Serious Deficiencies in Nursing Homes Are Often Missed, Report Says

WASHINGTON — Nursing home inspectors routinely overlook or minimize problems that pose a serious, immediate threat to patients, Congressional investigators say in a new report.

In the report, to be issued on Thursday, the investigators, from the Government Accountability Office, say they have found widespread “understatement of deficiencies,” including malnutrition, severe bedsores, overuse of prescription medications and abuse of nursing home residents.

And this is news? Not to most CNA’s who work in nursing homes.

The nine states most likely to miss serious deficiencies were Alabama, Arizona, Missouri, New Mexico, Oklahoma, South Carolina, South Dakota, Tennessee and Wyoming, the report said.

More than 1.5 million people live in nursing homes. Nationwide, about one-fifth of the homes were cited for serious deficiencies last year.

“Poor quality of care — worsening pressure sores or untreated weight loss — in a small but unacceptably high number of nursing homes continues to harm residents or place them in immediate jeopardy, that is, at risk of death or serious injury,” the report said.
[…]
The study was done at the request of Senators Charles E. Grassley, Republican of Iowa, and Herb Kohl, Democrat of Wisconsin, who is chairman of the Senate Special Committee on Aging.

I have an idea for the Senators.

Put a CNA on every survey team. A CNA who has worked in nursing homes, who has some experience, who is savvy and can point out the cover ups and lies and distortions that we KNOW are happening.

With all due respect to the average survey team made up of people with numerous fancy titles, education and college degrees, who is better at identifying abuse and neglect than the seasoned CNA?

All the intellectual brilliance in the world will not be able to sniff out perfumed and powdered and otherwise fluffed and buffed, but not truly clean (as in showered recently) residents.

No degree in any field can separate real malnutrition caused by lazy and uncaring aides who don’t take the time to feed residents who cannot feed themselves, from the sad but very common and natural lack of desire to eat we see with people with late stage dementia.

Only a CNA can assess a unit for the true needs of any given resident population…a quick look around, copies of assignments, and observation of am or pm care pretty much tells it all. And CNA’s know the odors of pretty smelling air fresheners used during the inspections to cover up the real scents of a nursing home.

How about this: CNA’s who are part of a survey team should seek employment at facilities a month or so before the scheduled visit…get hired and work a few weeks beforehand. Then file a report with a lot of useful and honest and true information.

I suspect most nursing homes would sorely fail their inspections if this were to happen. The fact is nursing homes operate one way when it’s inspection time (”THE STATES’ HERE!!*) and another way the rest of the year (*ARE WE SHORT AGAIN TODAY?!?*) It’s time to re-think how surveys are done and who makes up these teams. By not having a front line worker on the team, the team always misses out on what’s really happening, since, it is the front liner who really KNOWS.

Send Senator Grassley a message about this HERE. He’d love to hear from CNA’s, this I know.

And Senator Kohl likes feedback as well…contact him HERE.

The faulty lift equipment that caused the death of an east Toronto nursing home resident had already malfunctioned twice within the same long-term care chain, according to a health ministry document obtained by the Star.

Leisureworld Caregiving Centres documented the two earlier incidents when the same type of lift broke down at another home in its chain, last November and December, according to the ministry’s May 8 letter to Health Canada, warning of safety hazards. The letter said there were no injuries as a result of the first two malfunctions.

It was not until Wally Baker’s April 30 death that Leisureworld replaced the lifts (motorized equipment used to move residents from bed to chair to toilet) throughout its 26 homes in Ontario. But chief executive officer David Cutler said the company took action to address the problems last November and December, including contacting Health Canada, which monitors nursing home equipment.

Wow. Pardon me for a moment here. I have worked with all kinds of mechanical lifts, of every variety and made by most manufacturers. Some are better than others; some are easier to use. None ever presented a hazard to my residents though, as long as I used the equipment correctly. We were trained by the manufacturers on how to use each lift, through the years, as we got them. I really don’t understand how this happened.

Has anyone ever experienced a close call with a lift? Was it the lift itself, the staff using it improperly a (lack of training on the proper use)? Was it the resident being unsafe and jeopardizing the transfer? I’ve seen that happen many times as well.

“After going from crisis to crisis, Joan is finally in a place where they have the time and training to really help,” said her husband, Terry, 76, a retired math teacher and businessman from Shoreview. “How many places can you get kicked out of? Let’s see, for us it was four in one year.”

The combination of dementia and behavioral problems can overwhelm families.

The combination can even overwhelm care facilities, said Annette Peterson, an Alzheimer’s Association counselor in Bloomington who talks every day with weary and sometimes frantic family caregivers.

To meet the needs of people with dementia, and who tend to be “violent”- facilities must have enhanced staffing ratios and dementia-specific activity based programming/care. The facility needs to be designed to allow for freedom of movement while ensuring the safety of wandering residents. Meals should be served buffet style and not at specific times. Routine is good for some with dementia but not all. Ware-housing these people with the non-memory impaired will not result in good outcomes. In the future, facilities will need to copy the model written about in this article.

While many studies have looked at MRSA in hospitals, “we found no studies that looked at ways of preventing the spread of MRSA in nursing homes for older people,” the reviewers said.

That’s despite nursing home conditions that are ripe for breeding the bacteria, including residents with compromised immune systems living in close proximity and taking multiple medications that can foster bacterial resistance.

Open wounds such as bed sores – a common problem in nursing homes – and the use of catheters, also common, enhance older people’s vulnerability.

Recognizing the importance of the issue, the Association for Professionals in Infection Control and Epidemiology (APIC) is updating its MRSA recommendations to “apply more specifically to long-term care settings,” according to Liz Garman, a spokeswoman.

Those new recommendations are due to be released late this summer, she says.

One of the typical things is strict isolation of patients who test positive for this infection. There are not enough single beds in most nursing homes to accommodate this. It will be interesting to see how nursing homes follow up on the recommendations.

HANOVER, N.H. — Edie Gieg, 85, strides ahead of people half her age and plays a fast-paced game of tennis. But when it comes to health care, she is a champion of “slow medicine,” an approach that encourages less aggressive — and less costly — care at the end of life.

Grounded in research at the Dartmouth Medical School, slow medicine encourages physicians to put on the brakes when considering care that may have high risks and limited rewards for the elderly, and it educates patients and families how to push back against emergency room trips and hospitalizations designed for those with treatable illnesses, not the inevitable erosion of advanced age.

Slow medicine, which shares with hospice care the goal of comfort rather than cure, is increasingly available in nursing homes, but for those living at home or in assisted living, a medical scare usually prompts a call to 911, with little opportunity to choose otherwise.

The only issue I have with this is how they have to mention the **costs** factor. All human life is priceless, and to mention costs as a factor in making life and death decisions causes me concern. When we starting going down that road, many lives will be considered not **worth it**.

Professional Boundaries

The 7 Habits of Highly Effective CNA’s

Asides: Managing YOUR Anger

Spot Light: Filling In The Blanks

7 Habits of Highly INeffective CNA’s

Survey Lessons: Resident Dignity and CNA’s

ALLNurses: Offer A Free Resource Page for Nurses and CNA’s!

At first the article didn’t seem to say much new or different; the issues of low pay and poor benefit packages are discussed as being barriers to attracting good staff. We all know this is the number one problem nursing homes and assisted living facilities face- high turnover.

What disturbed me and caused me to write this post:

The study, which was funded by the National Institute on Aging, also revealed that assisted living workers, who are primarily black, often face racial discrimination from residents, who are primarily white. Nearly half of black employees reported experiencing racism, Ball says, with many of those situations arising from comments made by residents suffering from dementia. Overall, she says, facilities need to make sure their employees feel valued and appreciated.

This is in Georgia. But it happens in every state.

Of all the careers one can chose to work in, nursing is one of the most rewarding. To help another person in need is a good feeling. In no other profession, though, do we see management allowing discrimination to happen, daily, as a matter of routine course. Under the guise of resident/patient rights, aides of color are constantly victims of resident harassment and disrespect. Management bars these aides from caring for said residents- and this leads to resentment and bad morale among all the aides.

No where in any Resident Rights document is the right to ask for or turn down care from nursing staff based on their the race, sex, religion or sexual orientation. Period. Not only is this illegal, it’s immoral. It’s also just poor management when the leaders promise residents and their families only female aides will work with their loved ones. What happens when only male aides show up for work? Don’t say it won’t happen. It has and it will.

In most businesses the customer is always right, no matter what. Business owners and their agents will do most anything to satisfy those who purchase their products or goods. This is, after all, customer service. But what do we do when it’s a patient/resident, demented or not, who overtly displays racism against a nurse or an aide of color?

I’ve seen it at my work. Most of my residents (patients actually) cannot speak for themselves and they are not of age anyway. Some of our best aides, who happen to be black, have been singled out as not being good enough to work with some of our residents, by their families. They insist upon “white aides” for caregivers and that their child never have to have a permanent aide of any other color…and management cowards right down to them. They send out announcements to the nurses (via emails) stating “only so and so CNA’s are allowed to be assigned to Mrs. Smith, per family wish”…and the only names listed are of Caucasian aides. The nurses keep this all quiet of course but we hear them talking about it when they’re making out the assignments. How does it make one feel if you’re an aide of color?

Oftentimes families cite a language barrier as the problem. This is a legitimate concern. We’ve had aides from Haiti, Mexico and other nations, who barely speak any English. How they passed a CNA course and state test baffles us, because they often cannot read and comprehend care plans, assignments and other written directives. Concepts of math are not well understood either- so weights and percentages of meals consumed are huge problems for these aides. I can understand and justify a request for non- English speaking staff not be assigned to certain residents/patients. These staff CAN take charge of this problem themselves and learn to speak English fluently; as well as learn to truly understand this language and work with it. They have a choice here.

But we cannot choose the color of our skin.

In any kind of work the management should never stand for this quasi-discrimination that they excuse or write off as resident rights. While we want our customers to be happy and content, we have to take a stand that’s morally right as well as legal. Discrimination is wrong on every level and for any reason.

How can facilities make sure their staff feel valued and appreciated?

Simple. Tale a stand to this nonsense right from the get-go.

Nursing home administrators and DON’s need to tell residents and their families upon admission that they never ever have a choice or say in which CNA is going to care for their loved one. It doesn’t hurt to mention aides (and all staff) of color, or certain religions or sexual orientations are protected by labor laws. Administrators and DON’s need to make it clear they will not tolerate any form of discrimination.

Demented residents will make comments and sometimes these will be very nasty. Some demented residents will always react poorly to having certain aides care for them, and be fine with other aides. I don’t have an answer for this dilemma. I can say it certainly burdens everyone when this happens. One of the good things about dementia is it causes people to FORGET…usually within minutes of any event or problem or escalation. Sadly this memory deficit can be of help in situations where derogatory remarks are made. Usually these residents are able to become very tolerant of their aide, regardless of race, sex, religion- when the resident realizes on some level that the aide is not out to harm them. This can only happen over time, through consistent assignment.

When a facility is looking to really change, actions do speak very loud. Pioneer Network has been working tirelessly to assist nursing homes and assisted living facilities with culture change. Matt over at Setting The Nursing Home On Fire found this gem of an article at the Pioneer site:

Low Cost Practical Strategies to Transform Nursing Facilities
it is a pdf report.

One of the things I noted quickly was the attention to the staff break room. When the staff are respected and trusted, it shows in many ways. Having a retreat style break room is a viable and cheap idea most nursing homes could manage. With the right motivational leadership, the nurses and aides would be more than willing to assist with creating this room.

Staff Amenities
Overall Goal:
Routinely staff members have been assigned break room space in the basement of a facility that is
furnished with cast offs, has equipment and appliances that often malfunction, and space that is expected to serve the dual purpose for staff who want to socialize as well as those who want a quiet time. Reverse this trend and provide staff with an abundance of spaces including tables in main dining room, a computer station and quiet space for reading or meditation.

Really now? Do staff need all this? DO we really care if our break room is nicely outfitted with decent working microwave ovens and fridge large enough to accommodate ALL our bagged meals and drinks? And who has a computer in their break room? Management would never trust the staff to go online because they might be wasting time, right?

Get with the times, management.

Examples of Improvement Strategies:
• Enhance the staff break room. It should have good lighting, comfortable chairs, conversation arrangements, appliances that work, flat surfaces for both eating and writing and a quiet corner

• Provide computer area or computer station for private staff use

• Designate a table and regular day as “give-away or exchange” where children’s clothes, extra produce from gardens, reading material, videos, and other items can be exchanged or given away

• Provide prayer corner or small meditation room designated for staff

• Encourage staff to use lounge or dining spaces to hold baby or wedding showers or other celebratory events. Invite residents to participate along with members of the community

A big bulletin board might be the only resemblance to the “old” break room.

Wow. Comfortable chairs and seating arrangements that mirror a living room more than a waiting room? Why not? When respected, staff deserve such spaces. Most of the furnishings for such spaces can be purchased cheaply through group purchasing associations, trade group memberships and, the old fashioned way- yard sales and thrift shops.

Another GREAT source of help is the resident families. I am quite sure most would donate a chair or small table; an area rug and some table lamps. The residents themselves could make wall quilts and other artwork. Bookcases and ottomans (YES- so the tired feet of CNA’s have a place to rest UP on);
everyone has a book or two they would be willing to give to the new staff LIBRARY located in the break room (same with DVD’s and the TV/Player to go with it).

Think outside the lead box. A transformation can happen within a week if it is truly wanted. Under the culture change movement every room has significance and front line staff have much more value and respect.

1. Interviewable sample resident #2 was admitted to the facility on 2/6/01 with diagnoses including rheumatoid arthritis and a thyroid disorder (according to the face sheet). The quarterly Minimum Data Set, dated 6/12/07, coded the resident as having mild short term memory loss.

Observations of the resident on 7/1/07 at 10:30 a.m. revealed a certified nurse aide (CNA) was preparing to transfer the resident from her bed into a wheelchair using a Hoyer lift. The resident stated she needed to go to the bathroom prior to being transferred. The CNA stated the resident experienced pain using the toilet in the bathroom, so he had her go in the trash can by suspending her in the lift and placing the trash can underneath her.

A follow up interview was conducted with the CNA at 1:55 p.m. The Unit Manager was present during the interview. Both stated the day shift and evening shift used this method to toilet the resident. The Unit Manager stated the night shift had the resident use a bedpan, and did not get her up.

And:

On 7/1/07 at approximately 1:00 p.m., supplemental sample resident #27 was heard calling for help in a loud voice. The resident was seated in a wheelchair in the Silver Key office and appeared in no distress. There was a CNA seated in the Siver Key (sic) office with the resident. The CNA stated that was her job for the day, to sit with the resident. The resident could be heard calling for help in the hall outside the office. The CNA asked the resident several times why she was calling for help when there was nothing wrong. The resident yelled for help again and the CNA stated, “You are just a problem child.”

In the first example. the staff used a mechanical lift and trash can to assist with toileting a resident. Is this normal? Is this digified? What are some options?

Commodes: They make commodes in all sizes and shapes, out of soft and hard plastics. Most CNA’s have seen these PVC models. The CNA’s are the resident’s advocate. In this case they should have (and perhaps did) ask for a comfortable commode for this resident to use.

Bed Pans: They also come in many shapes and sizes. Some are made of softer plastics as well. The CNA’s should always encourage the resident to use this before getting OOB.

In the second example things aren’t so clear. Just the name of this room suggests dignity is an issue. When a CNA is expected to be a sitter, they need to have clear expectations of what they are to do with the resident. Just sitting there and watching them often isn’t enough and is very undignified. Usually a resident who needs 1:1 supervision really needs to be occupied. To be kept busy and somewhat distracted.

The CNA’s working with this resident could have foreseen situations where 1:1 time would be needed; and anticipated the need for activities and other things to do. Seeking the help of the Activity Director or other person, puzzles, board games, reading materials or any number of other items could have been available. Smart aides know these times will come and have a box of items at the ready for these moments.

We never tell a resident they are a “problem child”. To do so is border lining on verbal abuse.

To wrap this up, when we are caring for a resident who has special equipment needs for ADLs, ask to see one of the medical supply books to see what is available. If you find something that will work ask for it to be ordered.

Plan ahead. Anticipate needs. Ask for equipment. If your facility employs the services of a physical and/or occupational therapist, seek out their input on resident comfort and equipment issues. Document all of this in your personal log. Ask the charge nurses to document equipment requests in the resident’s medical records.