The phrase “nursing home” conjures up several images. One might be that of a caring environment where a level of healing can take place. Alternatively, one’s thoughts can go to media depictions of places where people are left towards the end of life with minimal – and sometimes adverse – treatment.
Nursing homes have their purpose. When hope of rehabilitation is gone, and close kin do not have the time, energy, or knowledge to meet their loved one’s daily needs – and hospice is not an immediate possibility – long-term facilities can provide a space for end-of-life care. The questions become: How long a period might “end-of-life” be, and what will be the quality of care? We live in an age where medications can keep us alive yet barely functioning. Is this providing quality care? Who gets to determine the criteria for quality care and then assess whether or not it is occurring?
Like everything else in our health care system, there are myriad regulations in long-term care provision. Nursing home administrators will tell you they do their best to comply with state, federal, and insurance codes. They claim that the care required is enormous and their profit margin is low. They say that families thrust their guilt and anxieties on staff and demand the impossible in caring for their relative. They assert that most of us are in such denial about our loved one’s inevitable demise that our inability to accept what is happening only makes their jobs harder and more frustrating. We want answers; we want cures; we want better outcomes. And the staff lumbers along putting in time and energy with little improvement to show for it.
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In this article, I will present three scenarios from Leah K. Barron, a local malpractice attorney, who fights on behalf of families whose loved ones have been abused or neglected in nursing homes. Each scenario describes an actual case of abuse or neglect that her law firm has recently dealt with. I am a mental health and movement therapist who has worked in nursing homes to help provide quality care to patients and to support families through the process.
Both Leah and I believe that more conscious care along the way could have prevented pain and wrongdoing. To be clear, my suggestions do not represent Leah’s opinions regarding the legal standard of care in each case and do not in any way provide a legal analysis. Leah has agreed to provide the factual scenarios of abuse and neglect cases she has seen. I am now offering suggestions as to how the abuse or neglect in these scenarios may have been avoided based on observations and experience of what I believe to be best practice both for the patients and their involved and concerned families.
A person’s chances of living in a nursing home are minimal. Currently, about 4.2% of persons 65 and older are in nursing homes at any given time, with the greatest percentage 85 and older. One-and-a-half-million persons total are in this country’s 10,000 nursing homes. Not only are the patients themselves deeply affected, but the ripple effects of less-than-adequate care remain with families long after the patient is gone. The anxiety and trauma caused by some nursing home scenarios linger in a person’s psyche. Besides the loss of their loved one, families come to associate the person’s last months and days with pain, frustration, anger, guilt, depression, and helplessness.
Why are things this way, and what might improvement look like? I begin with Leah’s case scenarios and then I offer my suggestions.
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Case #1: A man’s family moved him into a nursing home because he had suffered from a stroke that left him partially paralyzed. He required 24-hour skilled nursing care and supervision, and he was specifically known to have several conditions that increased his risk of choking. These conditions included partial paralysis, dental problems, weak hand muscles, and a seizure disorder. Yet, despite knowing that he needed full-time skilled care and had a substantiated choking risk, the nursing staff brought in his evening food meal tray one night but did not provide assistance with eating. The staff removed the lids from his food and drink, moved his bed to an upright position, cut his food, then left the room. When staff later entered the room to collect the meal tray, they saw him “unresponsive with food particles in his mouth.” This man had died from choking. Moreover, it is likely that he experienced seconds or even minutes of excruciating pain, fear, and discomfort as he realized he could not breathe but could do nothing about it – and that he was all alone.
Suggestions: Signs indicating requirements for patient care should be posted over the bed. “Fall Risk,” “Nothing by Mouth,” and “Choking Risk” are standard signs. These restrictions are also to be noted in patients’ charts and discussed at team planning meetings. One would expect that staff who typically work with these patients would be familiar with their care regimen and that staff who might be meeting the patient for the first time would read these warnings prior to interaction.
Yet many times, there are temporary or substitute staff, particularly on nights and weekends, and it is par for the course for nursing assistant staff who have the most direct contact with the patient to have 10 or 12 or even 15 patients to look after in the course of their eight-hour shift. Then you have staff that may work 12-hour shifts or a double shift of 16 hours. How is it possible for one person to be fully alert and aware with this intense level of required patient care?
It is my observation after years in nursing homes that the ready potential for neglect is built into the system. The great majority of staff do not intentionally want to harm patients, yet almost superhuman prowess is demanded of them and, most often, at a barely cost-of-living wage which, truthfully, does not inspire the most dedicated care-giving.
Change in this system must begin at the top with fewer patients assigned per shift and greater quality control of staff with supervision and training.
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Case Scenario #2: A woman with a history of many falls entered a nursing home. Yet despite the facility knowing it needed to take fall risk precautions, she sustained at least 10 falls inside the nursing home during her first six months living there. During her seventh month, she suffered two falls in one evening. First she fell and hit her head on the floor of her room. Shortly thereafter, she fell and hit her head on the floor of the TV room. The second fall resulted in cuts on her face and head, and blood pooled around her left eye. When the paramedics arrived, she was unresponsive and bleeding from the mouth and nose. She was taken to the hospital, and for the next two weeks endured multiple surgeries. Tragically, she then died due to complications from her brain bleed, caused by her 11th and 12th falls in the home.
Suggestions: Falling is the highest risk of death by injury for anyone 65 plus, whether in or out of a facility. Many medications that seniors take incur side effects of dizziness or loss of balance. Decreasing muscle mass is a standard aging component, and inactivity makes mobility all the more challenging. These are all givens, and this woman particularly had her own history of fall risk.
Was she even allowed to be out of bed or chair on her own? Was a walker prescribed? Was use of it supervised? Were the floors slippery, as is often the case if spills are not immediately mopped. Did she have skid-proof socks or shoes? Since she fell in the evening, was she too tired to be standing at that time?
These are all issues that staff needs to be on top of when dealing with a patient who is not totally bedridden. Perhaps staff observed her one day doing fine navigating on her own, but the next day something had changed in her behavior to make things riskier. The point of being in a nursing home is that people need care, not just medication, food, or wound cleansing but actually having extra sets of eyes and ears focused on their well-being. Staff immersed in their own issues and not always fully attentive to what is transpiring around them allow for these gaps in care. I have witnessed patients in acute pain or wracked with fear and confusion while staff stood around nonchalant chatting with one another.
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Case Scenario #3: A woman was moved into a nursing home, and her doctors identified her as being at risk for pressure ulcers or bedsores. About a year after admission, she was hospitalized for various conditions that caused infections in her body. One cause of infection was a bedsore measuring eight centimeters long, eight centimeters wide, and two centimeters deep. The woman had to undergo surgery to remove unhealthy tissue in and around the wound to promote healing. After this surgery, the woman was in such pain that she repeatedly told the nursing staff her pain was severe: eight on a scale of one to ten. Months later, she was brought to the hospital again with additional bedsores, including one extending all the way to the bone. She then underwent other painful surgeries to remove unhealthy tissue. Shortly after the surgical procedures, she passed away.
Suggestions: COMAR, the Code of Maryland (in Title 10, Subtitle 7, Chapter 2, Section 2, Number 4), specifies that staff in “comprehensive care facilities should encourage and assist residents to change positions at least every two hours to stimulate circulation and prevent decubitus (bedsores).”
Certainly, for patients who are unable to position or turn themselves, this is essential. Yet I have been in rooms of such patients for four or five hours when I have not seen staff come in to do this requisite task. True, air beds have been a more recent development to help stave off pressure sores, yet Medicare does not allow these for every patient. It is a Faustian enigma that, often, residents must already have had a severe pressure sore to merit one of these. Still, it is up to staff to check to see if a patient’s body is holding up.
Skin thins with aging and, correspondingly, the minimized circulation due to inactivity makes skin breakdown and pressure sores an implicit risk. How did it get so bad with this woman? Was no one minding the store until a crisis set in?
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My overall assessment of the problems in nursing homes is that many issues stem from lack of care and oversight by the direct care workers, the geriatric nursing assistants (GNAs). One can become a certified nursing assistant (CNA) with 75 hours of classroom instruction (less than two full weeks) and a 40-hour on-the-job internship shadowing an established GNA and participating in some tasks. The classroom training is out of the book, with discussion and written quizzes. The internship does not allow one full responsibility for patients. One must become a CNA first but can quickly take a written and skill set test to become a GNA. No further classroom instruction is required, although there may be a review of basic skills.
Beyond this, there is on-the-job training and a few hours per year of required continuing education. The quality of education varies greatly. I have sat in rooms with 100 GNAs, where papers were handed out, people sat listless as the instructor gave a monologue, then signed their name on a sheet and left with a certificate. While concepts about how to relate to patients with dementia and behavioral health issues may have been discussed, there was little to no training in how to establish emotional rapport with a patient who may be on a totally different wave length than the worker. Thus, an essential component of true care giving – deciphering the needs and sensory experience of patients who, most times, cannot not express themselves verbally – was completely missing. This shuts down hopes of establishing a relationship, so that the patient becomes just a body to the worker, who may be trying to accomplish his or her tasks yet is not tuned in to the humanity and integrity of this person.
This dearth of real relationship certainly does a blow to the vulnerable patient, who, unable to express his/her real needs, has minimal chance of getting them met. Yet it also injures the nursing aide, who must now deal with her own frustration in the disconnection and may also have to bear the wrath of the family members, who is confused and often appear demanding.
So now we enter the world of continual turnover in the working life of GNAs. They get fed up with the low pay, the big caseloads, and being called on the line for infractions – in addition to the essential nature of the work, in which, even with their best efforts, their patients wither and die. GNAs quit or are fired. The home must then spend more money in marketing and training replacements.
Last month, the U.S. Senate Committee on Finance sponsored a hearing on “Not Forgotten: Protecting Americans from Abuse and Neglect in Nursing Homes.” David Gifford, MD, MPH, Senior V.P. of Quality and Regulatory Affairs for the American Health Care Association, offered testimony. His response to allegations of abuse and neglect in his industry led him to make three recommendations: expand programs that attract workers to the nursing home industry, strengthen federal regulations around reporting abuse, and give greater transparency to the public of satisfaction surveys of residents and their families.
Unfortunately, he said nothing about increasing salaries or ameliorating working conditions for nursing assistants and other care workers. Nor does he mention the need for greater and more specified training. I do not think that continuing a malfunctioning situation while finding better ways to reveal its shortcomings is a viable solution. Rather, the idea should be to revamp the way the work is being done and to create a better system for all concerned.
Legal sanctions will continue to exist for these critical and most unfortunate cases. If you would like to learn more about how legal claims can help individuals and families affected by nursing home abuse or neglect and can force nursing homes to change practices and begin taking better care of our elderly community members, please contact Leah Barron at www.brownbarron.com or 410-547-0202.
We all have been or will be care-givers, and most of us will need care giving at some point. To understand more about how we may have an impact on the standard care giving system, please contact Joyce Wolpert at jbdance8@yahoo.com or 410-358-0977, or see my blog: www.walkingthewalkhandinhand.com. As consumers, families, and individuals, we have the right to push for change in this universal issue.
