Drugging and Diapering Seniors??

Drugging and Diapering Seniors??
My sedated mother-in-law

My sedated mother-in-law

Apparently drugging and diapering seniors in the hospital is common knowledge in higher levels of senior living care, such as assisted living, memory care and skilled nursing?!!?

This is horrifying new knowledge for me. I am all about exposing dirty secrets in my new book, “Your Senior Housing Options.” So let me share what I have recently learned through my mother-in-law’s experience. My mother-in-law, Amy, has dementia and was cared for by my father-in-law for the last several years. Three days after he had a heart attack, she became psychotic. My husband and I had to hire a geriatric care nurse to help her because we live 1000 miles away. Learn more of the story HERE.

It took over two weeks to get Amy admitted to the hospital (it’s a long story). Initially, we were relieved that she was going to get the psychotropic drugs she needed. Since Amy was in crisis mode, we didn’t dwell on her being diapered because of diarrhea. She’d had colon cancer 25 years ago and has self-managed her own colon care with diarrhea medications for years.

Costs for Incontinence

As she was in the process of transferring to a secured memory care, I was promised that they would be diligent about avoiding Amy’s trigger foods (that cause the diarrhea). My assumption was that she would surely regain continence again. This was vitally important, because incontinence can cost an additional $300 to $1,000 per month depending upon the assisted living community.

My Mother-in-law Was Over Sedated

We flew to Seattle to see Amy and to help find a reasonably priced memory care community for her. She was so sedated that she could not keep her eyes open and kept saying, “I am so tired,” over 25 times. She apologized that she needed to lie down and take a nap. She was in a wheelchair and needed a one person transfer to get in bed. What?!!? One month ago, she was walking around. My husband and I were shell-shocked to see her so drugged and lethargic. We talked to the memory care community and they said they would contact the doctor immediately to reduce the medications.

The next day, we arrived to see Amy again. After being told that she was engaged and walking around, we found her asleep in a wheelchair in the middle of a singing class. It was heart wrenching to witness. Again, she spoke of her sleepiness.

Advocacy is Key for a Senior with Dementia

The administrator came over and had the nerve to tell me, “My team feels we should follow the doctor’s recommendation of not changing Amy’s drugs for one or two months.” What?!!? I asked the nurse, “Do you see Amy’s lip trembling?” She said, “Yes.” I inquired if she saw both of Amy’s arms shaking too. She agreed. Then I said, “Do you see how sleepy she is and how her eyes can’t stay open?” “Yes,” she said. I simply said, “That is not Amy.” “Oh,” she said, “Then she is on too much medication.” “Exactly,” I said and was relieved that someone finally understood.

It took till the next evening for the community to contact her doctor and reduce one of her medications by half.

At this point Amy has been drugged and diapered for five weeks (between the hospital and the memory care community).


That was five weeks too much of over drugging and diapering a senior with dementia. Can she ever come back and resume continence again? Will she be able to walk freely like she used to in her own home? My own mother was given psychotropic medications in skilled nursing care. Four months later, her walking had decreased dramatically; a few months later she became wheelchair bound for life. Was it the drugs or aging decline? I will never know, but I want to protect my mother-in-law from being over sedated and permanently wheelchair bound. I hope she has a fighting chance to walk again.

Drugs as Restraints?

I have talked with several administrators of assisted living and skilled nursing communities. They say it is common for seniors to arrive from the hospital drugged and diapered. The hospital can’t use restraints, so they use drugs as restraints. My mother-in-law was prescribed haloperidol twice a day and trazodone four times a day as needed.  Why did the hospital dope her up so much?  It is an advocacy nightmare to get it reversed.

What have you encountered?  Has you ever witnessed the sedation and diapering nightmare of a senior?

Diane Twohy Masson’s new guide book for seniors, “Your Senior Housing Options,”  is available on Amazon.com with a 5-star rating.  It reveals a proactive approach to navigating the complex maze of senior housing options. It will help you understand the costs and consequences of planning ahead or waiting too long.

More related articles by Diane can be found at  Tips2Seniors.com or like Tips 2 Seniors on Facebook.

Diane Twohy Masson has worked in senior housing since 1999. She is an award-winning certified aging services professional and the author of Senior Housing Marketing: How to Increase Your Occupancy and Stay Full for senior living professionals.

Among the thousands of seniors she and her teams have assisted in finding the right senior living community, the most difficult case has been helping her own parent. Masson spent two years exploring senior housing options with her mother before finding the ideal Continuing Care Retirement Community for her. After eight years in this independent living setting, she helped her mother transition into an assisted living community. Seven years later, even as a senior housing expert, Masson struggled with the decision to move her mother into a skilled nursing community.  


  1. “Diapering,” as you call it, is a normal and standard aspect of assisted living and nursing homes. Some, but certainly not all, facilities build into their pay structure the cost of disposable underwear, which is the preferred terminology. First, it protects the patient/resident dignity, by not having body fluids dripping down and staining outer clothing. Second, it protects the facility from smelling strongly of same body fluids. And third, it can protect delicate skin from breaking down, if the caregivers are diligent about checking for accidents. The cost is just something families have to pay, unless they can get the state to help. (She’s in WA state, so chances are good that she’ll get help with at least some of that.)
    Chemical restraint is illegal in WA state. If you have a concern about that, contact the Ombudsman for her region, or DSHS. They can help get her off the chemical restraints.

  2. Just a fantastic article and drugs as restraints are often used because there often times are an insufficient number of employees per resident ratio – so this can be the “go to” plan….horrendous. I am so sorry for your family and glad that you get in an “wallow around” with some of this down and dirty activity. Kudos to you!

    • Thanks Carroll! When they admitted her to the hospital, there were no rooms on the psych floor. So she was in ER for 2 days. Restraints are against the law, so I can only imagine that the heavy drugging began there.

  3. I, too as a (retired) professional in the field was stupified by the care offered to my husband by a nursing home of high repute. With Parkinson’s disease, Parkinson’s dementia and suddenly psychosis, he was sent to a good psych unit in our community. But the nursing home, though it originally agreed to accept him back, refused when he was ready for discharge and I entered a maze of nursing home refusals due to the psychosis. I later located a wonderful, small, for profit home of long standing (Bayberry Home in New Rochelle, NY). They keep him on a small anti psychotic regime, keep him clean and well cared for though I have chosen to have 24 hour private care. He is now in the dementia unit where care is of a higher level. Despite all of my concerns about the ‘nursing home avoidance agenda,’ I have found a caring environment. Not perfect, but then neither am I as I tried to keep him at home for two years (part of the time with 24 hour superb care) and my own disabilities prompted me to locate compassionate institutional care. It does exist. Hard to find. But it’s there.

    • Thanks for sharing Judith! My story is similar. No assisted living or memory care would take my mother-in-law without drugs. So we had to go the hospital route first and that is how the nightmare began.

  4. What a nightmare indeed Diane! She is lucky to have you as an advocate. I agree with Carroll, most facilities are under staffed.

  5. Your story OOZES of Self Promotion & advocacy of your up coming book. It really is distasteful for you to use your mother’s story to shamelessly promote your NON EXPERT OPINION on the masses. From what I have read, you made some POOR choices in this whole story and are using others as a SCAPEGOAT for not owning up to your own mistakes. I AM AN EXPERT and I have been in this Industry for over 10 years and it is really despicable of you to cast shame on others when you should be casting shame on yourself. When making decision about your mother’s mental health and well being, don’t you think you should have involved an expert since you were so far away instead of relying on your local brother whose knowledge barely scratches the surface of this industry? Had you used and EXPERT, you would not have been in that position and experienced such trauma throughout the process.

    • Casting shame Larry? Between my husband and I, we are advocating for three parents in long-term care. I have worked in senior housing since 1999. I am trying to actively advocate for my mother-in-law who has been over drugged and diapered. Five weeks ago she was walking around, now she is wheelchair bound. This story is important to share. Look at the other comments of professionals and children who have witnessed this themselves. If you are an expert, then give me advice instead of criticizing me. There is much more to this story. I hired a geriatric nurse to be our eyes and help us 1000 miles away. It did not stop my mother-in-law from getting drugged and diapered. People need to know the truth so they can advocate for their parents too.

  6. From Linked In -The Elder Care Network
    Patricia Faust
    Corporate Wellness Director at Brain Health Center, Inc.
    That is unconscionable. Restraints are classified as physical or chemical. If your mother-in-law was in a skilled nursing facility she would be classified as chemically restrained. The Feds are starting to crack down on this within long-term care facilities. Apparently hospitals don’t have to follow the same guidelines. Advocacy is important. You have to look after your loved one no matter where they live. It is such a shame.

    Kathleen O’Neill
    Bookkeeper/Software Consultant/Virtual Assistant
    Same thing happened to my Mom. No one believes you because our prior experience with Healthcare is so good. When I heard my Mom tell me she was so tired and did not know why it broke my heart. The diaper is mandatory even of you don’t need it. No accidents waiting for the bathroom shared by 6-12 people.

    Thank you for sharing reality.

    Kathleen O’Neill
    Bookkeeper/Software Consultant/Virtual Assistant
    PS. The doctor was not involved in that the caregivers were lying and not following the Rx. It was my fault for not being educated about end of life care. Facility still open and only fined $150 per violation. Now standing at 18 citations with 13 citation A. I pray every day for those unable to communicate their feelings and needs. I especially pray for those that just don’t get listened to.

    Patricia Faust
    Corporate Wellness Director at Brain Health Center, Inc.
    I always recommend consulting with a geriatric care manager when you have to make big decisions like placement in an assisted living. They are knowledgeable about practices and will find the best fit for your circumstances. Our loved deserve much better than this.

    Kathleen O’Neill
    Bookkeeper/Software Consultant/Virtual Assistant
    Our Case Manager completely failed us. Seems she benefited financially with all of those involved. After investigating she was being sued by creditoRs. Anyone can call themselves Case Managers and anyone can have a.check book for advertising they are the best. When I checked last these rating companies don’t even inspect the.facility. Write the check and you are outstanding.

    Donna Rybacki
    Owner of American Senior Home Finders
    I have seen this as well in Skilled Nursing Facilities. They do not seem to have the capability to care for those that need help toileting so that appears to be a solution and since they have the authority to prescribe medicines, it seems to be observed protocol. However in Assisted Living Communities these are non-medical facilities and no one can prescribe medication. They can help manage medications that the senior’s doctor has prescribed but no authority to prescribe any. In some places I have seen that it behooves the care staff to assist the seniors to use the bathroom instead of the depends or a diaper because it is easier to do and less mess and clean up. It also helps prevent UTIs in seniors which is a problem when in the diaper too long.

    Kathleen O’Neill
    Bookkeeper/Software Consultant/Virtual Assistant
    @Donna treat yourself to a diaper and over medication. Then ask yourself this question, “This isn’t working will you help me?”
    No one even listens.
    They don’t care.

    30000×4=120,000 minimum
    Less expenses and property appreciation=Lots of money

    Care=overdrug it’s easier no labor


    Money from from the incompetent.

    James Conway
    Principal at Senior Home Healthcare of the Western Shore, LLC
    I have been in this business for 5 months as a private owner to a Non-Medical business serving our Seniors and I am determined to make a difference!!! I have heard and seen firsthand and it makes me mad as Hell!!! I am a small business owner and really hope to change my market. Our Seniors deserve the very best – they are the foundation of this great country!!! I truly hope I can make a difference in many famiies lives.

    Delores Moyer
    Consultant/Administrator (Interim) at Own-Optimum Health Care
    I’ve been in the health care business for my entire career until recently semi-retired and doing mostly ombudsman work/lecturing and on City Committees to help resolve issues with those we are suppose to serve in these businesses. The Restorative Care part of these residents care means that you (Nursing Services) is suppose to help walk people daily, help them with activities of daily living the residents are proficient in/need help/more training to keep going appropriately vs. becoming totally dependent on others (or diapered) and the staff were to put together Restorative Programs to accomplish this which should include a 2 week review of bowel/bladder habits of each new resident and, then after the regular schedules are determined and/or help/further education is needed, that is in the Restorative Plan —-but, but, but, what happens? Most of it doesn’t get done at all and especially any restorative and/or maintenance of a resident’s bowel/bladder program which would leave them without jut sticking a diaper on them. These are the things I, as an Adm. could not get Nursing Staff to do/accomplish and it made me sick. I was the Adm., but certainly never had all the control or ability to change things as it was seen as a Nursing Function and I was either to “butt out” or I’d most likely be considered a troublemaker. It’s a shame but that’s what happens…….

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Delores – Thank for sharing your in the trenches view point. Good luck James, but you may be in Delores shoes. Kathleen, I am so sorry and agree. Donna, I wish they toileted them instead of diapering them. It provides more dignity. Patricia, so much of long-term care is now licensed as assisted living and it is not as regulated. The average senior and their families have no idea. It is vital to find a good quality place. My new book, “Your Senior Housing Options,” teaches how to find them. The key is you have to be local and I am 1000 miles away from my mother-in-law.

    Kathleen O’Neill
    Bookkeeper/Software Consultant/Virtual Assistant
    @DONNA my apologies if this sounded rude. This topic just heats me up. Thanks for your patience.

    Kathleen O’Neill
    Bookkeeper/Software Consultant/Virtual Assistant
    I’m not sure you can do this long distance. I am near an excellent Senior Living Community and went to many places and tried to get the best help possible. There are only a few good Case Managers and they are hard to find.

    Donna Rybacki
    Owner of American Senior Home Finders
    Thanks Kathleen, it is heated for me too. I am in California. I help people locate quality care. One reason they need help finding it is because it is not just “right there” although we have over 900 licensed Assisted Living Communities and care homes. I constantly inspect them both in person and through the licensing department so that I can keep my finger on the pulse of the ones that are providing good care. Family involvement is KEY and a BIG part of the who equation. 90 % of the help I provide to families is education so they can have more awareness and in turn more control over the care.

  7. From Linked In – Executives in Long-term Care
    Harvey Bogarat
    Retained Consultant – Acute & Post-Acute Network Strategist
    You should read the series in the Sacramento Bee on Nursing Homes. You should also watch the Public Television expose’ on Emeritus. Shortly after the airing, the company was sold to Brookdale.

    There are great providers that don’t use antipsychotic’s to snow the patients and they should be recognized for the good work they do. It is often a matter of staffing. Give them drugs and you can staff down and save $$$ or staff up and maintain a high level of surveillance and you don’t have the chemical restrain issue and pay $$$ the extra money on the CNA hours. That’s not to suggest that training and staff compliance is to be discounted.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Excellent points Harvey! The average senior and their families don’t know how to find good quality long-term care.

  8. From Linked In – Senior Living Care Professionals
    Richard Vaughn
    Psychologist and West MI Regional Director at Behavioral Care Solutions
    Maybe I hang out with the wrong crowd but this didn’t surprise me. Dismay me, disgust me,but not surprise.
    Fortunately the new federal initiative and regulations may lower the use of psychotropics, especially atypical antipsychotics, in LTC environment.
    What struck me was the decline in mobility. My experience is unless you have restorative aids walking a resident DAILY, the risk of decline to wheechar status is huge. Make sure she’s being walked.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Thank you Richard! Excellent point to check out. What’s tough is not being local. They can say they walk my mother-in-law, but do they really?

    Nourit Braun
    As proud owner – administrator of one of the pioneering home for the memory impaired clients that is now for politically correct term is being referred to as a ” Memory Care community” I am personally offended by this discussion that put all of us in the same boat.
    Large Assisted Living/ independent Living facilities are keeping resident with cognitive impairments and Alzheimer – dementia clients too long. With limited staff and not enough supervision they decline quickly and become incontinent and on behavior controlled medication. At times or after an accident , families are approached by the facility and are offered to have their loved one move into the ” memory care unit” with significant raise in rent.
    That’s when a bit too late we get those clients who are socially neglected and are on diapers for BxB and heavy psychotropic medication.
    Our first step is to get our residents evaluated by a physician to conduct medication evaluation.
    Second step is to provide security and comfort to the confused resident as he/ she are traumatized by the move
    Theirs is to successfully encourage them interact with other clients in activities and especially our ” memory in the making ” program , music yoga and Tay Chi .
    Low ,low beds with fall and movement alarms as well as call buttons to prevent falls are part of our furnished rooms
    Awake staff with bed check schedule at night time is part of our “best practice ” Moto.
    Toilet training is a must for each resident however by the time they are arriving they have been put on diapers long time ago and it is a challenge we are working on day in and day out.
    Another big challenge is long hospitalization or keeping residents in convalescent homes longer than needed ( to work up Medicare days) returning them to our home is to start the process all over again for they are tiered, appetite is poor and they come back much physically declined from before.
    If one does apply those measures in their “memory impaired communities” they should be out of business.
    Again we at North Lake Villas : ״ do what we love and love what we do”!

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Nourit, I am sharing the personal story of mother-in-law and mother. I am sharing facts of what I have witnessed and learned. Hospitals are drugging and diapering the seniors. Long-term care providers either continue it because of a lack of staff or turn it around. There is no question that some providers are better quality than others. The average senior and their families don’t know how to find good quality long-term care. My new book, “Your Senior Housing Options,” gives tips to look for, questions to ask and more.

  9. From Linked In – Healthy Living for Healthy Aging
    Lorie Eber
    Personal Wellness Coach at Lorie Eber Wellness Coaching
    Unfortunately, this is fairly common in my experience as an Ombudsman. A lot of the impetus is lack of staff. Staff finds ways to “control” the workload.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Seniors need to be informed so they can have proper advocacy if they can’t speak for themselves.

    Lorie Eber
    Personal Wellness Coach at Lorie Eber Wellness Coaching
    Most seniors have no idea that they have any rights when they live in a care facility. Education is definitely needed!

    Peggy O’Malley
    Owner, Shamrock Senior Services
    Seniors frequently say no to drugging but their wishes are not listened to! Some facilities even sneak meds into food and juice drinks. I would like to see some of these people prosecuted but if an employee questions these actions then they are terminated.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Peggy, what do you mean by sneaking drugs into the food? I have seen them crush pills and put it in the applesauce because my mom can’t swallow the pills anymore.

  10. From Linked In – The American Society on Aging
    Deborah Sakic-Vranic
    Care Companion Team Leader

    I am so sorry for this family to endure this, moreover appalled at this facilities inability to properly care for Amy. Such obvious over-medication and diapering to that extent is beyond dispicable- it is harmful to her body(if not changed promptly and over-medicated), harmful to to her self-esteem and independence. It is a form of neglect-abuse. She and her family deserve much better than that. Amy is in a form of medicated restraint. That is unlawful in Canada unless under extreme circumstances and ok’d by family (substitute decision-maker), client prior to any incidents requiring this form of restraint.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Thank you Deborah! I understand that chemical restraints are against the law in skilled nursing in the United States. My mother-in-law is in a licensed assisted living. I don’t know all the regulations. She came from the hospital this way. It is so hard to get it reversed.

  11. From Linked In – Marketing Professions Advocates for Seniors
    Patricia Deck
    Owner, Fleetridge Estate
    you have now been exposed to the truth. There are many dishearting realities in our long term care communities.

  12. From Linked In – Elder Care Professional
    Dr. Kim Ratcliff, DNP, ACNP-BC
    LifeCare Solutions, LLC
    I would venture to say that this happens way more than anyone thinks in the geriatric population today.

    Doreen Campbell
    Experienced Real Estate Appraiser & ElderCare/Assisted Living Pro, Seasoned Entrepreneur
    Well, yes, it is common. Far too much so, and that’s why we get them back home to our home ALF, out of the hands of the medical profit machine, asap.
    You see these commercials, “Ask your doctor” and that supposedly washes the blood off the hands of the doctors… Well, they Asked for it, and people have a Right to medicine they think may help them, all that sort of nonsense to justify the drugging.
    Medicare will pay for a certain number of days for each time, and especially in the fall, they begin to “keep them for observation” more often, as they see the remaining days of the 100, slipping away from their grasp. It’s horrific.
    Thank God for small, hands-on, right-minded and Caring ALFs, or it would be worse. The ugly profit-motivated synergy between the Large ALF and other large providers (hospitals & rehabs, SNFs) is really ugly and people don’t See it, because of the beautiful chandelier and the self-playing piano….. And they pay these jerks twice what we get, without a second thought.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Thanks Dr. Kim for your comment. Doreen, you 100% correct. Adult children see the beautiful lobby and move their parent in. It is vital to pull back the curtain and find out if a place has great care.

  13. From Linked IN – Assisted Living Professional Network
    Susan Kohlleppel
    Owner at Kohlleppel Consulting
    Sadly, this is nothing new. Years ago as a young social worker, I came face to face with ‘narcing and parking’ the seniors at a SNF I worked at. It was a deplorable practice then and even more so now that we are supposedly evolving as care givers. I usually found 2 things were occurring if someone was narced and parked. First, they needed a higher level of care to meet their needs. Secondly, the staff needed education as to how to deal with behaviors, medications etc. This horrid practice, in my opinion, is nothing more than warehousing vulnerable people until they move to their next home or die. Those who practice this archaic method of care need to be ashamed of themselves and those who know about it, and do not speak out, double shame on you.
    The very best way to curb this is to advocate. Know your loved one and question their medications and treatment just as you would question treatment prescribed for your self or your child. Do not be afraid to ask questions and if you don’t like the answers you are getting, shop for a new doctor or community. Educate yourself, and educate others. It is up to all of us to speak for those who can no longer speak for themselves.

    Diane Masson
    Regional Marketing Director at Freedom Management Co.
    Susan, I loved what you said, “Do not be afraid to ask questions and if you don’t like the answers you are getting, shop for a new doctor or community. Educate yourself, and educate others. It is up to all of us to speak for those who can no longer speak for themselves.” I feel this way 100%, it is so hard being an advocate.

  14. Diane, I am so sorry to hear of your experience. Thank you for sharing this difficult story. This is a National epidemic and as the Baby Boomers enter the Medicare system at the rate of 10,000 per day for the next 17 years, this problem is only going to get worse. After being in your situation with both of my parents, I decided to put 20+ years of experience in the health care industry to good use. I opened my Patient Advocacy practice two years ago and there isn’t a day that goes by, that I don’t see this scenario. Even when family are local, they are at a loss a majority of the time to effectively advocate for their loved one. Few people realize that a facility Dr. is only legally obligated to see a SNF resident In CA, once every 30 days. The only time the doctor sees the patient beyond the 1 time in 30 days, is if the nursing staff is doing their job and charting an issue as it is identified. It is not widely known that you are able to remove a patient from a SNF to have them evaluated for a specific issue. For example, I had a client that was dealing with a worsening pressure sore. The staff was providing very basic would care and the area was worsening each day. I requested the patient be taken out to a wound care specialist and the facility fought hard and tried at every turn to discourage my recommendation . Ultimately, two days later, I had my client at the wound care clinic. They treated the pressure sore aggressively, added a protein supplement daily that would nutritionally aid in the healing process and follow up visits to the clinic. The pressure sore was healed by the time she was discharged. Patients and families need to educate themselves regarding Patients Rights and be willing to challenge the facility with an informed perspective. It is however, a delicate dance with the staff to “Identify an issue and work together to find a solution.” I have this statement in quotations marks because that is what is say and do. Also, few people realize that a SNF has a DON that is typically in an administrative role and that LVN’s (one year training) are manning the nursing station. Typically, the only time the LVN interacts with a patient, is when the meds are administered. An example of a response from the LVN at the nursing station- I spoke to the LVN each day for three consecutive days regarding the increasing level of edema that my client was experiencing. (she has a long history of COPD and CHF) She said she would “chart it and the Doctor would check on the patient when he comes in.” On the third day, my client was still continuing to gain fluid weight a total 12 pound in four days, and the LVN told me that “if the weight gain was indeed a problem, she would have dietary cut back on her meal portions.” I then asked her to call the facility doctor, to ask why he had not prescribed lasix and was first told by the doctor, “he was not aware of the issue, and secondly, the elderly can become dehydrated very easily and he likes to be conservative when prescribing lasix. Let’s just say he had no response to my comment that dehydration is an easy fix, compared the CHF. CHF would result in a hospital readmission and possibility of the patient not surviving. It is an uphill, daily battle to get things turned around for a SNF patient/resident. There is a national network of Patient Advocates that will allow you to find an advocate in your area by entering your zip code and a few pieces of information. The network is AdvoConnection. My apologies for the not so short story, but this is why I have gone into practice. One patient at a time….. Thank you again Diane