longest time, were the farm team for the Cincinnati Reds. So we got – I can’t remember, I think the Nashville Sounds, I think at some point, Pete Rose might have played for them, Chris Sabo, these types of mid-80s types of pros. But anyways, the National Consumer Voice is our guest farm team, like we recruit the National Consumer Voice.

Smith: The convention.

Schenk: The convention, yeah.

Smith: Yeah, because Kelly is not a – well she’s probably a member of Consumer Voice, but AARP is its own league.

Schenk: Yeah, you’re right. I need to be more specific. The National Consumer Voice conference is the farm team.

Smith: The conference is.

Schenk: It’s the Nashville Sounds of our guests.

Smith: Because you’ll have people like Kelly from AARP or next week, we’ll have Eric Carson, who wrote the book on long-term care advocacy.

Schenk: And prior to that, we had Dr. Caspi.

Smith: And then Diane Carter, all of these people belong to organizations that are major hitters in their own right, but everybody converges at the conference.

Schenk: Big league hitters.

Smith: Yeah, big league hitters.

Schenk: Big league hitters.

Smith: And it’s amazing what Kelly does and it’s so important because at the end of the day, we get a lot of calls and there are legitimate complaints, but we are not able to take those cases, because our funding comes from the verdicts and the settlements that we get in these personal injury cases. So we have a very limited ability to litigate problems in the nursing home industry. It is limited to issues where the breach of standard of care has resulted in damages that can be monetized, and that ties our hands a lot. But you’ve got issues here where AARP is a massive special interest group. I mean that its revenue is over a billion each year and that’s phenomenal. It’s a nonprofit organization, but that money goes towards fighting for these interest.

Schenk: Yeah, the good fight.

Smith: Yeah, fighting the good fight.

Schenk: I was trying to think of something like fighting the good fight, fighting the good crunch – I don’t know why I was going to put crunch in there, and then from crunch, I was going to go into pistachios again.

Smith: Again, just to make sure that you remember that we’ve already talked about National Pistachio Day.

Schenk: I did, but I was going to circle back. It’s a bookend. Like it’s two pieces of the shell coming together, so to speak.

Smith: Speaking of ends to begin with, I think that this episode has come to an end.

Schenk: You know what’s funny? Let me bring in one more thing because nobody listens this far into the podcast.

Smith: Yeah. Everybody’s…

Schenk: Everybody’s checked out. So this is a special treat if you’re still listening.

Smith: Yeah.

Schenk: I thought, until I was probably in my mid-20s, maybe even later, I will admit this that I might have been in my 30s, that the phrase, “They’re trying to make ends meet,” was literally they’re trying to make a type of meat, like beef, called ends, like we can’t even afford to make end’s meat. Okay, like we don’t have the money to buy the accoutrements to cook this food called end’s meat. Only until maybe 10 years ago, I’m a 40-year-old man, 41, as this goes to air, I’m 41 for a couple of weeks. You’re trying to make the end, two of those ends…

Smith: Meet.

Schenk: …meet together.

Smith: Yeah.

Schenk: So that’s what I was going to say.

Smith: I was going to say until about eight years ago, I thought that spin class was an arts and crafts class that women went to, because I would hear people say, “I’m going to spin class,” and I was like, “Man, everyone’s so artsy here.”

Schenk: I think that’s more of a sexist thing than making ends meet.

Smith: Well I think that in my mind, it was spin and I remember like on “Ghost…”

Schenk: The ghost.

Smith: Yeah, so I thought it was something like women would do because men don’t care about arts and crafts, generally.

Schenk: Or the Temptations song, “Papa Was A Rolling Stone,” I literally – and this is true story – I thought that when they said that “All he left us was alone” was literally all he left us was a promissory note that’s owed, like literally a loan, L-O-A-N.

Smith: Well part of the problem is you’re from Tennessee and you put the wrong emphasis on everything.

Schenk: Right.

Smith: Because when you describe that song, it sounds like he was a band member with Mick Jagger and Keith Richard – “Papa was a Rolling Stone.” It should be “Papa was a rollin’ stone.” There’s a difference between Tennessee and Georgia.

Schenk: Oh, I see what you’re saying.

Smith: Yeah.

Schenk: Okay, yeah. “Papa was a rolling stone.” “Papa was a Rolling Stone.”

Smith: “Papa was a Rolling Stone.”

Schenk: This transcript is going to be amazing.

Smith: Yeah, you’re welcome, Cody.

Schenk: No, you’re welcome, Dennis.

Smith: Dennis.

Schenk: Cody is the video editor.

Smith: Okay.

Schenk: Dennis Ting is in fact the person that transcribes this.

Smith: Dennis Ting.

Schenk: Thank you, Dennis. Another shout-out to Dennis.

Smith: This has gone over about eight minutes.

Schenk: It has. So you can always listen to the podcast through iTunes, Stitcher, Spotify, or you can watch us if you choose to watch us. You can watch us through the YouTube channel or at our website, NursingHomeAbusePodcast.com, new episodes every Monday morning. And with that, we will see you next time.

Smith: See you next time.