Nursing Homes: a Wolf in Sheep’s Clothing

Nursing homes are a safe haven for families who need help with loved ones. Walking in you see a nice sitting area with free cookies and coffee. A tour is given showing all of the highlights of the facility while talking about your family member and the expectation of care that they will receive. All the while stretching the truth to get that bed filled to gain revenue. With the perception of nursing homes in the media, reviews on the internet, and some first-hand experiences it is easy to understand the bad reputation. The mere mention of nursing homes brings visuals of abandonment, neglect, bodily harm, and mental and sexual abuse. With nursing homes being stigmatized it’s unfortunate that many of the good qualities become overlooked. Due to society's negative biases towards nursing homes, state regulations have been placed to provide these individuals with a quality living situation. These state regulations that nursing homes must follow are put in place by the Centers for Medicare and Medicaid Services (CMS). It is the job of the CMS to survey different facilities with the hope that these regulations are being met; However, these regulations are only in place for a week or two at a time. It is not an uncommon sight to see department heads running down the halls yelling “state is here, I repeat state is here” with a frenzied look in their eyes, or department heads running around almost like chickens with their heads cut off, which in a sense offers some comedy relief. With the importance of state regulations, it boggles many minds as to why these regulations are not enforced throughout the year, particularly sufficient nursing staff. It is critical not only to the success of the facility but more importantly the individuals who reside there that state regulations regarding staffing issues are enforced throughout the year; Hence, to provide these residents with the high standard of quality care that is deserved.

Providing quality care is sponsored in part by the CMS who is the top dog in the medical field because of Medicare and Medicaid. Nursing homes that wish to use Medicare and Medicaid must meet certain obligations that are regulated by the state. Medicare is a necessity in any nursing home because of the variety of health care costs that are paid for. The regulations put forth by the CMS are critical to the success of any facility; however, these regulations are often overlooked including the most important one, sufficient nursing staffing. This regulation itself should be common sense to any facility and should be met regardless of situations or standards. Considering this issue, one would think why not hire more caretakers and nurses? A question so simple deserves a simple answer yet there is not. This problem has manifested itself into its own entity which has the capability of demolishing not only the nursing home but the individuals who reside there.

The main focus of any nursing home or other institution is the individualized quality of care plan for each resident. These plans are put into place to prevent any form of abuse or neglect that unfortunately happens. Abuse and neglect are not new problem and has in fact been happening for decades. A study was done where 2000 residents were interviewed. Shockingly “44 percent said they had been abused and 95 percent said they had been neglected”. The Omnibus Budget Reconciliation Act of 1987 or OBRA-87 for short was created as a reform act due to the overwhelming reports of abuse and neglect. Despite this reform act hundreds of thousands of residents are still being abused and neglected, with 1 in 5 cases going unreported. With the admission of a new resident, a comprehensive care plan is created which includes objectives and timeframes for that individual to meet. In addition to the care plan, ADLs (activities of daily living) are used as a tool to gauge the resident’s highest possible level of functioning and welfare, while taking into account that person's medical conditions. There are many common occurrences of abuse and neglect ranging from falls, pressure ulcers, medication errors, and malnutrition just to name a few. Regrettably falls result in more than 2.8 million injuries. Due to the severity of falls, this has been divided into two categories assisted falls and unassisted falls. Assisted falls happen when a resident is being assisted by a staff member, while unassisted happen when a resident is not being attended to by a staff member. Falls are an overlooked cause of injury for the older population with 1 in 5 going unreported. With occurrences of falls being more prevalent many residents begin to fear them and in turn lose their self-confidence and possibly their independence. Pressure wounds affect individuals who cannot move freely on their own and who stay in one position for too long without repositioning from the staff member. Essentially the weight from the individual's body cuts off blood circulation killing off the tissue surrounding the point of pressure. These points of pressure are localized and mostly affect the bony prominences of the body. These wounds can develop anywhere between 4-6 hours and range from moderate to severe. These injuries are critical to avoid and are necessary for that individual to be repositioned every two hours. Medication errors happen on a daily basis and can occur in many forms. Prescribing the wrong medicine, writing the prescription itself, administering the drug, and even being uninformed about the medication itself. With regards to medication errors, there are five types of errors rule-based, action-based, knowledge-based, technical-based, and memory-based. In a study done the most common form of prescription error was writing the wrong dose accounting for 41%. Many medication errors can be avoided by asking questions and getting away from distractions. It is easier said than done to get away from distractions considering you have both residents and their family members wanting to talk to you, doctors wanting to talk to you, or just how many medications one individual needs to take within a certain time frame. It should come as no surprise that with proper staffing inadequate care would be a thing of the past.

With staffing being a big issue for inadequate care in nursing homes and other facilities we also need to look at the standards set forth. Due to a lack of staffing standards “20.5% of nursing homes received deficiencies for causing actual harm or jeopardy to residents in 2014 and 6% of homes were rated as substandard”. Higher standards associated with staff would help this overwhelming problem, considering 41 states have established higher staffing standards than the federal standards, but still remain below levels. In 2015 the government proposed new regulations with the hope that it would improve the quality of care, essentially providing good quality care with high quality. For this to happen it is necessary for the staff to be well trained and managed. Studies have shown that after implementing higher staffing standards falls, pressure wounds, and cases of incontinence have decreased. Staffing levels above the federal requirements also show that there is a stronger effect on nursing levels with a decreased rate of turnover. Staffing levels need to be increased beyond the CMS minimum recommended level because the acuity of residents has increased leading to the assurance that resident care actually meets acceptable quality standards. Medicaid programs are providing financial incentives to keep payments low enforcing a negative impact on staffing levels. “Under current federal and state payment systems, nursing homes are able to make choices on how to allocate their resources with few regulatory restrictions”. The implementation of current staffing requirements has been weak. Deficiencies for inadequate staffing levels are rarely issued by state inspectors, and CMS has not set guidelines for penalties regarding staffing violations. Furthermore, once state agencies adopt stronger enforcement quality of care will increase along with an improvement in staffing.

First and foremost, certified nursing assistants, or CNAs for short, need to be utilized due to the fact they are the backbone of any facility. The demand for CNAs is at an all-time high for many reasons. Primarily the population requiring twenty-four-hour care, higher job positions, and high turnover rates. “Today, 8.5 percent of people worldwide (617 million) are aged 65 and over” and this number is expected to jump by 17%. This increase in the elderly population is due to the baby boomer generation, which is ultimately the largest population of people in the U.S., along with the advancements of modern medicine. Despite the baby boomer generation making up the large population in nursing homes, “young people ages 31 to 64 now make up 14 percent of the nursing home population”. Many believe the increase in this younger demographic is due to mental health issues, diabetes, renal health issues, and many other disabilities. There is a lack of programs that may help these individuals receive care at home due to funding or availability; Consequently, causing this influx of younger individuals in these facilities.

Despite the demand for CNAs and nurses, there is an even higher rate of turnover. The average rate of turnover for CAN’s is at 65% while nurses are at 17% leading to major problems in nursing facilities. Many administrators know that the turnover of both of these professions is in fact affecting the profitability of such facilities. These facilities can identify cost categories such as recruitment, orientation, and training but were unable to assign monetary figures. With such high turnover rates, many facilities will bring in traveling or agency workers to help offset the shortage. Staffing agencies can charge anywhere between 20-50 percent on top of the employee's hourly rate, leading the facility to fork out more money. Considering what a CNA’s job duties are, many fail to see that not only is this field of work physically demanding but mentally demanding as well. Unfortunately, there is no state regulation determining the minimum level of staff for CNAs who provide more of the day-to-day care. Due to this problem, the staff-to-patient ratio averages 20 individuals to one CNA. With the high patient-to-staff ratio the training for CNAs has been called into question, due to shortcuts to get these bodies on the floor as soon as possible. With inadequate training many report feelings of being overwhelmed including a lack of confidence. “CNA training should consist of 225 hours of multilevel training” but federal regulations mandate no less than 75 hours. Improved training would have to be accompanied by a higher hourly wage. If it is mandated by state regulations to give the best care possible “it is only reasonable to conclude that the position is more valuable to the institution and should command more than a near-minimum wage”. It is critical for nursing homes, hospitals, and other facilities that employ CNAs to bridge the gap of trained hours because CNAs are ultimately a source of comfort, and companionship while establishing a realistic staff-to-patient ratio.

It's necessary to know that nursing homes function simply because of profit. They do not want to increase staffing for monetary reasons, and would rather underpay their staff, and work them to the brink of exhaustion while providing inadequate training to save money. The facility itself would rather put a band-aid on the problem instead of putting in the work to fix what is broken. Unfortunately, the old adage quantity over quality describes this situation to a T. Nursing homes have the best of intentions at heart but are going about providing the quality of care in the wrong way. Focusing on adequate staffing along with proper training for all jobs in nursing homes would be the first step in the right direction. It's unfortunate that staffing seems to be such a small concept but plays such a big role in the success of any facility.

Putting a loved one in a nursing home is a decision that should not be made lightly, and when made should take into account all factors. Researching facilities and looking up current regulations is a good way to tackle this problem. Unfortunately, no nursing home is perfect and may be prone to awful situations. Abuse and neglect are concepts that aren’t taken seriously until it’s happened. Being an advocate for your loved one is the best thing one can do to promote a sense of knowledge with yourself and your family member. The CMS needs to take a stricter approach on the staffing shortage that these facilities are experiencing. It is only once their feet are held to the fire that change happens. Having adequate staffing levels would not only ease the burden of CNAs, and nurses but also residents knowing they are getting the quality of care that they have worked so hard for. The fact that facilities are providing subpar care is not only a slap to the face of these individuals but shows that residents are fighting a losing battle.