The Realities of Nursing Home Care

If you have been considering a nursing home for your loved one, you already
Know that it’s not an easy decision, nor an inexpensive one. In 1990, the average cost
For a year in a nursing home was $ 30,000. (NAELA.com., n.d.)

While only about 5% of elderly live in nursing homes, over 40% of people 65 and over will at some time require a nursing home or long-term care facility. Less than 1/3 of those, however, are financially prepared for it. Medicare pays approximately 45 % of nursing facility costs. (National Academy of Elder Law Attorneys, NAELA.com,( n.d.)

Many elderly or chronically debilitated people live with their spouse or family members. Many adult children have become caregivers. Often, the physical and emotional toll on the caregivers becomes unbearable. Most people would prefer to take care of their spouses or parents, but sometimes this becomes impossible. There are alternatives to nursing home care that are worth considering. Respite care gives the caregiver a break, and providers can be found through contacting your doctor, or senior services agencies in your community. Sometimes, in-home nurse’s visits are the best option. In-home caregivers are a good option if the person requiring care does not need skilled nursing care.

If a nursing home is your family’s decision, there are some important things to consider when choosing a facility. Having worked as a nurses’ aide in three different care facilities, my eyes were opened to the realities of what really goes on in a nursing home. While most staff members are dedicated, caring professionals, they are faced with a shortage of help. Nurse’s aides pay rate in the state of Oregon, for example, starts out in nursing homes at a level which barely exceeds minimum wage. This is important because the workload and stress level of the job is high. Many quickly burnout and leave the profession, or plan to leave after they continue on with schooling to become licensed or registered nurses. The majority of daily care the residents receive comes directly from the nurse’s aides. Additionally, in Oregon, there is a class of aide called a “hospitality aide�. The hospitality aide has much less training than a Certified Nurses’ Aide, and yet is allowed to dispense certain medications to residents. Surprised? Get ready for another shock- the average patient load per aide is between 8-15 residents per day.

A nurse’s aide or hospitality aide is responsible to wake up residents first thing in the morning, take their vital signs and record them, and get them dressed and ready for the morning meal, which usually takes place in a cafeteria-like setting. After assisting the residents to the cafeteria, aides often help the patients with eating, depending on the resident’s state of health.

After meals, the aide helps the resident with basic hygiene and toileting, and positions the resident for comfort- this may be in bed, or resting in a chair. The aide has 8-15

residents to perform the same task for, at relatively the same time. Certain people will have their meals in their rooms, but most are encouraged to eat with the group.

Throughout the rest of the day, the aide must assist each resident with bathing, toileting, feeding, and positioning. With eight hours in a shift, minus the aide’s thirty minute lunch and two fifteen minute breaks, there is very little time for socializing. In fact, there is barely time to adequately take care of the residents in this time span. In a skilled-nursing care facility, time is even more precious. Many of the residents have complicated care routines. The average time spent with each resident by an aide is less than twenty minutes.

When you go to the care facility you are considering, find out if it as skilled nursing care facility, which offers the highest level of medical care, or if it is a specialist facility- such as a center specifically tailored to Alzheimer’s patients. Perhaps the unit in question is a moderate care facility, where the majority of residents are mobile and relatively healthy. Finally, there is the assisted living facility, wherein which the residents are all basically healthy, and only suffer from the normal signs of advanced age. They just need help with meal preparation, or housekeeping, and they enjoy the socializing with other residents.

If your family member will be in a moderate-to-heavy needs facility, here are some things to ask the Director of Nursing, or facility director- most likely the person who you will be meeting with at your initial interview session.

The Patient’s Bill of Rights:

These vary slightly from state to state, but you should be aware of these rights, and the nursing home should also. Ask to see a copy. The bill of rights should be part of intake documents, which you and the facility both would sign. These rights are very important. You can see a complete listing of these at http://www.health.state.mn.us/divs/fpc/consumerinfo/otherlang2.html. However, the Department of Health and Human Services in your community should be able to provide the Rights as applied in your state.

Cleanliness:

Cleanliness should extend beyond the lobby and office, or the waiting room. The lobby of most facilities is likely to feel very homey, even luxurious. Faux plants, elaborate artwork, ornate furnishings, and great wallpaper do not tell the full story. Look beyond the obvious.

Use your senses. What does your nose tell you? With minor exceptions, you should not smell urine, feces, or other foul odors. Accidents do happen, but what is the overriding feeling of clean that you get from the place?

No, it isn’t polite to look into the open doorways of residents. However, if this is where your loved one is going to live, it will pay you later to be extra-observant now.

Look at the staff. Do they seem confident and professional, or harried, hurried, and stressed? Stop someone who is walking by and ask a few questions. Do they seem to be in a great hurry to leave? Ask a nurses’ aide how many patients she or he will be attending to that day.

Ask the director or person you are interviewing with how many nurse’s aides per patient they have. Do you get a direct answer, or does the person hem and haw attempting to answer?

Look at the Surroundings:

Do you observe ceiling sprinklers? Are there visible fire extinguishers? Can you count plenty of well-marked exits? In the office, are the certifications and documentations on the wall from the state ombudsman, or other safety/human services agencies?

Visitors.

Depending on the time of day, of course, there should be plenty of visitors in the facility. Do they look unduly upset? Lost? Confused? Angry? Don’t be shy. If you find an opportunity, politely ask someone their opinion of the facility.

The Residents:

This might be the most important observation of all. Look at the residents you see. Meal time is a good time to see them up and around. Is the staff patient with the residents? Is there a sense of order and cleanliness in the meal area? How many aides or nurses do you see there? Seeing only one caregiver in a large crowd is not a good sign. They may very well be understaffed. What type of food is served? Do the meal preparers use gloves? Are they clean? Do you see much or any interaction between staff and residents? Are there any bruises, cuts, or open wounds on any residents? Elderly people’s skin is very delicate and tears easily. Some accidents are bound to occur- but there should not be a large quantity of visible injuries on the residents.

Do the residents look reasonably well-groomed and dressed? Look at their hands. Do any resident have uncut nails or nails that are not filed? More importantly, is there noticeable debris under their nails? Do the majority of residents look comfortable, or happy? Are they being kept warm? Do they look clean? You are looking to see if there are lapses in care. Many residents in moderate-to-heavy needs facilities are unable to groom themselves, dress themselves, and are unaware of their appearance or hygiene.

They depend upon others, and are at the mercy of their caregivers. A facility suffering from a shortage of care providers will be evident in the condition its residents are in. Look throughout the hallways. Observe those who are in wheelchairs. Take time to stay long enough to see whether or not there are certain people who have been in wheelchairs without being moved or repositioned for over two hours.

Are the residents receiving medication with their meals? Some may be. The important thing to notice here is who is dispensing the medication. Look at name tags, and don’t be too shy to ask questions. Professionals will welcome your questions. If someone on the staff is impolite or does not welcome questions, see this as a red flag.

Activities:

Many facilities excel in this area even when their basic care level isn’t good. More people would rather work with the residents in fun activities than to assist in the daily activities of living. However, activities are important. Look for activity calendars on the wall, and look at the activity room(s). Arrange to speak with the activity’s directory, if at all possible. Plan to make more than one trip to any facility you visit. Come at different times of day, and try to make at least one trip as late in the evening as possible.

Rooms:

As a brand new nurse’s aide, I remember my first impression of a resident’s room. From the doorway, it looked fine. In a cabinet, however, I found a dirty bed pan. The bathroom was also a mess. I found out that despite the rules, many of my coworkers who had been employed there for a long time did not follow many rules regarding cleanliness and hygiene. Many did not wash their hands after handling soiled linen, and went on to the next room . Some would change their gloves, but not wash their hands. The point here is, watch. Without invading privacy, watch as much as you can.

The Horror Stories:

Do as much homework on as many facilities as you can. Be skeptical of claims made by the facility regarding the patient-to-aide or nurse ratio. Use your powers of observation. My good friend lost her grandfather in a nursing home because the night staff, who was sitting on a sofa in the lobby between duties, ignored his call button for hours, dismissing his requests for assistance as nuisance calls. They thought he was just using his call button to annoy them, apparently. He had been asphyxiated in his bed rails when he was checked on some hours later. My friend’s family sued, and the establishment was closed down. Nothing will erase the horror of the event, however, or bring her grandfather back. The point is, you can find some very startling and appalling statistics on the level of abuse or neglect found in nursing homes. Fire safety violations, cleanliness issues, and neglect are other big problems in nursing homes.

Again, the majority of staff is professional and dedicated. Why else would they work so hard for so little? The problem is in the system itself. If you must choose a nursing home, it pays to do the homework. Below is a list of national organizations you can contact for further assistance. Be sure to check with regulatory agencies in your own state, however.

Once you have made the decision to admit, visit regularly. Not only is it important for your loved one’s well being to have regular visitors, it will allow you to be sure that he/she is receiving the proper care. Follow-up with staff doctors and nurses to be sure that doctor’s orders are being followed. Check to be sure that any prescribed physical therapy is being scheduled and appointments kept.

Talk to your family member, if possible, and ask them how they are being treated. While some people may exaggerate perceived wrongs because they simply don’t like the arrangement, listen to what they have to say, and investigate when appropriate.

Look at the condition of how their personal belongings are being maintained. Check closets for basic order and the room for cleanliness. Don’t be too shy to look at your loved one’s knees, buttocks, and elbows. Take note of any bruises, and especially any sores. If you notice round, red spots on pressure points, they are not being moved about enough. (This applies to the mostly bed-bound or wheelchair bound). They should be repositioned at least every two hours to prevent ulcerations- bedsores- from developing. Is the person’s weight dropping noticeably? Are they being fed regular, nutritious meals? Are they allowed a variety? When you are in the room with your family member, and you press the call light button to ask for assistance, how long does it take for someone to arrive?

In the next blog, which I will post within one week of this one, we will be discussing more about the statistics of nursing homes, and keeping the nursing homes accountable with the financial aspects of nursing home care. We will discuss how to protect your loved one’s personal belongings in the nursing home.

Following are a list of helpful websites where information can be found regarding nursing homes, caregiver issues, and regulatory agencies that can steer you in the right direction.

http://www.michigan.gov/mdch/0,1607,7-132-27417_27655_27662---,00.html This one applies first to Michigan, but lists federal laws and lists links, as well.

http://www.elder-abuse-foundation.com/

http://www.nccnhr.org/uploads/NHStateStaffingTables.pdf A bit technical, but valuable for showing state-by-state regulations regarding staffing at nursing homes.

http://www.medicare.gov/Nursing/Alternatives.asp A valuable resource for providing alternatives to nursing homes !

http://wwcoco.com/cfs-care/stresstest.html take this test if you think you suffer from caregiver burnout.

http://familydoctor.org/645.xml Help for caregiver stress !

http://www.caregiverstress.com/yourhealth.html click on additional resource link for ideas, help.