Nursing Home Issues

Choosing and Evaluating a Nursing Home

Can there be a more difficult job than finding a nursing home for a parent or spouse? No one wants to live in a nursing home. They serve as institutions of last resort when it’s impossible to provide the necessary care in any other setting. And, typically, the search takes place under the gun – when a hospital or rehabilitation center is threatening discharge or it’s no longer possible for the loved one to live at home. Finally, in most cases, finding the right nursing home is a once-in-a-lifetime task, one you’re taking on without the experience of having done it before.

That said, there are a few rules of thumb that can help you:

1. Location, location, location. No single factor is more important to quality of care and quality of life of a nursing
   home resident than visits by family members. The quality of care is often better
   if the facility staff knows that someone who cares is watching and involved. Visits can be
   the high point of the day or week for the nursing home resident. So,
   make it as easy as possible for family members and friends to visit.
2. Get references. Ask the facility to provide the
   names of family members of residents so you can ask them about the
   care provided in the facility and the staff’s responsiveness when
   the resident or relatives raise concerns.
3. Check certifying agency reports. CareScout is an unbiased source for ratings and reviews of eldercare providers nationwide. Detailed, 7-10 page Nursing Home reports are available for a small fee, and include over 100 pieces of information on quality, resident population profiles, and health violations. Another source for nursing home reports is HealthGrades. For a fee, HealthGrades will provide you with a report that rates the nursing home and provides information on inspections and complaint investigations. You can also get a report that compares the nursing homes in your area.
4. Talk to the nursing home administrator
   or nursing staff about how care plans are developed for residents
   and how they respond to concerns expressed by family members. Make sure
   you are comfortable with the response. It is better that you meet
   with and ask questions of the people responsible for care and not
   just the person marketing the facility.
5. Tour the nursing home. Try not to be
   impressed by a fancy lobby or depressed by an older, more rundown
   facility. What matters most is the quality of care and the interactions
   between staff and residents. See what you pick up about how well residents
   are attended to and whether they are treated with respect. Also, investigate
   the quality of the food service. Eating is both a necessity and a
   pleasure that continues even when we’re unable to enjoy much else. It is also advisable to try and get a tour of the facility that is not prearranged. While this is not always possible, it does give you the opportunity of seeing an unrehearsed atmosphere.

For more pointers on evaluating nursing
homes, see our Checklist .

Talking With Family About Placement

Few decisions are more difficult than the one to
place a spouse or parent in a nursing home. Since nursing homes are seen as a
last resort, the decision is generally overlaid by a sense of guilt. Most
families try to care for loved ones at home for as long as (or longer than)
possible, only accepting the inevitable when no other alternative is available.

The difficulty of making the decision can be
compounded when family members disagree on whether the step is necessary. This
is true whether the person disagreeing is the person who needs help, his or her
spouse, or a child.

The placement decision can be less difficult if,
to the extent possible, all family members are included in the process,
including the senior in question, and if everyone is comfortable that all other
options have been explored. This will not ensure unanimity in the decision, but
it should help.

We recommend the following steps:

1. Include all family members in the decision.
   Let them know what is happening to the person who needs care and what
   providing that care involves. If possible, have family meetings, whether
   with the family alone or with medical and social work staff where available.
   If you cannot meet together, or in between meetings, use the telephone, the
   mail, or the Internet.
2. Research other options. Find out what care can
   be provided at home, what kind of day care options are available outside of
   the home, and whether local agencies provide respite care to give the family
   care providers a much-needed rest. Also, look into other residential care
   options, such as assisted living and congregate care
   facilities. Local agencies, geriatric care managers, and elder law attorneys
   can help answer these questions.
3. Follow the steps above for finding the best
   nursing home placement available. If you and other family members know you’ve
   done your homework, the guilt factor can be assuaged (at least to some
   extent).
4. Where necessary, hire a geriatric care manager
   to help in this process. While hospitals and public agencies have social
   workers to help out, they are often stretched too thin to provide the level
   of assistance you need. In addition, they can have dual loyalties, to the
   hospital that wants a patient moved as well as to the patient. A social
   worker or nurse working as a private geriatric care manager can assist in
   finding a nursing home, investigating alternatives either at home or in
   another residential facility, in evaluating the senior to determine the
   necessary level of care, and in communicating with family members to
   facilitate the decision. To find a geriatric care manager in your area, visit the Web site of the National Association of Professional Geriatric Care Managers at www.caremanager.org.

These steps cannot make the decision easy, but they
can help make it less difficult.

Resident Rights

While residents in nursing homes have no fewer
rights than anyone else, the combination of an institutional setting and the
disability that put the person in the facility in the first place often results
in a loss of dignity and the absence of proper care.

As a result, in 1987, Congress enacted the Nursing
Home Reform Law that has since been incorporated into the Medicare and Medicaid
regulations. In its broadest terms, it requires that every nursing home resident
be given whatever services are necessary to function at the highest level
possible. The law gives residents a number of specific rights:

1. Residents have the right to be free of
   unnecessary physical or chemical restraints. Vests, hand mitts, seat belts
   and other physical restraints, and antipsychotic drugs, sedatives, and other
   chemical restraints are impermissible, except when authorized by a
   physician, in writing, for a specified and limited period of time.
2. To assist residents, facilities must inform
   them of the name, specialty, and means of contacting the physician
   responsible for the resident’s care. Residents have the right to
   participate in care planning meetings.
3. When a resident experiences any deterioration
   in health, or when a physician wishes to change the resident’s treatment,
   the facility must inform the resident, and the resident’s physician, legal
   representative or interested family member.
4. The resident has the right to gain access to all
   his or her records within one business day, and a right to copies of those
   records at a cost that is reasonable in that community. The facility must
   explain how to examine these records, or how to transfer the authority to
   obtain records to another person.
5. The facility must provide a written
   description of legal rights, explaining state laws regarding living wills,
   durable powers of attorney for health care and other advance directives,
   along with the facility’s policy on carrying out these directives.
6. At the time of admission and during the stay,
   nursing homes must fully inform residents of the services available in the
   facility, and of related charges. Nursing homes may charge for services and
   items in addition to the basic daily rate, but only if they already have
   disclosed which services and items will incur an additional charge, and how
   much that charge will be.
7. The resident has a right to privacy, which is
   a right that extends to all aspects of care, including care for personal
   needs, visits with family and friends, and communication with others through
   telephone and mail. Residents thus must have areas for receiving private
   calls or visitors so that no one may intrude and to preserve the privacy of
   their roommates
8. Residents have the right to share a room with
   a spouse, gather with other residents without staff present, and meet state
   and local nursing home ombudsperson or any other agency representatives. They
   may leave the nursing home, or belong to any church or social group. Within
   the home, residents have a right to manage their own financial affairs, free of
   any requirement that they deposit personal funds with the facility.
9. Residents also can get up and go to bed when
   they choose, eat a variety of snacks outside meal times, decide what to
   wear, choose activities, and decide how to spend their time. The nursing
   home must offer a choice at main meals, because individual tastes and needs
   vary. Residents, not staff, determine their hours of sleep and visits to the
   bathroom. Residents may self-administer medication.
10. Residents may bring personal possessions to
    the nursing home such as clothing, furnishings and jewelry. Residents may
    expect staff to take responsibility for assisting in the protection of items
    or locating lost items, and should inquire about facility policies for
    replacing missing items. Residents should expect kind, courteous, and
    professional behavior from staff. Staff should treat residents like adults.
11. Nursing home residents may not be moved to a
    different room, a different nursing home, a hospital, back home or anywhere
    else without advance notice, an opportunity for appeal and a showing that
    such a move is in the best interest of the resident or necessary for the
    health of other nursing home residents.
12. The resident has a right to be free of
    interference, coercion, discrimination, and reprisal in exercising his or
    her rights. Being assertive and identifying problems usually brings good
    results, and nursing homes have a responsibility not only to assist
    residents in raising individual concerns, but also to respond promptly to
    those concerns.

Resolving Disputes

Disagreements with a nursing home can come up regarding any
number of topics, and almost none is trivial because
they involve the day-to-day life of the resident. Among other issues, disputes can arise about the
quality of food, the level of
assistance in feeding, troublesome roommates, disrespect or lack of privacy,
insufficient occupational
therapy, or a level and quality of activities that doesn’t match what was
promised.

The nursing homes that live up to the ideal
of what we would want for our parents or ourselves are few and
far between. The question is how far you can push them towards that ideal; what
steps should be taken in such process; and at
what stage does the care become not only less than ideal, but so inadequate as
to require legal or other
intervention. This can be a hard determination to make and in some cases needs the involvement of a geriatric care
manager who can make an independent evaluation of the resident
and who has a sufficient knowledge of nursing homes to know whether the one in
question is meeting the
appropriate standard of care.

Following is a list of the interventions a
family member may take, in ascending order of degree. Move down the
list as the severity of the problem increases or the facility does not respond
to the less drastic actions you
take. In all cases, take detailed notes of your contacts with facility staff and
descriptions of your family
member and his or her care. Always note the date and the full name of the person
with whom you communicate.

1. Talk to staff. Let them know what you expect, what
   you care about and what your family member
   cares about. This may easily solve the problem.
2. Talk to a supervisor, such as the
   nursing chief or an administrator. Explain the problem as you see
   it. Do it with the expectation that the issue will be favorably resolved, and
   it may well be.
3. Hold a meeting with the appropriate
   nursing home personnel. This can be a regularly scheduled
   care planning meeting or you can ask for a special meeting to resolve a
   problem that wasn’t resolved
   more informally.
4. Contact the ombudsperson assigned to the
   nursing home. He or she should be able to intervene
   and get an appropriate result. Contact information for the Ombudsman Program in your state can be found at: www.ltcombudsman.org
5. If the problem constitutes a violation
   of the resident rights described above, report it to the state
   licensing agency. This should put necessary pressure on the facility.
6. Hire a geriatric care manager tointervene. An advocate for you who is not as personally involved
   as you and who understands how nursing homes function as institutions can
   help you determine what is possible to
   accomplish and can teach the facility to make the necessary
   changes.
7. Hire a lawyer. While a lawyer may be
   necessary to assert the resident’s rights, the involvement
   of an attorney may also escalate the dispute to a point where it is more
   difficult to resolve. This is
   why we have listed this as the second-to-last option. But when all else fails,
   a lawyer has the tools to make
   the facility obey the law.
8. Move your relative. If nothing else
   works, move your family member to a better facility. This may
   be difficult, depending on the situation, but it may be the only solution. It
   does not prevent you from
   pursuing legal compensation for any harm inflicted on the nursing home
   resident while at the earlier facility.

For more information contact The Law Offices of Osofsky & Osofsky.

Myths and Realities