When a Loved One Needs a Nursing Facility

If at all possible, plan ahead for any future long-term care needs. By doing so you will maintain greater control of your care or be better able to honor the preferences your loved one may have.

Before you look for a nursing facility, have your loved one’s condition evaluated by a specialist. Some medical conditions, when accurately diagnosed and treated, can improve significantly if the right treatment is undertaken.

Since most people prefer to stay at home, it is important to investigate alternatives to nursing home care such as home care, assisted living facilities, hospice and medical or social day programs. Providing good quality care that ensures your loved one’s safety and comfort should always be the guiding principal.

If a nursing home is required, determine whether short-term rehabilitation is needed or whether a long-term care stay is indicated.

Statistics have shown that a person is kept at home at least 6 months longer than is healthy for them or for their caregiver. The following indicators inform the caregiver when a decision for alternative care must be made:

  • The care requires physical abilities that the caregiver does not have.

  • The care requires around the clock care that the caregiver cannot maintain over a period of time. For example, loved ones may have care needs (such as being turned every two hours, suctioning, or constant supervision) which will prevent the Caregiver from obtaining a healthy amount of sleep.

  • The caregiver’s health is being affected adversely.

  • The family is endangered. Families are at risk when a patient becomes violent or non- compliant with the medical provider’s directions.

  • The caregiver cannot financially afford to care for a patient at home.

  • The caregiver is unable to insure a safe environment. The caregiver is unable to guarantee that their loved one will not accidentally walk outside where they could get lost or hit by a car, fall down stairs or find access to dangerous materials.

Steps to Take Prior to Entering a Nursing Facility

Family members dealing with an elderly and infirm relative cannot simply “check” their loved one into a skilled nursing facility. Skilled nursing care requires an assessment to determine whether a person is appropriate for that level of care. The Patient Review Instrument, or PRI, is an assessment tool used by hospitals and nursing homes to determine the cognitive and physical skill levels of a person.

The PRI screening is typically good for 30 days and is performed by a nurse and is performed in one of two possible environments. The majority of PRIs are completed at a hospital as the result of an emergency room visit as people with dementia or an advanced chronic illness are assessed before discharge in order to determine their cognitive and physical impairment. At this point, the hospital’s discharge nurse uses the tool to determine whether the person should be released to return home or whether skilled nursing care is appropriate. The second way is through an assessment at home by a private nurse. A family can either privately hire a nurse or they can call the nursing facility of their choice and obtain a home visit from one of their nurses. This nurse performs the PRI to determine whether skilled nursing is the next step. The PRI can either be paid privately or, if qualified, through Medicaid.

Prior to visiting any nursing facilities, it may be a good idea to do some preliminary research. Some important issues to consider when evaluating facilities include quality of care and life, bed availability, types of services available to meet your loved one’s needs, cost of care, and location in an area where friends and family of the resident can readily visit.

Try to get word of mouth opinions on different nursing facilities. Good sources of information can include current nursing home residents and their family members, hospital discharge planners, your physician, clergy and friends or family that have already gone through the process.

Nursing home data is also provided by the federal government through “Nursing Home Compare” http://www.medicare.gov/NHCompare/home.asp. This site will provide you with the opportunity to search for nursing homes by state, county, city, or zip code. To help make the task of comparing facilities easier, a Five-Star Quality Rating System was created. A five star rating means much above average and a one star rating means much below average.

Nursing home ratings are taken from the following three sources of data:

  • Health Inspections

  • Staffing

  • Quality Measures

To look at a summary of the state inspection information on “Nursing Home Compare” click on the tab labeled “Inspections”.

Important things to consider when viewing the inspection reports:

  • Each facility is required by law to make the latest state inspection report available in a place readily accessible to residents.

  • Inspections take place every 9-15 months.

  • View previous inspection results to see what the pattern of quality has been over a three year period.

  • Be aware of choosing a facility with a very high number of deficiencies compared to other facilities in the area or the state average.

  • Don’t assume that a ‘deficiency free” rating necessarily means that there are no problems with care at a particular facility.

  • If a facility has received a deficiency citation in a particular area, be sure to ask questions about this when you visit the facility.

Staffing levels are critically important to consider in evaluating the quality of care given at a facility. The “Nursing Home Compare” website provides information about the hours of nursing care provided at a facility, as well as the nurse staffing levels on a state and national average.

Important things to consider when viewing the Staff Levels are:

  • Pay attention to the number of Certified Nursing Assistant (CNA) staffing hours. CAN’s provide 90% of the hands-on resident care.

  • Look for facilities with high levels of RN staffing. Studies show that RN involvement in care is important for quality.

  • Visit the facility and ask staff and families about the actual number of staff available to directly care for residents of each shift.

  • The staff hour data used for “Nursing Home Compare” is self-reported by the facility and is not audited for accuracy.

The “Nursing Home Compare” website will also allow you to view Quality Measures. The quality measures provide an important in-depth look at how well each nursing home performs on important aspects of care. For example, these measures show how well the nursing home helps people keep their ability to dress and eat, or how well the nursing home prevents and treats skin ulcers or bed sores.

Quality Measures include 14 indicators for chronic (long term care) and 5 indicators for acute (short-term) care. Quality Measures are designed to provide comparison information among facilities and are not intended to be a nursing home rating system. You should use quality measure information as one indicator of care, however, the importance of actually visiting facilities and talking with residents, family members and staff can not be overemphasized.

Important things to consider when comparing Quality Measures:

  • Most of the Quality Measures are negative measures. Consumers should look for facilities that score below the state average and the lower the score the better.

  • A high percentage score on some Quality Measures may indicate that there is not enough staff available to attend to residents.

When Visiting a Nursing Facility

Since some nursing facilities may have wait lists or unavailable beds, it is recommended that you try to broaden your search to at least 5 facilities. Before making any decisions, visit the facility. It is also recommended that you visit a facility a second or even a third time during weekend or evening hours when many nursing facilities reduce their staff. You can learn a great deal about a nursing facility by taking the time to sit and observe how staff interacts with residents.

If at all possible, take your loved one who will be residing in the facility with you. By doing so you can gain insight into the resident’s wishes and may ease his or her own fears.

Since there are so many questions to ask and many things to review, we recommend you go with a checklist. Attached to this memo is a Nursing Home Checklist created by the Department of Health and Human Services.

When a Loved One Enters a Nursing Facility

There are important things to know when your loved one enters a nursing facility. As a loved one, you play an important role in helping to advocate for your loved one’s best interests. It is therefore important to know your loved one’s rights in a nursing facility.

The Nursing Home Reform Amendments of OBRA 1987 require that nursing facilities "promote and protect the rights of each resident." The resident’s rights must be displayed in the nursing facility along with a contact number for the state’s Long Term Care Ombudsman (a third-party resident advocate).

The general goals of this law are:

  • Quality of Life: The law requires nursing homes to "care for the residents in such a manner and in such an environment as will promote maintenance or enhancement of the quality of life of each resident." A new emphasis is placed on dignity, choice and self-determination for nursing home residents;

  • Provision of Services and Activities: The law requires each nursing home to "provide services and activities to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care which is initially prepared, with participation to the extent practicable of the resident or the resident’s legal representative;

  • Participation in Facility Administration: The law makes "resident and advocate participation" a criteria for assessing a facility’s compliance with administration requirements;

  • Assuring Access to the Ombudsman Program: The law grants immediate access by the Ombudsmen to residents and reasonable access, in accordance with state law, by Ombudsmen to records; requires facilities to inform residents how to contact Ombudsmen to voice complaints or in the event of a transfer or discharge from the facility; requires state agencies to share inspection results with Ombudsmen.

It is equally important to stay involved in your loves one’s care:

    1. Be familiar with staff members. Get to know their names, roles and responsibilities in resident care. Know who is in charge of your loved one’s care and how various grievances are addressed.

    2. Educate the facility staff about your loved one’s preferences, daily routine, activities, work, etc.

    3. Pay attention to the care provided. Note any changes and try to determine if they are due to any deficiencies in the care provided.

    4. Report concerns and problems to staff members as soon as they arise so they can be addressed immediately. First voice concerns to those directly involved. If the action yields no results, report your concerns to staff supervisors.

    5. Document your concerns and the actions taken to report them. Be sure to include the names of those involved, the date, time, and details of the event.

    6. Request a meeting with appropriate staff involved in your loved one’s care. Focus the meeting on the outcome you would like to see and how it can be accomplished. The meeting should result in a concrete plan that addresses the problems and identifies who is responsible for implementing them.

What You Can Expect From the Facility

All nursing facility residents must have a comprehensive assessment within 14 days of admission to a nursing facility. The goal of the assessment is to evaluate your loved one’s physical and mental condition including their ability to perform activities of daily living (ADLs) such as eating, walking, dressing, and bathing. Their personal preferences and habits should also be discussed. Within 7 days of the initial assessment, the facility must hold a Care Plan Conference. At this conference, an individualized Care Plan is developed for the resident by an interdisciplinary team including a nurse, nurse aide, activities director, dietary staff, and social worker. It is very important that the resident and family members actively participate in this initial assessment and the Care Plan conference to ensure that all of the resident’s needs are addressed.

The Care Plan specifically outlines how individual staff will assist the resident on a daily basis to ensure they maintain the highest physical, mental and social functioning.

Every 90 days after the initial Care Plan is developed, or whenever there is a significant change in the resident’s condition, another Care Plan Conference is held to determine what changes need to be made to the Care Plan.

Resources Available to Nursing Facility Residents and their Families

A Long-Term Care Ombudsman is an advocate for residents of nursing homes, board and care homes and assisted living facilities. Ombudsmen provide information about how to find a facility and what to do to get quality care. They are trained to resolve problems. If you want, the Ombudsman can assist you with complaints. However, unless you give the Ombudsman permission to share your concerns, these matters are kept confidential. Under the Federal Older Americans Act, every state is required to have an Ombudsman Program that addresses complaints and advocates for improvements in the long-term care system.

To find an Ombudsman in your community you can contact http://www.ltcombudsman.ny.gov or call 1-800 342-9871.

Join the Family Council in the Nursing Facility. The Family Council in a nursing home is a consumer group composed of friends and relatives of the home’s residents. Although each family council is unique, a typical council has 5-10 active members; meets monthly at the nursing home; is run by relatives and friends or residents; has an advisor (usually a staff person at the nursing home) who assists the Council but is not a member; and has a variety of activities.

The main purposes for having a Family Council are: (a) to protect and improve the quality of life in the home and within the long-term care system as a whole, and (b) to give families a voice in decisions that affect them and their resident loved ones. Beyond these general goals, specific purposes exist, such as support for families; education and information; services and activities for residents; joint activities for families and residents; action on concerns and complaints; and legislative action, among others.

What to do if you Suspect Improper Treatment in the Nursing Home

Talk about your concerns and make the residence’s Director of Nurses, Social Worker, Doctor and Administrator aware of your concerns.


Know the signs of Abuse:

Physical Abuse – can include unreasonable physical restraint, deprivation of food and water, giving too much medication, or not enough medication, unexplained injuries, forcing an older person to stay in a room;

Neglect- lack of care for existing medical problems, disregard for activities of daily living, bed sores;

Verbal/Emotional Abuse- Humiliating, insulting or threatening, or ignoring behavior toward family and friends.


To learn more about abuse call the NY State Office of Children and Family Services at 518-473-7793 or visit www.ocfs.state.ny.us/main/psa or visit The National Center on Elder Abuse’s website at www.ncea.aoa.gov


Call your local ombudsman:

Nassau County: Margaret Hromada- 516-466-9718 mhromada@familyandchildrens.org

Suffolk County: Joan Burke -631-427-3700 x273 Jburke@fsl-li.org

New York State- Mark Miller –800-342-9871 mmiller@ofa.state.ny.us


File a Complaint with the State Licensing and Certification for Nursing Homes the New York State Department of Quality and Surveillance of Nursing Homes is responsible for investigating complaints and incidents for Nursing Homes in New York State.


The hotline can be called 24 hours per day at 1-888-201-4563


* Information used in this memorandum was obtained by the National Citizens’ Coalition for Nursing Home Reform

This Memorandum is based on current law and is for informational purposes only. It is important that you discuss all legal options and consequences with a qualified elder law attorney prior to any action. Should you wish to discuss your situation with us, please call (631) 424-2800 for a consultation. For additional Memoranda, please call or visit our website at www.elderlaw.pro.


Advocate’s Check-Off Sheet

Resident's Name: ________________ Advocate's Name: _______________ Week of: _____________


Mon. Tue. Wed. Thur. Fri. Sat. Sun.

Each Visit









Does the facility appear clean, odor free, well maintained?







Is resident clean and comfortable? (Are they wearing appropriate clothing for the seasons, well groomed, are they slumped over in the chair or sliding out of them, are they still in bed at 11AM, are they participating in activities?)







Check for wrinkles in the sheets? (Wrinkles in bed sheets or clothing can decrease circulation and cause skin problems)







Apply lotion to skin? (Dryness increases the chances of skin breaks and tears)







Look for red spots? (Report any sores to staff. Monitor on on-going basis and ask staff to report to you the steps they are taking to manage and heal sores)







Look for skin tears? (If resident is bed ridden are they being repositioned every two hours?)







Does resident’s skin look dry, unusually pale, sunken, flushed? (Dry, sunken skin can indicate dehydration. Dehydration will heighten the poor skin integrity plus put patients at risk for problems such as urinary track infections, confusion, disorientations)










Mon. Tue. Wed. Thur. Fri. Sat. Sun.


Does the resident look like they are experiencing breathing problems? (Short, shallow and gasping can signify problems and possibly severe problems. Make Nurse Aware)







Check for swelling? (Report to Nurse any extreme swelling in feet, ankles, arms, etc. Discuss ways to alleviate swelling with staff).







Are residents nails properly maintained? (Are nails clean and smooth? If resident is a diabetic are they properly being attended to by a nurse or podiatrist?)







Check oral hygiene? (Make sure it is being addressed daily)







Has the resident lost any significant amount of weight? (If so, is staff addressing the issue?)







Offer water? Ounces taken?







Feed resident? How much eaten?







Report resident intake to nurse?












Mon. Tue. Wed. Thur. Fri. Sat. Sun.


Weekly









Clothing tears & loose buttons?







Do you need to relabel items?









Monthly or Twice Monthly








Review Chart:










Weight








Plan of Care








MD Notes








Therapy Notes








Wounds








Monthly










Attend Family Council Meeting







Talk to Doctor if Needed












Notes: