Chapter 2 - THE WORD COMBATIVE
I had been good at difficult residents.
That was what my supervisor used to say.
“Hannah can get anybody into a shower.”
It was meant as praise.
I accepted it as praise.
At twenty-four, competence can become an identity very quickly.
Especially when you are working a job people often describe as low-skilled until they suddenly need someone to convince a frightened eighty-nine-year-old man that the stranger standing in his bathroom is not there to steal from him.
I liked being good.
I liked being the aide residents requested.
I liked having nurses say:
“Send Hannah.”
The problem was what I occasionally counted as success.
A resident said no to changing clothes.
I joked until she agreed.
Fine.
A man with dementia refused breakfast.
I brought toast into the hall and sat beside him.
Good.
A woman said she did not want to shower.
I told her:
“Your granddaughter’s visiting.”
She sighed and let me help.
Was that persuasion?
Pressure?
Both?
Maybe.
Context matters.
But I had developed a belief without realizing it.
If the result was good, the method was probably good too.
Clean skin.
Dry clothes.
Medication taken.
Meal finished.
Task completed.
The checklist trained us.
Not maliciously.
Healthcare has real needs.
Skin must be checked.
Falls must be prevented.
Infections matter.
People can refuse something today and be harmed by the refusal tomorrow.
Care is not as simple as saying yes to every no and walking away.
But that complexity can tempt helpers into a dangerous shortcut:
I know what is good for you.
Therefore getting you to do it proves I helped.
Eleanor exposed the weakness in that logic.
After our incident, I went to Paula Ramirez, Westridge’s director of nursing.
Paula was fifty-one.
Twenty-seven years as a nurse.
The kind of person who could silence a room by lowering her voice.
I told her exactly what happened.
Including my reaching after Eleanor said no.
Paula looked at my hand.
“Any injury?”
“No.”
“Need employee health?”
“No.”
“Did she strike anywhere else?”
“No.”
“Threaten?”
“No.”
“Throw anything at you?”
“She shoved the tray. Not toward me.”
Good.
Specific.
Then:
“What did you see?”
I described the scar.
Paula’s face changed.
“Photo?”
“No.”
“Why not?”
“She didn’t consent.”
Paula nodded.
Good.
Then I told her about the care-plan language.
“Combative.”
Paula looked at the computer.
“It came from intake.”
“Who wrote it?”
“Assessment nurse.”
“Based on?”
She opened the source notes.
“Daughter reports longstanding resistance to bathing and skin checks. Prior home-health notes mention striking caregivers during back care.”
There.
History.
Maybe.
Then another note:
Resident requires firm cueing. Daughter states patient will refuse initially but appreciates care afterward.
I stared.
“That’s not consent.”
Paula looked at me.
“No.”
“Why is it in the care plan?”
She did not become defensive.
That mattered.
“Because we inherited a bad framing and didn’t challenge it.”
Simple.
Institutional mistakes do not always require cartoon administrators shredding records.
Sometimes everybody assumes someone else already asked the right question.
Paula scrolled.
Eleanor’s healthcare power of attorney named Rebecca.
Activation only upon physician determination that Eleanor lacked decisional capacity.
There was no such determination.
Eleanor had mild forgetfulness in the chart.
Nothing approaching incapacity.
Paula leaned back.
“We’ve been treating Rebecca like a decision-maker.”
“Yes.”
“She’s a contact.”
“Yes.”
“Not current substitute decision-maker.”
“Yes.”
Paula rubbed her forehead.
“This is not good.”
I appreciated that she did not say:
But everyone does it.
Then she looked at me.
“You know the other side.”
“What?”
“If Eleanor refuses all skin assessment and develops a wound, we cannot pretend refusal removes our clinical responsibility.”
“I know.”
“So?”
I thought.
“We ask what she’ll allow.”
“Good.”
“Maybe she can use a mirror.”
“Good.”
“Maybe one nurse.”
“Good.”
“Maybe same person each time.”
“Good.”
“Maybe no surprise touching.”
Paula nodded.
Then:
“And if there’s an urgent condition she cannot safely evaluate herself, the nurse explains risk and options. If she still has capacity and refuses, we document informed refusal.”
There.
Not abandon.
Not overpower.
Process.
Paula asked:
“Do you want off her assignment?”
“No.”
“Why?”
I almost said:
She trusts me.
Too grand.
“She didn’t ask me off.”
Paula nodded.
“Ask her.”
Good.
Again.
That afternoon I went to Eleanor’s room.
Knocked.
“Come in.”
Door open.
She was reading.
I stayed near the entrance.
“Can I ask one work question?”
“That depends.”
“Do you want me to keep helping you?”
Eleanor looked over her glasses.
“You mean after I slapped you?”
“Yes.”
“What happens if I say no?”
“I get reassigned.”
“No punishment?”
“No.”
“No little sad face?”
“I’ll try to contain myself.”
She looked at me for ten seconds.
“You can stay.”
“Okay.”
“On conditions.”
I smiled.
“Of course.”
“No touching my back unless I ask.”
“Okay.”
“No men for bathing.”
“Okay.”
“No students.”
“Okay.”
“No photography.”
I hesitated.
That was a real clinical limitation.
“What if there’s something the nurse believes needs serial monitoring?”
Eleanor’s face hardened immediately.
I held up a hand.
“I’m not saying yes.”
She waited.
“I’m saying if that situation comes up, we ask you again and explain why.”
Her face softened slightly.
“Fine.”
“Door?”
“Closed for bathing.”
“Okay.”
“And no Rebecca.”
That one was harder.
“During care?”
“During anything about my back.”
I sat.
“Do you want her excluded from information too?”
Eleanor stared at me.
“She already knows I have a scar.”
“That isn’t what I asked.”
There.
She almost smiled.
“I don’t want you discussing this with her without me.”
“Okay.”
“You can tell her if something threatens my life.”
“I’m not the person who decides disclosure law, but I can put your preference in the chart and ask Paula to review it with you.”
Eleanor snorted.
“There’s the institution.”
“Yes.”
I smiled.
“Unfortunately I cannot personally rewrite privacy law.”
“Lazy.”
Maybe we were going to be okay.
Before I left, Eleanor said:
“Hannah.”
I turned.
“Why did you say it wasn’t surgery?”
I thought.
“Because of the shape inside the scar.”
“The buckle.”
“Yes.”
“What do you think a buckle means?”
“I don’t know.”
Good.
Her shoulders dropped.
Then:
“They used one to hold me still.”
I did not move.
“At a hospital?”
“Yes.”
“Do you want to tell me?”
“No.”
“Okay.”
She stared at me.
Waiting for the second attempt.
I did not make one.
That was the moment I realized how often caregivers turn:
Do you want to talk?
into a request with an expected answer.
No can be complete.
Two days later, Eleanor asked Paula for a physician to look at the scar.
Not because I pushed.
Because she wanted one question answered.
She wanted to know whether the story she had been told for sixty years was medically plausible.
May you like
That was the beginning of the real investigation.
And it began only after nobody was trying to investigate her.
