Most long-term care facilities strive to provide both excellent care and a comfortable home for their residents, who are oftentimes — but not always — the frail elderly.
However, there are harsh secrets in some nursing homes: stark problems like resident neglect or abuse. And recently, COVID-19 created difficulties with infection control and put resident isolation and loneliness in the spotlight. As a prospective resident or their family member, you deserve to know a facility’s past deficiencies and current situation.
“There is nothing that nursing homes should not tell family members or potential residents,” says Katie Smith Sloan, president and CEO of LeadingAge, an association of nonprofit, mission-driven providers of aging services. “The question is: What do family members want to know? We certainly encourage people to visit. We encourage them to talk to residents, talk to staff and talk to other people (such as) other family members who have other adults in a nursing home.”
You may need to bring up issues yourself and research proactively to learn about the nursing home’s quality and what goes on behind the scenes. Below, experts identify long-term care areas where transparency may be lacking, what’s being done to address them and how you can learn more about an individual facility.
Nursing Home Issues You Should Know About
These are key nursing home concerns to be aware of as a prospective resident or family member:
— Persistent and worsening staff shortages.
— High staff turnover.
— Too many residents per caregiver.
— Fewer RNs onsite than recommended.
— Ownership that’s unclear and frequently fluctuating.
— Supply shortages.
— Recurring resident and family complaints.
— Antipsychotic drug overuse for dementia.
— Drug-resistant bacteria among residents.
— COVID-19 vaccination gaps among staff.
— Hospitalization challenges for residents.
Severe staff shortages
A nursing home you’re considering may have to turn away new admissions because there isn’t enough staff to care for them.
In April 2022, the Biden administration proposed requirements for mandatory minimum staffing levels in nursing homes. However, some nursing home trade groups are pushing back, asking for more flexibility and citing factors, like local labor availability, that can hamper staffing efforts.
An American Health Care Association report released in June 2022 highlighted survey responses from 795 nursing home providers. It found that 60% are experiencing worsening staffing situations even since January. Nearly 50% face high-level staffing shortages, with 98% having difficulty hiring staff. And 61% of respondents are limiting new admissions.
The top obstacles, which developed or grew during the pandemic, include a lack of interested or qualified candidates, personal commitments preventing people from entering the workforce and facilities’ inability to offer competitive wages with their current financial situations.
High staff turnover
High staff turnover threatens the continuity of care, leaving fewer caregivers who are really familiar with individual residents’ preferences and needs. That can be particularly important for certain residents, such as those with dementia who may find it harder to express themselves.
“Staffing and staff turnover is something folks should be looking for,” says Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care. “The average turnover is 50%. However, there are facilities that do better. We see staff turnover as a barometer of job quality. And facilities with lower turnover also do better on most quality measures.”
Too many residents per caregiver
You have to drill down on staffing numbers in general. A single figure can help you compare the total direct care nursing time that a resident receives in a given facility. About two decades ago, the Centers for Medicare and Medicaid Services released a staffing study, mandated by Congress, identifying a daily minimum standard of 4.1 hours of total direct care per resident to avoid putting them at risk. Direct care refers to hands-on care, services and support given to older adults or those with disabilities. That number is further broken down by specific caregiver type.
Those numbers matter, and 4.1 hours per resident day or more “is where folks should be,” Brooks says. “That has been (identified) in studies and is the gold standard for nursing home care. So, people looking at a facility should really be looking to get to that 4.1 hours or care, or as close as possible.”
Fewer registered nurses
Registered nurses have more training and a wider scope of practice — including the types of drugs they can administer and monitor, inserting and managing intravenous catheters and developing patient care plans — than licensed practical nurses. In nursing homes, LPNs and certified nursing assistants, or CNAs, make up the bulk of the staff. And the RNs aren’t necessarily working directly with residents.
The skill mix of a nursing home’s staff can affect how well residents do, combined studies suggest. “Registered nurses were consistently associated with fewer significant pressure ulcers, hospitalizations and urinary tract infections,” according to a systematic review published in the International Journal of Nursing Studies in July 2021.
However, “in nursing homes, many registered nurses are doing administrative work,” says Alice Bonner, senior advisor for aging at the Institute for Healthcare Improvement and chair of Moving Forward: Nursing Home Quality Coalition. “They’re not necessarily on the (units) with the residents and supervising the resident care.”
Depending on the time of day and staff composition, RNs may not always be present at the facility itself. For instance, there may be an RN on call, but not in the building, at night. Despite evidence-based recommendations to have at least one RN on duty 24/7, only six states have such a requirement for all facilities, notes a report on nursing home staffing released by the National Consumer Voice for Quality Long-Term Care in December 2021.
Ownership that’s unclear
“Wouldn’t you want to know who owned the nursing home if you were going to live there?” Bonner says. “Seems like a pretty basic question.”
However, nursing home ownership isn’t always straightforward. “There have been so many companies coming into the space,” Bonner explains. “And they have divided up the ownership in ways that make it difficult for anyone to tell who actually owns the nursing home. It can be that there are a bunch of partial owners. It’s just very hard to track all of the ownership and who’s responsible, actually, for the quality in the home.”
It’s always worth asking the nursing home director about ownership, and recent transparency regulations and a new online tool (described in the improvement efforts section below) make it easier.
Basic care supplies lacking
Shortages in care necessities such as masks, gowns and gloves hamper infection control efforts, making it harder for staff members to avoid contact with viruses and bacteria while providing direct patient care, and increasing the risk of spreading infectious organisms from one patient to another. Even basics like bed linens may be inadequate depending on how responsive facility owners are to staff members’ requests for more.
Antipsychotic drug misuse
In some nursing homes, certain antipsychotic drugs — approved to treat conditions such as schizophrenia and bipolar disorder — are given to residents with Alzheimer’s disease or dementia who are exhibiting difficult-to-manage behaviors. Such controversial off-label use has been called ‘chemical restraints’ or ‘chemical straightjackets.’
The Food and Drug Administration has issued warnings about the use of antipsychotic drugs like Haldol. as well as the increased risk of death for elderly patients with dementia-related psychosis who are treated with them.
In 2012, the CMS established a public-private coalition to improve care for residents with dementia living in nursing homes. A key mission was protecting residents from being prescribed and treated with antipsychotic medications, unless they were clinically indicated and systematically evaluated for an individual resident’s needs.
Although unwarranted antipsychotic use in nursing homes has since decreased, it’s beginning to uptick slightly, according to data released in April 2022.
These are important questions to ask the attending physician, staff nurses or facility administrator: What medications are you using to treat my family member with dementia? With antipsychotic medications, why are they being used and what benefits do you expect them to have? Could other health issues, like a urinary tract infection, be causing confusion or aggressive behaviors?
Reoccurring complaints by residents and families
A nursing home ombudsman, or long-term care ombudsman, handles complaints against these facilities and works to resolve issues regarding the safety, health, welfare and rights of residents. Every state has an ombudsman program to improve senior care. According to the Administration for Community Living, nursing home ombudsman programs most frequently handle these five complaints from residents or family members:
— Improper eviction or inadequate discharge planning.
— Unanswered requests for assistance — call lights for help going unanswered.
— Lack of respect for residents, including poor staff attitudes.
— Medication administration or organization problems. Prescribed medications may be administered incorrectly. This could look like medication given at the wrong time of day, in the wrong dosage, not given at all, or the wrong medication given altogether.
— Quality of life issues like resident-roommate conflicts.
Sometimes called ‘superbugs,’ certain multidrug-resistant bacteria are present in about one-quarter of nursing home residents, according to a systematic evidence review in the May 2017 issue of the American Journal of Infection Control. As the name implies, these germs, like pneumonia-causing Klebsiella, are resistant to widely available antibiotics. Basic infection prevention measures like consistent handwashing help reduce the spread of other bacteria such as MRSA, which is transmitted by skin-to-skin contact.
COVID vaccination gaps
When comparing healthcare personnel including hospital and long-term care workers, those in long-term care settings had among the lowest COVID-19 primary vaccination and booster rates — and lowest flu vaccination rates –according to the Oct. 21, 2022 issue of the Morbidity and Mortality Weekly Report, released by the Centers for Disease Control and Prevention.
Hospital transfer challenges
When a nursing home sends a resident to the emergency room — for instance after a fall or for worsening symptoms of a chronic condition — it can be a long, bewildering ER visit. If a resident is evaluated by emergency room staff and their condition appears to be stable, they could potentially spend hours on a stretcher waiting before finally being cleared for discharge back to the nursing home. So, the decision to send the resident to the hospital must be made carefully.
“Clinical need and resident acuity are the factors that drive the decision to move a resident from a nursing home to a hospital,” explains Lisa Sanders, director of media relations for LeadingAge. “The process is usually that the nurse practitioner or registered nurse who oversees direct care will assess a resident’s condition, and then calls in the attending physician or the nursing home medical director who would then make the decision to transfer the resident to the hospital. It is the attending physician or the medical director who has the authority to decide on the transfer.”
The responsible family member must be informed immediately. “The nursing home team should call the resident’s family to tell them that the doctor has determined the need for a transfer to the hospital,” Sanders says.
Nursing Home Star Ratings: What They Mean
You can locate possible facilities and find inspection data by searching the U.S. News Best Nursing Homes ratings, which are based in part on CMS surveys. Nursing home surveys are public reports that you can access. CMS contracts with every state to do in-person inspections of nursing homes. These on-the-ground inspections, also called surveys, are federally mandated to occur about once a year. Surveys include measures of nursing-home quality and uncover deficiencies such as resident abuse, lack of an infection control program or cases of overmedication.
In Nursing Home Care Compare’s five-star system, the CMS assigns a star rating to long-term care facilities based on three main domains: health inspections, staffing and quality. The first two categories are more dependable, Brooks says.
At issue is how the nursing home outcomes are measured. “We encourage families and potential residents to rely as much as they can on the staffing rating and the health inspection rating,” Brooks says. “You’ll often see nursing homes with two- or one-star ratings for staffing and health inspection, but high-quality metric ratings. That’s because that measure is based on self-reported data — data that’s provided by facilities. It’s not based on payroll data, which the staffing measure is. Health inspection is based on survey data.”
Quality measures include items such as mobility decline, physical restraints and pressure ulcers, moderate to severe pain and urinary tract infections among long-stay residents.
No single data point or ranking system tells the whole story. There’s also COVID-19 data from the CDC, which is updated weekly. You can find nursing home-related data from other sources, such as state departments of health, which are there to enforce laws and regulations. States may have separate websites on nursing home violations, Brooks says, and may offer more in-depth information on COVID-19 cases and deaths.
“Oftentimes residents aren’t aware they’re afforded a long list of really important rights,” Brooks says. Broad categories include the rights to:
— Be treated with respect.
— Participate in activities.
— Be free from discrimination.
— Be free from abuse and neglect.
— Be free from restraints (both chemical and physical).
— Get proper medical care.
— Have your representative notified of important events or changes affecting you.
— Get information on services and fees and manage your own money.
— Get proper privacy, property and living arrangements.
— Spend time with visitors.
— Get social services like counseling and discharge planning.
— Have protection against unfair transfer or discharge.
These rights include the ability to file a complaint to the ombudsman’s office without fear of punishment.
“The local long-term care ombudsman is just a priceless resource,” Brooks says. An ombudsman can sometimes answer questions for family members even prior to a resident going into a facility, he says. “Ombudsmen are advocates for making sure that residents are having their rights followed and they’re aware of what rights they have.”
Every nursing home resident should have an individualized, comprehensive care plan that is updated as their needs or condition changes, with their family kept abreast of the resident’s status. The care plan process includes regular discussions with the person designated as the responsible decision-maker.
“Long-stay residents’ care plans are scheduled quarterly, or if there is a significant change in condition,” Sanders says. “These meetings, usually phone calls or Zoom calls include the care team — the RN in charge of the resident’s neighborhood or unit, a dietitian, social worker and occupational therapist, and, often the doctor.” A nursing home resident receiving skilled care or rehabilitation may have more frequent meetings, such as every two weeks.
What You Can Do
As a family member, keeping informed about a resident is a two-way proposition. The nursing home has that responsibility, but you can also take steps to keep in the loop:
— Visit in person if possible: Being there is half the battle.
— Observe staff-resident interactions.
— Watch for infection control practices like handwashing and proper masking.
— Go on Care Compare to get pertinent data.
— Review the facility’s surveys: current and past.
— Ask about resident engagement.
— Speak with an ombudsman.
— Talk to members of resident or family councils.
If you suspect abuse or neglect, go to the National Center on Elder Abuse website to learn how to report it, and consider contacting a nursing home abuse attorney.
Efforts to Improve Nursing Homes and Protect Residents
In March 2022, the administration announced plans to examine nursing home ownership roles involving corporate structures like private equity and real estate investment trusts. In late September, a list of ownership information on currently active nursing homes became available on the CMS website.
“We totally support the transparency,” Sloan says. “In many ways, it’s a move that levels the playing field between for-profits and nonprofits. Because, as nonprofits, we have always disclosed ownership.”
However, frequent buying and selling among for-profit nursing homes makes keeping up a real challenge, Sloan adds: “There’s just a lot of churning.” For the CMS, she says, “They’re going to be chasing a moving target.”
In April, the National Academies of Sciences, Engineering and Medicine released a report on improving nursing home quality. Key recommendations addressed strengthening the nursing home workforce, improving emergency preparedness and increasing transparency and accountability of finances, operations and ownership of nursing homes.
The Moving Forward Coalition, for which Bonner is the chair, is focused on advancing the goals outlined in the NASEM report to improve nursing home quality. Committee members, along with outside experts, nursing home residents and the general public, are involved in an ongoing effort to create, test and promote action plans to meet those goals.
Nursing Homes: Not All the Same
All nursing homes should not be painted with the same brush, experts emphasize. “It’s really important to know that there are 15,000 nursing homes in the country, and they’re not all the same,” Sloan says. “But we often treat them as if they are. Some are large, some are small and some are county- or government-owned. Some are part of for-profit entities, but within that, there’s private equity. They’re often larger chains that are investor-owned.”
By contrast, “There are a lot of nursing homes that are owned by nonprofit, mission-driven organizations,” Sloan says. “Many of them have a faith tradition or are faith-based and have longstanding ties to their community.”
Younger people live in nursing homes, too, although in smaller proportions. In 2019, more than 1.1 million adults over 65 lived in long-stay nursing homes. By contrast, about 210,000 residents were younger, according to an article in the October 2022 issue of Health Affairs. Disabilities such as serious mental illness, cerebral palsy, paralysis and traumatic brain injury are more common among younger nursing home residents.
Nursing homes exist for a reason: They provide ongoing care and support that most residents can’t receive elsewhere. They’re not in-and-out facilities like hospitals but are intended as homes where people can live good lives, especially as improvements are made.
“A nursing home … is where you see the opportunity for a relationship to be built between residents and staff, and the desire to create activities and engagement for the resident,” Sloan says. “So, that is their home and they feel like they’re not just hanging out there — they’re actually part of a community. They can build relationships with other residents, they can eat meals together, can get to know staff, and even, sometimes, go on outings together.”
People may have the wrong idea about nursing homes and what they stand for, Sloan says. “There’s a misconception, perhaps, that nursing homes are a place where people go and then we forget about them,” she says. “That’s not the case. They’re dynamic places with enormous amounts of love and compassion.”
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Update 11/29/22: This story was previously published at an earlier date and has been updated with new information.