Choosing and Evaluating a Nursing Home

Can there be a more difficult job than finding a nursing home for a parent or spouse?  No one wants to live in a nursing home. They serve as institutions of last resort when it's impossible to provide the necessary care in any other setting. And, typically, the search takes place under the gun—when a hospital or rehabilitation center is threatening discharge or it's no longer possible for the loved one to live at home. Finally, in most cases, finding the right nursing home is a once-in-a-lifetime task, one you're taking on without the experience of having done it before. That said, there are a few rules of thumb that can help you: 1. Location, location, location. No single factor is more important to quality of care and quality of life of a nursing home resident than visits by family members. The quality of care is often better if the facility staff knows that someone who cares is watching and involved. Visits can be the high point of the day or week for the nursing home resident. So, make it as easy as possible for family members and friends to visit. 2. Get references. Ask the facility to provide the names of family members of residents so you can ask them about the care provided in the facility and the staff's responsiveness when the resident or relatives raise concerns. 3. Talk to the nursing home administrator or nursing staff about how care plans are developed for residents and how they respond to concerns expressed by family members. Make sure you are comfortable with the response. It is better that you meet with and ask questions of the people responsible for care and not just the person marketing the facility. 4. Tour the nursing home. Try not to be impressed by a fancy lobby or depressed by an older, more rundown facility. What matters most is the quality of care and the interactions between staff and residents. See what you pick up about how well residents are attended to and whether they are treated with respect. Also, investigate the quality of the food service. Eating is both a necessity and a pleasure that continues even when we're unable to enjoy much else. It is also advisable to try and get a tour of the facility that is not prearranged. While this is not always possible, it does give you the opportunity of seeing an unrehearsed atmosphere. When you visit, ask for the admissions coordinator, who will introduce to the features of the facility and give you a formal tour. Afterwards, you may ask to return and view the facility at your own pace. Questions to Ask the Nursing Home:
  • Is the nursing home Medicare certified?
  • Is the nursing home Medicaid certified?
  • How many Medicaid beds are certified?
  • How many Medicaid beds are currently available?
  • What is the monthly or daily base rate and what services does it cover?
  • What services are not covered in the base rate, such as telephone, toiletries, salon, activities and what is the cost of each charge?
  • What is the procedure to pay for the add-on charges?
  • Is the nursing home accepting new patients?
  • Is there a waiting period for admission?
  • Is the licensing and certification for the nursing home current?
  • Is the license of the nursing home administrator current?
  • Does the nursing home have any specialty care units?
  • Are residents able to make choices about their daily routine, such as when to go to bed and what to eat?
  • How is the interaction between staff and resident?
  • Does the nursing home meet your cultural, religious and/or language needs?
  • Does the nursing home smell and look clean?
  • Can residents have personal articles and furniture in their rooms?
  • Are there a variety of activities to choose from?
  • Does the nursing home have volunteer groups?
  • Does the nursing home have outdoor areas for resident use?
  • Did the facility correct any Quality of Care deficiencies that they received on their most recent survey?
  • Can residents continue to see their personal physicians?
  • Are the residents clean, appropriately dressed and well groomed?
  • How well does the administrator interact with staff and residents?
  • Does the nursing home have a resident and family council that meets independently of the nursing home’s management?
  • Are care plan meetings held at times that are convenient for residents and family members to attend?
  • Is there enough staff to assist each resident who requires help eating?
  • Does the food smell and look good?
  • Are residents offered choices of food at mealtimes?
  • Are nutritious snacks offered?
  • Does the dining room environment encourage residents to relax, socialize and enjoy their food?
  • Are there handrails in the hallways and grab bars in the bathrooms for safety?
  • Are the exit doors clearly marked and clear of impediments?
  • Does the nursing home have a disaster plan to move residents in emergencies?
  • Are spills cleaned up quickly?

There are also two online resources available to find out a little more about the facilities' history and track record:

1. Go to www.medicare.gov. Toward the bottom of the page under “search tools” there will be a link to "Compare Nursing Homes in your Area." Click on the link and it will bring you to a page that will allow you to sort by zip code and the distance you want to travel from the zip code.  Check the facilities you want to compare and then click "next step" at the bottom of the page. You'll get a summary of the facilities you've chosen with the ability to get more details for each individual facility. 2. Florida's Agency for Health Care Administration provides a Nursing Home Guide (http://ahcaxnet.fdhc.state.fl.us/nhcguide/) that allows you to search for nursing homes in Florida by geographic region or by the characteristics of the facilities.  Click the search option you prefer.  If you choose geographic region, a map of the State of Florida will appear and you will then click on the appropriate region.  If you choose to search by characteristics, you will receive a multiple drop down questions to answer.  Either way, you will then receive a list of facilities to choose from.  Within the search results, click on the facility you want more details on and you’ll receive a summary report, which will rate the nursing home based on a star system.  If you want the specific inspection details for the facility, click on “Inspection Details for this Facility” to see a list of a facility's citations (failure to meet established standards) from the past 45 months. The Agency for Health Care Administration also provides a Nursing Home Watch List (http://ahca.myflorida.com/Nursing_Home_Guide/index.shtml) that provides details on facilities in Florida that were cited for deficiencies (failure to meet established standards) during their inspection and if and when these problems were corrected.

Talking With Family About Placement

Few decisions are more difficult than the one to place a spouse or parent in a nursing home. Since nursing homes are seen as a last resort, the decision is generally accompanied by a sense of guilt. Most families try to care for loved ones at home for as long as (or longer than) possible, only accepting the inevitable when no other alternative is available. The difficulty of making the decision can be compounded when family members disagree on whether a nursing home is necessary. This is true whether the person disagreeing is the person who needs assistance, his or her spouse, or a child. A nursing home placement decision can be less difficult if, to the extent possible, all family members are included in the process, including the senior in question, and if everyone is comfortable that all other options have been explored. This will not ensure unanimity in the decision, but it should help. We recommend the following steps:  1. Include all family members in the decision. Let them know what is happening to the person who needs care and what providing that care involves. If possible, have family meetings, whether with the family alone or with medical and social work staff where available. If you cannot meet together, or in between meetings, use the telephone, the mail, or the Internet. 2. Research what types of care can be provided at home, what kind of day care options are available outside of the home, and whether local agencies provide respite care to give family member care providers a much-needed rest. Also, look into other residential care options, such as assisted living and congregate care facilities. Local agencies, geriatric care managers, and elder law attorneys can help answer these questions. 3. Follow the steps above for finding the best nursing home placement available. If you and other family members know you've done your homework, the guilt factor can be reduced (at least to some extent). 4. When necessary, hire a geriatric care manager to help in this process. While hospitals and public agencies have social workers to help out, they are often stretched too thin to provide the level of assistance you need. In addition, they can have dual loyalties—to the hospital that wants a patient moved as well as to the patient. A social worker or nurse working as a private geriatric care manager can assist in finding a nursing home, investigating alternatives either at home or in another residential facility, in evaluating the senior to determine the necessary level of care, and in communicating with family members to facilitate the decision. To find a geriatric care manager in your area, visit the Web site of the National Association of Professional Geriatric Care Managers atwww.findacaremanager.org. Resident Rights While residents in nursing homes have no fewer rights than anyone else, the combination of an institutional setting and the disability that put the person in the facility in the first place often results in a loss of dignity and the absence of proper care. As a result, in 1987, Congress enacted the Nursing Home Reform Law that has since been incorporated into the Medicare and Medicaid regulations. In its broadest terms, it requires that every nursing home resident be given whatever services are necessary to function at the highest level possible. The law gives residents a number of specific rights:
  • Residents have the right to be free of unnecessary physical or chemical restraints. Vests, hand mitts, seat belts and other physical restraints, and antipsychotic drugs, sedatives, and other chemical restraints are impermissible, except when authorized by a physician, in writing, for a specified and limited period of time.
  • To assist residents, facilities must inform them of the name, specialty, and means of contacting the physician responsible for the resident's care. Residents have the right to participate in care planning meetings.
  • When a resident experiences any deterioration in health, or when a physician wishes to change the resident's treatment, the facility must inform the resident, and the resident's physician, legal representative or interested family member.
  • The resident has the right to gain access to all his or her records within one business day, and a right to copies of those records at a cost that is reasonable in that community. The facility must explain how to examine these records, or how to transfer the authority to obtain records to another person.
  • The facility must provide a written description of legal rights, explaining state laws regarding living wills, durable powers of attorney for health care and other advance directives, along with the facility's policy on carrying out these directives.
  • At the time of admission and during the stay, nursing homes must fully inform residents of the services available in the facility, and of related charges. Nursing homes may charge for services and items in addition to the basic daily rate, but only if they already have disclosed which services and items will incur an additional charge, and how much that charge will be.
  • The resident has a right to privacy, which is a right that extends to all aspects of care, including care for personal needs, visits with family and friends, and communication with others through telephone and mail. Residents thus must have areas for receiving private calls or visitors so that no one may intrude and to preserve the privacy of their roommates.
  • Residents have the right to share a room with a spouse, gather with other residents without staff present, and meet state and local nursing home ombudsperson or any other agency representatives. They may leave the nursing home, or belong to any church or social group. Within the home, residents have a right to manage their own financial affairs, free of any requirement that they deposit personal funds with the facility.
  • Residents also can get up and go to bed when they choose, eat a variety of snacks outside meal times, decide what to wear, choose activities, and decide how to spend their time. The nursing home must offer a choice at main meals, because individual tastes and needs vary. Residents, not staff, determine their hours of sleep and visits to the bathroom. Residents may self-administer medication.
  • Residents may bring personal possessions to the nursing home such as clothing, furnishings and jewelry. Residents may expect staff to take responsibility for assisting in the protection of items or locating lost items, and should inquire about facility policies for replacing missing items. Residents should expect kind, courteous, and professional behavior from staff. Staff should treat residents like adults.
  • Nursing home residents may not be moved to a different room, a different nursing home, a hospital, back home or anywhere else without advance notice, an opportunity for appeal and a showing that such a move is in the best interest of the resident or necessary for the health of other nursing home residents. The resident has a right to be free of interference, coercion, discrimination, and reprisal in exercising his or her rights. Being assertive and identifying problems usually brings good results, and nursing homes have a responsibility not only to assist residents in raising individual concerns, but also to respond promptly to those concerns.

Resolving Disputes

Disagreements with a nursing home can come up regarding any number of topics, and almost none is trivial because they involve the day-to-day life of the resident. Among other issues, disputes can arise about the quality of food, the level of assistance in feeding, troublesome roommates, disrespect or lack of privacy, insufficient occupational therapy, or a level and quality of activities that doesn't match what was promised. The nursing homes that live up to the ideal of what we would want for our parents or ourselves are few and far between. The question is how far you can push them towards that ideal; what steps should be taken in that process; and at what stage does the care becomes not only less than ideal, but so inadequate as to require legal or other intervention. This can be a hard determination to make and in some cases needs the involvement of a geriatric care manager who can make an independent evaluation of the resident and who has a sufficient knowledge of nursing homes to know whether the one in question is meeting the appropriate standard of care. Following is a list of the interventions a family member may take, in ascending order of degree. Move down the list as the severity of the problem increases or the facility does not respond to the less drastic actions you take. In all cases, take detailed notes of your contacts with facility staff and descriptions of your family member and his or her care. Always note the date and the full name of the person with whom you communicate. 1. Talk to staff. Let them know what you expect, what you care about and what your family member cares about. This may easily solve the problem. 2. Talk to a supervisor, such as the director of nursing or an administrator. Explain the problem as you see it. Do this with the expectation that the issue will be favorably resolved, and it may well be. 3. Hold a meeting with the appropriate nursing home personnel. This can be a regularly scheduled care planning meeting or you can ask for a special meeting to resolve a problem that wasn't resolved more informally. 4. Contact the ombudsperson assigned to the nursing home. He or she should be able to intervene and get an appropriate result. Contact information for the Ombudsman Program in your state can be found at: www.ltcombudsman.org. 5. If the problem constitutes a violation of the resident rights described above, report it to the state licensing agency. This should put necessary pressure on the facility. 6. Hire a geriatric care manager to intervene. An advocate for you who is not personally involved and who understands how nursing homes function as institutions can help you determine what is possible to accomplish and can teach the facility to make the necessary changes. 7. Hire a lawyer. While a lawyer may be necessary to assert the resident's rights, the involvement of an attorney may also escalate the dispute to a point where it is more difficult to resolve. This is why we have listed this as the second-to-last option. A lawyer has the tools to make the facility obey the law. 8. When all else fails, move your family member to a better facility. This may be difficult, depending on the situation, but it may be the only solution. It does not prevent you from pursuing legal compensation for any harm inflicted on the nursing home resident while at the earlier facility.