How to Prevent Abuse and Neglect in Nursing Homes: Prevention
By Ted Sherwood
It has been estimated that there are over 28,000 Oklahomans receiving long term care in nursing homes. Despite the fact that there are a number of overlapping regulations designed to ensure minimum standards of quality of care and quality of life for these residents, there are continued reports of neglect and abuse.
The Office of the Long Term Care Ombudsman (“State Ombudsman”) tracks the number of formal complaints made to state agencies concerning residents in nursing facilities. In its most recent report covering fiscal years 1996-97, the State Ombudsman noted that there were 1,465 formal complaints, 44% of which were verified or partially verified.
The results of poor nursing care in nursing homes can be tragic. We have seen many instances where a nursing home resident suffered serious injury or death due to abuse or neglect. Many of these injuries or deaths could have been prevented.
Family members play an important role in prevention of abuse or neglect. The old saying that the “squeaky wheel gets the grease” applies with great force to the nursing home environment. Loved ones whose family members visit frequently, ask questions, and demand quality care, are less likely to suffer from abuse or neglect.
The following information is intended to assist you in preventing injuries to your loved one when they are residents of a nursing home.
PREVENTION THROUGH SELECTION
Not all nursing homes provide the same quality of care. As in all service-based businesses, some provide good care and some provide poor care. You can go a long way towards ensuring good care for your loved ones by choosing a nursing home carefully.
The first thing you must do is narrow the possible choices. It is wise to choose a nursing home close to family members who will visit regularly. Nevertheless, location should not be the only factor in selection.
Ask for referrals of prospective nursing homes from friends, fellow employees or people at your church. Check with physicians who see patients in the nursing homes in your area. Another good source is the Area Supervisor for the State Ombudsman. Call the State Ombudsman’s office at (405) 521-6734 and ask for the Area Supervisor responsible for the town or county where you desire to place your loved one. Other good sources of information are Oklahomans for Improvement of Nursing Care Homes (OK-Inch) (405) 364-5004 and Tulsa Senior Services (918) 664-9000.
Once you have narrowed your list of prospective nursing homes to two or three prospects, you should schedule an appointment with the Administrator and the Director of Nursing for the nursing home. When you go to the nursing home, consider asking some of the following questions and listen carefully to the answers.
- What does the nursing home look and smell like?
- What do the other residents look like? Are they clean and dressed appropriately? Are they actively engaged?
- What is the background and experience of the Administrator? The Administrator is the Captain of the ship. You are looking for someone who is experienced and has some stability of employment. Look for someone with a healthcare background.
- What is the background and experience of the Director of Nursing? You should be looking for someone who is experienced and has some stability of employment. Look for someone with hospital training and experience.
- Who is the owner and where is the owner located? National chain versus regional chain. An onsite or local owner can be more responsive and is probably more concerned about his reputation in the community.
- What activities are available for the residents? Meet the Activities Director and ask for the activities calendar. Observe some of the activities conducted for the residents.
- What specialty therapies are available? Does the nursing home have in-house therapists, like physical therapy, speech therapy and occupational therapy? If these specialty services are contracted out, how frequently do the therapists come to the nursing home?
- What does the food look and taste like? Older folds are just like the rest of us. They still like to eat if the food is good and don’t want to eat if it is not. Check to see if the food is hot and appropriate for the resident.
- Does the nursing home have adequate staff during meals? Some residents require no help in being fed and some are totally dependent on the staff to eat. Proper nutrition is critical to maintaining physical strength or recovering from illness.
- What is the nursing home’s fall prevention policy?
- How does the nursing home prevent skin breakdown?
- How does the nursing staff document turning and repositioning of bedfast residents?
- What different methods does the nursing staff use to relieve pressure on the skin of bedfast residents?
- Who performs the dietary consultations for the nursing home?
- How does the nursing home ensure that residents maintain good nutrition?
- What is the nursing staff-to-resident ratio? The state nursing home regulations require a minimum number of staff to care for the residents in the nursing home and this number changes depending on the time of day. So, more staff are required for the morning shift (7 a.m. to 3 p.m.) and less staff for the night shift (11:00 p.m. to 7:00 a.m.). Unfortunately, the state regulations allow the nursing homes to count non-healthcare staff or people who do not perform hands on care for the residents, such as the Activities Director or dietician. You should ask the nursing home how many residents area at the home and how many LPNs (Licensed Practical Nurse), CNAs (Certified Nurse Aide) and CMAs (Certified Medication Aide) are assigned to work on each shift. Look for a direct care staff-to-resident ratio that does not exceed 1:7 for the morning shift; 1:10 for the afternoon shift and 1:15 for the night shift.
- What is the average length of service for the principle charge nurses? Experienced charge nurses are critical to a nursing home’s quality of care. These are usually Licenses Practical Nurses (LPN) who supervise the care of the residents on each shift.
- What is the average length of service for the nurse aides?
- How are the nurse aides trained?
- Are the nurse aides certified?
- What background check is done on the nursing staff before they are hired?
- If a family member is not satisfied with the care being given by the nursing staff, what can they do?
- What were the results of the nursing home’s last two annual surveys by the State Department of Health?
- Has the nursing home ever been sued and, if so, what was the outcome? If the answer is yes, you might want to pull the records of the lawsuit and call the attorney who handled the case.
- Who is the Medical Director?
- How many patients does he/she have at the nursing home?
- How often does he/she come to the nursing home?
- What other physicians have patients at the nursing home?
- How often do they come to the nursing home?
- Do any of the physicians use physician assistants? Physician assistants (PA) are nurses with specialized training and authority to write some prescriptions. Some physicians use their PAs to make interim visits to the nursing home and act as an independent source of information for the physician. If the physician has a PA, this can enhance your contact with the physician.
- Does the nursing home have a Residents or Family Council?
- Who can you talk to who has had a family member in the nursing home? Get several references and call them.
- Does the nursing home have a religious affiliation?
- How many skilled or Medicare beds does the nursing home have?
- Whether there is a waiting list?
- What is the private pay rate?
- What kind of security measures are taken to prevent residents from wandering away from the facility? All nursing homes have a certain number of residents suffering from some type of dementia. These residents are often still physically active, but have a reduced sense of appreciation for their own safety. Many residents have suffered serious injuries or died when they wandered away from the nursing home due to inadequate security measures. Look for coded button pads or other special measures that must be activated to leave the building. Some residents may require a special bracelet that will trigger an alarm if they leave the building unattended. Some nursing homes have secure or locked Alzheimer’s units. Also, ask about the procedure for checking a resident out of the facility. Does the nursing home have security cameras which monitor the entrance and exits?
- Does the staff interact well with the residents?
- Is there interaction between the residents?
Once you have narrowed your choices, you should complete your investigation by consulting independent sources of information about the subject nursing homes. You can obtain valuable information from the public licensure files on the nursing home from the Oklahoma State Department of Health (OSDH) by calling (800) 234-7258 and asking for the records department for nursing homes. If requested, the OSDH will send you the last two Annual Surveys of the nursing home; the nursing home’s license; ownership information, and any recent complaint investigations conducted by the OSDH.
For those of you with internet access, the following website will prove a valuable resource:
- HCFA www.hcfa.gov/
- National Council on Aging www.ncoa.org
- Tulsa Senior Services www.seniorline.org
- Tulsa Area United Way www.tauw.org
- Senior Law Resource www.seniorlaw.com/resource.htm
- National Citizens Coalition on Nursing Home Reform www.nsclc.org/nursing.html
- www.seniorcarehelp.com
- www.angelfire.com/tn/NursingHome/index.html
You should personally talk with other independent sources of information regarding their experience with the nursing home under consideration. Talk with the State Ombudsman Area Supervisor assigned to the nursing home and the Volunteer Ombudsman. Talk with the Family Council representative and call a physician who regularly sees patients at the nursing home. If you take these steps, we believe you will be in a position to make a good decision about whether this nursing home is right for you and your loved one.
PREVENTION THROUGH VIGILANCE
After you have selected what you believe to be a good nursing home, you must continue to closely monitor the quality of care your loved one receives. The following is a list of suggestions which will help you stay on top of the care provided by the nursing home.
- Visit frequently and at different times.
- Furnish a complete medical history on your loved one to the nursing home. Obtain medical records from previous treating physicians or nursing homes and furnish these records to the nursing home.
- Provide telephone numbers for several family members who can be reached if there is an emergency and make it clear that the family wants to be called if there is any problem or change in condition or change in treatment orders. If an incident occurs, such as a fall, the nursing home is required to fill out an incident report. See example incident report, Attachment No. 2. Ask for a copy of the incident report.
- The nursing home is required to prepare a comprehensive care plan on each new resident. The care plan is supposed to include input from a number of disciplines including nursing, physical therapy, dietary and activities. It is also supposed to be updated quarterly. Ask for a copy of the care plan and any updates. See example care plan, Attachment No. 3.
- Choose the physician who will be responsible for your loved one’s care. The nursing home may recommend a physician, since many internists will no longer go to nursing homes. Ask for the names of other physicians who regularly come to the nursing home and interview those physicians.
- Ask the nursing home to notify you when the treating physician has seen your loved one and find out what treatment orders were given to the nursing home. See example treatment orders, Attachment No. 4.
- Monitor any significant weight changes by asking to see the vital signs chart. See example vital signs chart, Attachment No. 5. Confirm that your loved one is being weighed regularly, usually once per month, and that the weights appear to be consistent with your own observations. If there is a weight loss of more than ten percent (10%), request a consult with the nursing home’s dietician.
- Periodically review the clinical chart. The clinical chart is usually kept at the nurses’ station and contains nurses’ notes, progress notes from the physician, laboratory test results, and physician orders for treatment. Review these records to confirm they are consistent with your own observations of the resident.
- Periodically review the Activities of Daily Living (ADL) sheets. See example ADL sheet, Attachment No. 6. These are also sometimes referred to as Nurse Aide sheets. This is where the nurse aides are supposed to chart the treatments regularly afforded to the nursing home resident such as turning every two hours, showers, whirlpool baths, oral hygiene, percentage of meals consumed and the like. Confirm that the treatments which are supposed to be given are documented.
Now the nursing home may initially refuse to allow you to examine these medical records. Under Federal regulations, a resident, or his legal representative, has the right, upon oral or written request, to access all records, including current clinical records and to purchase a copy of same with two (2) working days’ notice. However this regulation only applies to nursing homes accepting Medicare of Medicaid recipients. Oklahoma law provides that any person who is or has been a patient of a medical institution shall be entitled to access to the information contained in his medical record upon request, and shall be furnished with copies of all records pertaining to his or her case upon request and tender of the expense of the copies.
Sometimes the nursing home will argue that if the person requesting access to the medical records is not a legal guardian, access to medical records will not be granted. Clearly, the resident, the resident’s legal guardian, or attorney-in-fact (power of attorney) is entitled to examine the medical records and, pursuant to OSDH Regulations, the resident can authorize someone to access the medical records. If the resident is mentally incompetent to give authorization or execute a power of attorney, a family member should immediately seek to be appointed as guardian. If the nursing home continues to refuse access to the medical records, you should report the matter to the OSDH and turn the matter over to the District Attorney’s office for prosecution.
