Selecting a Long-Term Skilled Nursing Care Facility for your Elder
by Catherine D'Ambrosio, RN, PhD dambrosi@uw.edu
Choosing a nursing care facility that meets your needs, requirements, expectations, preferences and budget will require some research, some planning and some soul searching. Having knowledge of your elder's actual financial assets will be essential to making some of the decisions. Many elders wish to keep their finances private and return only vague, obtuse answers about their finances, such as "We have plenty of money dear." (which might they have assets amounting to $200 to $300), or "I don't know how I am going to afford anything." (with a financial portfolio worth tens of millions of dollars). Most people fall somewhere in the middle.
I've organized this set
of blogs (on nursing home placement decisions) around three questions most
often asked of me by elders and their family caregivers who are considering
relocation to a nursing care facility.
This entry addresses the
third (III) question of how do we select the very best nursing care facility
for our elder? Questions I and II are addressed in separate blog entries
(but are listed below along with their links).
I.
What are some of the signs that it may be time to being exploring
nursing home placement?
II.
How much do nursing homes cost and who pays for nursing home care?
III.
We only have so much money, so how do we select the best nursing
care facility for our elder?
1.
Location of the facility
2.
Cost of the facility
3.
Smell
4.
Ignore the décor, the chef, and any gourmet menu –until after you
consider NURSING STAFFING RATIOS, and speak with a number of people.
5.
Nursing Staffing Ratios
6.
Interview the Nursing Staff
7.
Look around you and take note of whether elders are tied-up or
restrained. Ask the tour guide and the
nurses about the facility’s policy on restraints.
8.
Talk to the Patients in the Facility
9.
Talk to Family Members of Patients in the Facility
10.
Ask yourself some questions about your elder’s current condition
11.
Some things I would like for you to know
This blog entry
addresses the third question of:
III. We
only have so much money, so how do we select the best nursing care facility for
our elder?
Choosing
a nursing care facility that meets your needs, requirements, expectations,
preferences and budget will require some research, some planning and even some
soul searching.
1. Location
of the Facility
The locations most ideal
are near or easily accessed by family caregivers, friends, and relatives. Elders who are well-tended by out-spoken
advocates can sometimes be less vulnerable to neglect than elders who receive
no or infrequent visitors and without an advocate.
Like real estate, there
is location, location, and location to be considered. Sometimes it is not enough to consider the
city or town, but the neighborhood, and the location (such as a busy corner, a
secluded park, or a river bank) within the neighborhood.
2. Cost
You must consider how
much your elder can afford to pay, and how much they are willing to allocate to
their care in the nursing facility.
Having knowledge of your
elder's actual financial assets will be essential to making some of the decisions. Many elders wish to keep their finances
private and return only vague, obtuse answers about their finances, such as:
·
"We have plenty of
money, dear." (which might mean they have assets amounting to $200 to
$300), or
·
"I don't know how I
am going to afford anything." (with a financial portfolio worth tens of
millions of dollars).
·
I have worked with
plenty of people at both ends of the spectrum and contorted perceptions. Most people fall somewhere in the middle.
Knowing if and precisely how much any family, relatives
or friends are willing to contribute to funding the elder’s long-term care will
also need to be factored-in on the decision.
3.
Smell
The very first thing people notice when they enter a facility is the smell. People are immediately turned-off by the overwhelming odor of urine and feces. Any odor you once smell is unlikely to alter or diminish over time. Your sensitivity to and awareness of this odor will however become less acute.
4. Ignore the Décor
While
sumptuous lobby décor and a gourmet chef and menu are doubtless appealing, even
enticing, they are not the reason you are there. Please try to ignore the décor in your
initial assessment. After you consider
and make a decision based on #5 (below), then factor-in the lobby décor and the
gourmet menu with the location, the cost, and the smell.
5. Nursing Care Staffing Ratios
Ask to see the facility’s actual patient care nursing staffing ratios for both the facility and for the unit where your elder would be placed.
A. This
is not the number of RN’s, LPN’s and
CNA's employed by the facility, divided by the number of patients, because
i.
Many nurses and nursing assistants work
part-time.
ii.
Many nurses and nursing assistants work per
diem (on-call).
iii.
Nurses do not work 24/7. They work approximately 40 hours per week,
and they take vacations and sometimes get ill and take sick days.
iv.
Many of the RNs employed by nursing homes
perform management, staffing, planning, marketing, and administrative
functions, and do not provide patient care.
v.
Facilities often employ many RNs are to do
only paperwork, to fill-out Medicare, Medicaid and insurance forms necessary
for reimbursement, often on patients they have never taken care of
B. Look
at the facility’s actual –not their planned or optimal staffing ratios.
i.
What are the patient care staffing ratios today?
(remembering to subtract the number of nurses and nursing assistants who did
not show-up today.
ii.
What were the patient care staffing ratios yesterday?
iii.
What were the staffing ratios last week, last month, and last year?
iv.
Fill-out the chart (below) for each shift
(days, evenings and nights). Expect that
day shift staffing ratios will be higher than evenings, and evening staffing ratios
higher than night shift staffing ratios.
Weekend staffing ratios are often lower than weekday staffing ratios.
C. Make
sure you know and understand the facility staffing ratios and how that breaks-out for each unit on each
shift, including weekends and holidays.
Some units such as Medicare Skilled Nursing and Rehabilitation units
often have higher staffing ratios than other units that are not mandated to
comply with Medicare’s more stringent requirements.
D. Awards are interesting but
sometimes of little or no consequence.
All too often awards for “Best
Nursing Home in the World” or whatever, are meaningless marketing tools.
E. In addition to focusing on the patient care staffing ratios, inquire and request specific information about the degrees and certifications of the registered nursing staff, and training seminars attended by the nursing assistants. Ask questions including:
i.
How many Master’s prepared nurses are
on-staff at this facility?
ii.
How many Master’s of nursing consult with the
facility? When? How often?
What do they do? What training
education and training seminars do they provide to the nursing staff?
iii.
How many patient care nurses employed by the
facility have bachelor’s degrees in nursing (BSN)?
iv.
How many nurses in the facility have a wound,
ostomy, or continence care certification?
How often do they provide inservices (training seminars) to the other
nurses and the LPNs and nursing assistants?
v.
How many nurses in the facility have other
certifications –such as Gerontological nursing?
vi.
How often are nursing assistants required to
attend education and training seminars on provision of basic nursing care?
vii.
What types of training seminars are offered
to the facility’s nursing assistants? -or are basic nursing care seminars even
offered at the facility?
6. Interview the patient care RNs, LPNs, and nursing assistants
Optimally –if you can, take the opportunity to speak to the nurses and nursing assistants individually -away from the marketing director or facility tour guide.
Or, if you have a friend, neighbor or relative who is residing in this particular facility, visit them and talk to the nurses and nursing assistants who come to your friend’s or relative’s room to care for them.
If you are a gregarious or more sociable soul, offer to meet and host a nurse for coffee in the cafeteria or a local coffee shop.
When you speak with the nurses and nursing assistants, ask them:
A. How
many patients do you have today?
B. If
you are speaking with an RN, ask:
i.
How many LPNs (licensed practical nurses) and
CNAs (certified nursing assistants) do you have assigned to you?
ii.
What do your duties include?
iii.
Do you provide any direct patient care?
iv.
What is the most number of patients you’ve
ever been assigned in this facility? How
often does this happen (being assigned so many patients)?
v.
What is the least number of patients you’ve
ever been assigned in this facility? How
often does this happen?
vi.
How many patients do you think would be
optimal –for you to care for at one time?
Compare the RN’s optimal numbers with
the actual number of patients she’s caring for.
How substantial is the difference?
C. If it is an LPN you are speaking with, ask:
i.
How many CNAs do you have assigned to you?
ii.
What do your duties include?
iii.
What is the most number of patients you’ve
ever been assigned in this facility? How
often does this happen (being assigned so many patients)?
iv.
What is the least number of patients you’ve
ever been assigned in this facility?
v.
How many patients do you think would be
optimal –for you to care for at one time?
vi.
Compare the actual numbers with the stated
optimal numbers.
D. If you are speaking with a CNA, ask:
i.
How many of your (X –number of patients) are
physically and cognitively independent?
(expect this number to be none to exceedingly few in a skilled nursing
care facility)
ii.
How many of your patients are in a completely
dependent or a vegetative state?
(hopefully this number is as low as the independent number, with most of
the patients ranging somewhere between these two extremes)
iii.
What
do your duties include?
iv.
How
many of your (X –number of patients) required the assistance of more than one
nursing assistant?
v.
What
is the most number of patients you’ve ever been assigned in this facility? How often does this happen (being assigned so
many patients)?
vi.
What is the least number of patients you’ve
ever been assigned in this facility? How
often does this happen?
vii.
How
many patients do you think would be optimal –for you to care for at one time?
Ø Compare the CNA’s optimal numbers with the actual number of patients for whom she is currently providing care. How substantial is the difference?
Recommendations for interviewing nursing home staff
Highlight and print several copies of the questions listed below. Take them with you to the nursing home and fill them out as you speak with each nurse and nursing assistant.
Fill-out a separate form for each person you speak with.
Compare what the marketing director says about the nursing staffing ratios (the number of patients assigned to each nurse or nursing assistant) with the numbers the nurses and nursing assistants give you.
Date
__________ Time of day: ________________
Name of
Facility: __________________________________________
Name
& Title of the person you’re speaking to:
___________________
Location
in the facility:
___________________________________
------------------------------------------------------------------------------------------------
1. How
many patients are you assigned to take care of today?_______
2. Can
you please tell me what is a normal or average assignment (how many patients each) for RN’s, LPN’s, and
Nursing Assistants here (in this facility)?:
|
Weekday |
Day Shift |
Evening Shift |
Night Shift |
|
RN’s |
|
|
|
|
LPN’s |
|
|
|
|
Nursing Assistants |
|
|
|
|
Weekend |
Day Shift |
Evening Shift |
Night Shift |
|
RN’s |
|
|
|
|
LPN’s |
|
|
|
|
Nursing Assistants |
|
|
|
3.
What
is the worst staffing ratio you’ve ever seen here?
|
Worst Time |
Day Shift |
Evening Shift |
Night Shift |
|
RN’s |
|
|
|
|
LPN’s |
|
|
|
|
Nursing Assistants |
|
|
|
How did this happen? (i.e., a blizzard or a hurricane)
___________
How often do these sorts of (worst) staffing
ratios happen (in your experience)?
E. TOILETING
Ask any of the RNs, LPNs or CNAs the following questions. They should know the answers. More than half of all patients or residents in skilled nursing care facilities suffer from incontinence.
i. How
many of your patients toilet themselves independently?
ii. How
many of your patients require cognitive prompts to toilet themselves?
iii. How
many of your patients require physical assistance to toilet themselves?
iv. How
many of your patients are completely incontinent, diapered and dependent on the
nursing assistants for diaper changes?
·
How often are diapered and incontinent
patients cleaned and changed?
v. How
many of your patients require the physical assistance of more than one person
to toilet themselves?
vi. How
many of your (X number of) patients receive *Prompted Voiding?
vii. Can
you please tell me about how you provide *prompted voiding*, and how
often? Please note the following:
·
Providing prompted voiding every hour (while
awake) is optimal, but every two hours while awake is also effective and quite
acceptable;
·
Providing prompted voiding to support the
existing toileting capabilities takes
three times as long as diapering the elder in a dependent position.
·
Special training on provision of prompted
voiding is required. Prompted voiding is
not terribly complicated, but it is not intuitive either.
·
Be mindful of what is within the realm of
physical possibility and the time constraints of caring for multiple patients.
viii. Do you provide *prompted voiding* to patients
who require more than one nursing assistant to physically assist them to and
from the toilet?
·
Be mindful that dedicating the time and
expertise of more than one highly trained nursing assistant to support the
toileting continence of one single patient is a very time-consuming,
labor-itensive process, and thus very expensive to provide.
·
Do the math.
If the CNAs each have 8, 10, or 15 patients, they will not have the time
to reliably provide *prompted voiding* to even one patient, much less more than
one patient, or for patients who require the assistance of more than one
nursing assistant. This does not mean
the nursing assistants don’t try or that they wouldn’t like to provide this
intensive level of care, but they simply won’t have the time to dedicate so
much time to the toileting continence of one single patient.
·
Compare the answers given by the different
people you speak with.
·
Confrontation is not your purpose.
·
You are not there to prosecute the nurses and
nursing assistants for doing their job the best they can, or for dealing with
their assignment and the staffing ratios as they are.
·
You are asking these questions in order to
gather information and decide whether placing your dear one in their care is a
good idea.
ix. Have
you attended any special conferences or training seminars on mobility
assistance, cognitive prompting, and toileting care?
x. How
often do you attend training seminars on toileting care?
* prompted voiding references: Schnell, Ouslander, Hu
F. Eating
i. How
many of your patients feed themselves independently?
ii. How
many require some assistance with eating, but are not entirely dependent?
iii. How
many of your patients are entirely dependent in order to eat?
iv. Do
you feed your patients who require assistance, or does your facility have a
“feeding team”?
G. Bathing, Grooming and Dressing
i. How
many people do you have to (or have you given) a bath, or assisted with bathing
today?
ii. If
the nursing assistant answers zero, ask whether the facility employs bathing
teams.
iii. How
much time do you generally spend assisting each patient with their bathing (or
showering), grooming, and dressing?
iv. How
often are patients bathed or showered on your unit?
v. Do
you get everyone up and dressed every day?
·
If not, why not?
·
Under what circumstances? (answers you might
expect include when an elder:
Ø is ill, or
Ø recuperating
from an illness and simply too weak, or
Ø requests
to remain in bed, or
Ø refuses
to get out of bed.)
vi. How
many of your patients move-about independently –with or without any mechanical
assist devices (such as a cane or a walker)?
vii. How
many of your patients require two or more people to transfer and assist them
from one place to another (i.e., from the bed to the chair, from the chair to
the toilet)?
viii. How
many of your patients require the use of a mechanical lift to transfer them
from one place to another?
7.
Look
around you and take note:
A. Are
any of the patients tied to their beds?
(you might notice straps hanging from the side of the bed)
B. Are
any of the patients tied to their chair or wheelchair?
C. Are
any of the patients restrained to their chair with a lap table secured to their
chair?
D. In total, how
many patients do you see restrained?
E. Ask
the nurses and your tour guide about the facility’s policy towards restraints.
8.
Talk
to the patients.
A. How
do they like the facility?
B. How
do they feel about their nursing care?
C. It
can be advantageous to already know someone –even distantly- -whom you can
speak with and ask about the facility.
Sometimes however people want to say only good things about the facility
for fear of casting themselves or the nurses –whom they maybe attached to- in a
bad light.
9. Talk to the Family Members of patients
in the facility. Ask
them:
A. What
do they think of the nursing care provided to their elder?
B. Do
they feel the facility has worked to improve their elder’s health, function,
and / or quality of life?
C. Do
they regret having placed their elder in this facility?
10.
Ask yourself some questions about
your elder’s current condition:
Ø How
many people does it currently take to get your elder out of bed, and to and
from:
Ø the
toilet?
Ø the
dining room or kitchen table?
Ø the
living room chair or sofa?
Ø the
rocker on the front porch?
Ø Know
that if your elder requires assistance from more than one person for mobility,
that your elder’s mobility will likely diminish after admission to the skilled
nursing care facility –unless of course you are able to afford to place your
elder into a uber luxury skilled nursing care facility with very high nursing
staffing ratios.
11.
Some
things I would like for you to know:
A. Most
elders who are physically and cognitively independent now live in retirement
communities or Assisted Living Facilities where:
i.
They do not have to pay as much as skilled
nursing facilities cost.
ii.
They do not have to share a bedroom and a
bathroom with a virtual stranger whose habits (such as watching television
24/7, or frequently filling the room with their visitors).
B. Odds
are that in facilities with very low staffing ratios, a frail elder’s existing
function (unless independent) will likely be allowed to deteriorate to a
dependent state.
C. Caring
for a dependent elder is much easier to manage and less time-consuming than to
care for and promote the highest level of function possible among elders who
are struggling to maintain their function and independence –because such elders
tend to move very slowly.
D. Some
States do not specify minimum nursing staffing ratios for non-Medicare funded
beds. This means that:
i.
each RN could potentially have as many
as 90 patients –far too many to provide or even to competently supervise
minimal nursing care.
ii.
Each LPN could potentially have as many
as 50 patients to whom she is passing medications, far more than is safely or
optimally handled.
iii.
Each CNA could potentially have as many
as 15 patients. Such an enormous number
of patients is far too many for a single nursing assistant to provide even
minimal care.
E. Just
because your elder is in a skilled nursing care facility does not render them
invulnerable to neglect and its potentially devastating effects on their
health, function, independence, and quality of life.
F. Some
skilled nursing facilities provide “assembly line” nursing care where, for
example:
i. One
team of nursing assistants (sometimes) called “feeders” feed all elders who are
dependent upon or require assistance from others for eating. Elders are typically fed in the common dining
room where the feeding team members often move from one patient to another.
ii. Another
team of nursing assistants (sometimes) called “showers” wear shower thongs on
their feet and shower each patient in-turn.
iii. Another
team of nursing assistants (sometimes) called “beds” change all the bed linens
in the facility.
iv. The
remaining nursing assistants take elders to and from the toilet, clean-up
incontinent messes, and perform any other duties assigned such as taking and
recording temperatures, blood pressures, heart rates and respiratory rates..
G. Ask
the facility director or marketing representative about what kind of nursing is
practiced in the facility (i.e., team, assembly line, primary nursing,
etc.). Although primary nursing (where
the same nurses and nursing assistants are assigned to particular elders) is an
optimal ideal, it may be impractical –even logistically impossible in
situations where staffing ratios cannot support it (primary nursing care).
Team
nursing and assembly line nursing, while typically never optimal, maybe the
most efficient way (particularly in facilities with very low staffing ratios)
to ensure each patient receives a bath, timely assistance with meals, and
reliably toileted or diapered on a regular basis.
H. There
is not a cardinal right or wrong type of nursing (i.e., primary nursing, team
nursing, or assembly line nursing) for a facility to practice. What matters most is the level and quality of
nursing care provided to the elders in the facility. Having very low staffing ratios is not a
crime. It is simply less than optimal
and as such, can in many circumstances, be reasonably expected to result in
less than optimal outcomes for many of the recipients of the care.
