The Reality of Nursing Home Care: What you May Not Realize

I think it is important for anyone who is entering a nursing home (or considering a nursing home for their loved-one) to enter with eyes wide open. The truth may be alarming and somewhat disturbing, but it does not change the reality of nursing home care. I do think that the nurses, physicians, nursing home administrators and staff are trying to do the best that they can for the patients they serve. However, the reality of the matter is that nursing homes are a business. Would it make sense for the nursing home to spend more money than it makes? I am not an accountant nor am I a nursing home administrator, but I do think that in order to achieve the quality of care and outcomes that we all expect to receive and that we imagine we “should” receive….the nursing homes would end up being deeply “in the red”… and cease to exist.

Today’s patients in the nursing home are much sicker and more medically complex than they were even 10 years ago. What many people don’t realize, however, is that nursing homes are still operating under healthcare laws that were passed 30 years ago. The Federal Nursing Home Reform Act or Omnibus Budget Reconciliation Act (OBRA) of 1987 created a set of national minimum standards of care and rights for people living in certified nursing facilities.

The Nursing Home Reform Act requires nursing homes “to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident”. The law provides some specific requirements for staffing (such as a minimum of 8 hrs/day for RN staffing), however it does not provide specific nurse-to-resident staffing ratios for RNs, LVNs, LPNs or CNAs. If a nursing home only met the federal nurse staffing requirements as provided by the law, a resident would receive only 20 minutes of nurse time PER DAY! Most states have additional laws that exceed the federally mandated requirements, however, this is not by any significantly meaningful amount. Many states have requirements that require a total of approximately 3 hrs of nursing care per day. Whether this is performed by a certified nursing assistant or a licensed nurse (LVN, LPN or RN) the total is still only 3 hrs/day. This means that for the other 21 hours remaining in the day, the patient is likely not being attended to by any nursing staff. For most people and patients, this comes as a complete and total surprise. Many assume that there is an aid or attendant caring for those in nursing homes constantly. This is an example of where expectations and reality do no align.

In regards to attending physician requirements, the federal law only requires that a physician see the patient in nursing homes once every 30 days. This does not mean that a physician is unable to see the patient more often than required, however, there is no law that mandates that a physician see a resident anymore that once a month. Many of the patients that I attend to today are leaving the hospitals after an acute illness. Some patients even transfer directly out of the intensive care unit (ICU) at the hospital straight to the nursing home. Perhaps the required “once a month visit from the doctor” seemed reasonable 30 years ago, but I would say that for the majority of skilled nursing home patients, this is not sufficient (nor safe) for competent management of the patient.

Many healthcare organizations, hospitals and nursing homes are working closely together to try to improve overall patient outcomes. Hospitals and nursing homes are trying to better coordinate care. Physicians and medical groups are trying to offer a more consistent presence in the nursing home setting. One of the main problems, however, is that our government (Medicare) and current reimbursement model cannot afford the true cost of this higher level and higher quality of care that is required by this frail and sick population.

What can we possibly do to improve our own expectations, experiences and outcomes in the nursing home then? Because legislation through government often takes the longest time and is the most complicated and challenging to implement and change, I will offer some of my own personal opinions and suggestions that I think any one of us (as a patient or loved one) can use to improve our own outcomes and experiences in a skilled nursing facility. Rather than relying on or expecting that “the system” could/should meet all of your medical needs, we need to be better informed in order to take necessary steps to help ensure that those medical needs and requirements are met. The nursing home is, “technically speaking”, supposed to provide for all of your needs. The nursing homes are not supposed to suggest or require that you hire outside help. However, now that you are armed with the knowledge that nursing homes can meet all of their legal “staffing” requirements and obligations and likely still not be able to meet your personal healthcare needs, I hope that you can begin to now see that in order to insure YOUR best outcome, you will need to augment and take on some responsibility for yourself. Sure, you can try to “demand” that the nursing home to do everything that I suggest…because, you have the “legal right”, but the reality of it is, it will most likely NOT get you anywhere and leave you with only stress and frustration.

Here are some take home points for you to ponder:

#1 You must understand the inherent shortcomings of the current system. I have already discussed the minimal staffing requirements set fourth by the government. You must expect that the nursing home where you or your loved one is residing is operating at the bare bones minimum of this staffing requirement that has been set forth by law. If you understand this, then you will be able to “fill in the gaps” where it is medically necessary or functionally beneficial. You will also not be surprised or disappointed by the care that you receive because your expectations will now be more in line with reality.

#2. Know whom to talk with to help you meet your needs. Every nursing home is required to have a Director of Nursing (DON) and administrator (or executive director). If you have ANY nursing complaints or clinical care concerns, you should address these with the DON. If you have concerns re: staffing, safety issues or general nursing home concerns, the administrator is whom you should ask to speak with. If you want to bring in your own private nurse or personal assistant, you do have to go through the appropriate channels in order to make sure that your private nurse or assistant is authorized to be in the facility and provide you with their care.

#3 Ask for a list of your medications upon admission. Draw up your own checklist for the medications-you can make your own grid or print out this MEDICATION SHEET. If you happen to be the patient (and are alert and able to keep track of your medications) then keep the checklist at your bedside and keep track of what medications you are given by the nurses. If your loved-one is NOT alert, then I would strongly recommend that you HIRE an assistant (this does not have to be a nurse…just someone who is able to read and check off the medications on the grid) to help ensure that the patient/loved-one is getting what they are supposed to be getting. Believe it or not, even at some of the “best” nursing homes in America, medication errors occur. I have seen patients not receive medications that were prescribed; receive incorrect medications; and receive incorrect dosages of medications. I have seen patients who should have their blood sugar or blood pressures checked before medication administration, not have either or both performed. The list can go on and on. Medication errors are especially concerning in patients with dementia, who cannot advocate for themselves.

#4 Understand your disease process and why it is that you are in the nursing home in the first place. It is extremely important for patients to understand their illnesses and why they are taking the medications that they are on. It is also very important to understand if you have any prescribed physical limitations from your doctor, such as not putting weight on a recently operated leg when you walk as an example. Also, a doctor may want you to get weighed daily or have a certain consistency or amount of liquids. You should write this information down and by asking questions and understanding your illness(es), you become a champion in your own recovery.

#5. Find out if your loved one is eating adequately at mealtime. If someone is not eating, check with the staff to see if you can bring in food for your loved one. Many elderly people are creatures of habit and routine. Adequate nutrition is imperative for your optimal recovery. It is difficult, though, for most nursing homes to cater to specific requests from each and every resident. For example, I had one patient who, for over 40 years of her life, had a breakfast consisting of plain cheerios, strawberry yogurt and a boiled egg every morning. She had a hard time eating the scrambled eggs, sausage and white toast served at the nursing home. Most nursing homes will allow families and patients to bring in specific foods to serve it (hot or cold) at mealtime. You do need to be sure and check if the texture and type of food you bring in is allowable.

#6. Begin thinking about steps that need to be taken to get home as soon as possible. I have taken care of people who want to go home as soon as they step foot in a nursing home (not always safe or advisable). I have also taken care of those who refuse to go home even though they are medically stable enough to return (need to go home). I advise people to go home as soon as they are medically able to. People are more comfortable in their own environments are often heal and sleep better in their own homes. That said, things need to be properly planned out in order for someone who has recently been hospitalized, to succeed at home. This takes time and planning…which is why I suggest that “discharge planning” begins immediately upon admission to either the hospital or nursing home. You need to think about things like: are the doorways wide enough for a walker or wheelchair? Will a ramp need to be installed to get into the home? Will caregivers need to be hired upon return home? Who will cook? Who will drive the patient to appointments? Who will pick up all the new prescriptions and make sure the medications are administered correctly? Can the patient return home or do you need to think about alternative living situations? The ultimate goal of anyone overcoming an acute illnesses is to fully recover and not return to the hospital. So one does need to ensure that all of these questions are addressed prior to the patient returning home.

I hope that you do not find yourself or a loved one in a nursing home anytime soon, but if you do, you now know some steps that you can take to ensure a successful recovery and rehabilitation. As much as you may find it hard to believe (when you enter the nursing home), most people do get better…recover and return home.