My writing this piece is a purging for years of frustration. I am an RN, and I have been for over thirty one years. I grew up in Long Term Care (LTC) and my children were raised in the environment also.
My family built and ran LTC facilities. I have worked at every job in a facility from laundry to cook, NA, CNA, and Director of Nurses. Later in my career I was also a LTC surveyor in two different states. So you can see this particular topic is near, and dear to me.
My LTC background started at a time when you had individual run homes. You did not have the large corporations coming in and buying several in a state or across the country. You still had good homes and bad ones. Trying to make the all mighty dollar would drive a lot of issues.
The LTC facility I was first involved with was Regency House Nursing Center. It was owned by my uncle and my mother was the administrator. As I grew up, as I mentioned before, I did every job in the facility at one time or another. I knew how things were suppose to be done. Over time I became the Director of Nurses. It should go without saying the administration and myself had a very direct line of communication.
The first rule in that home was, you had to give good care. All of the patients were like family members. Even the poor souls who no longer were themselves. You had all the personalities from the very aggressive to the very meek. It was a family, and I lived with that family for ten years. I watched people I cared about leave this world and new ones would come in to take their place. It was a cycle of life.
We had annual state surveys that nursing always did well at. They might find a medication not being initialed, but the patient care was excellent. The building always received the same deficiency every year, but there was a waiver to cover that particular issue. Everything ran smoothly, and the patients were happy.
The food was good and fresh for three meals a day. The menu was catered to the farming community the patients came from. Diet guide lines were followed for the most part, but the bottom line was the patients were happy with the food. You also must know, there is always someone who doesn’t like something. The fact that the food can’t be seasoned properly with salt caused a lot of unhappiness to be voiced.
Then of course you always have the hard to please family members. You know the one’s that every member of the staff cringed when they came through the door. Absolutely, nothing you did, or tried to do made them happy. It didn’t matter if you had seventy other people who required care. If Mom or dad wanted something right now, then right now they should have it. Life in a facility did not and does not work that way. Luckily those family members were few and far between.
Since that time, let’s say from the mid 1980’s, multiple cooperation’s have bought up the LTC facilities and have also built many more. I feel the majority of Administrative staff in today’s homes want good quality care. The problem as I see it, is the cooperation’s bottom line has to be money. So everything is maintained at the bare bones level and if you talk to them about staffing the words will come out such as “we have more staff for the amount of patients we have, than what is mandated.”
Staffing a facility is a constant changing nightmare, for a number of reasons. Once again you are dealing with all different types of people and their personalities. I believe the majority of the personnel in any facility want what is best for the patients they care for. This goes from the maintenance person, to the nurses and CNA’s that are working directly with the patient.
Facility staff are overworked and underpaid for what they do. That is how the system is set up and will continue to be until something changes. I’ve got ahead of myself. I was talking about staffing. Some states do not require a particular number of staff to take care of the patients. Some states require a minimum.
Back in time when I was working in LTC, Oklahoma required one to seven direct care staff to provide care to the residents on day shift. This number counted the LPN giving the medications and providing treatments. It also counted the activity director as providing direct care. I always felt this was very deceptive. The CNA’s on the floor where the ones who were bathing, feeding, dressing, walking, cleaning changing, taking to the bathroom and just doing whatever the person could not do for themselves. The number of CNA’s decreased with each shift. If you had four people on day shift providing care on one wing, that would go down to two on a wing and then for night shift it could go down even further.
For some reason, the thinking is there is not as much to do on the evening and night shifts. That is not entirely true. You still have to do the care, feed the patient, problem solve, ect. I think you can see my point.
The facilities have people who call in sick, without thinking of the problems it will cause. You also have people who are so dedicated or need the money so badly, they come to work when they should have stayed home. That in itself can cause problems. Rampant virus illness is not pleasant for anyone, and it can go through a nursing facility quickly. Care should be taken, family or staff if you are sick, stay home.
It is not easy finding staff to work when someone calls in. Usually some overworked CNA, who needs more money will volunteer. It is not uncommon for the caregivers to work more because of the low wages they receive. When someone is tired, they can’t give their best, even though everything in them says they are.
States that do not have mandatory staffing use the premise that a facility must provide enough staff to care for the patients. This is well and good, sort of. You can have five on the floor caring for ten patients. You would think all the care would be done, and everything would be wonderful. It could be, only two of those people are really working. They bust their behinds getting all the work done while the other three take smoke breaks outside, hide, look busy doing something else, but not really accomplishing anything. So there is the dilemma.
Unfortunately, I have been in facilities that consistently ran short of staff to provide care to the patients. During the three days of survey, they would bring in staff from sister facilities to really make it look good. The survey team knew what was going on but nothing could be done about it. We would hear statements from patients such as “I am really glad you’re here, we have so much more staff today than we usually do. Another might say, my call light is sure being answered quickly today.” I always felt the difference I made in patient lives were the three days I was there doing a survey. I think it is a very sad thing not to be able to completely trust the care that is given to some of our geriatric population.
The general public has no idea how many restrictions are really placed on surveyors that go into a facility. We all started the job thinking we were really going to make a difference in people’s lives. Those money hungry cooperation’s that provide poor care, because they are trying to get more of those sacred dollars are going to be shut down.
Nope, that is not the reality. The federal government has a very large book of regulations for LTC and what you can and can’t do. It is almost impossible to shut a home down. It can be done, but it takes a great deal of time, effort and money that states do not have.
Then you have to consider the patients in these homes. Where are they going to go? In some areas they may be moved fifty miles away before a facility can be found that will accept them. If they have family that visits them, what happens if they don’t have the transportation or resources to get to where the patient is located. Families can’t take care of mom and dad like they use to because of being scattered across the country, or everyone is working trying to survive. So where does that leave the patients?
The survey process itself is unannounced. The facilities do not know exactly when the survey team will show up. What they do know is, a three month time frame it could happen in. The tension can be felt in a home when it is getting close to survey time. It has happened that a survey team will check into a motel and the facility will know the survey team is in town.
Surveyor’s are not suppose to talk about their schedules. It could mean their job if it is proven they let a facility know when their survey is going to take place. If a town has several facilities, you could go into a home to do a complaint and every facility in town will know you are there.
As soon as a team walks into a building, fresh drinking water starts being put out, and call lights put within reach of the patient. You can see the activity of preparing for surveyor’s beginning. If it wasn’t so sad it would be comical.
The numerous complaints called into a state office is usually held until survey time unless there has been harm or potential harm to the patient. One or more surveyors will go to a facility and pick a number of residents including the one the complaint was about. Trying to prove a complaint can be very difficult. Let’s say mom told you they are not changing her at night and she is laying in a wet bed all night long. First thought you have is, how dare they do that to my mother.
You go to the Director of Nurses and you tell her the staff is not changing your mother at night. She then tells you it will be taken care of. She instructs her staff in checking and changing the patient’s every two hours. It is well documented in the patient record. You go back in a few days and mom tells you the very same thing. This time you are livid, and you will take care of it, so you call the state and complain. Unless the patient has a bedsore, the state will probably hold that complaint until the next survey and then look into it.
So now you are frustrated because you think the state doesn’t care and is just blowing it off. Finally the survey happens and someone from the state calls you and tells you that your complaint is unsubstantiated. You just can’t understand this at all because you know they are not changing mom at night.
Let me explain a little to you about what has to be looked at, and what has to be there in order to prove your allegation.
- Mom’s initial and subsequent evaluations has your mom coded as incontinent.
- Does your mom have any skin break down. Has she had previous breakdown and if so did it heal properly.
- Has your mom had any urinary tract infections. Females tend to develop UTI’s more frequently if not changed.
- What is your mothers mental status. If the evaluation the facility has completed, has her sometimes confused, then that can be one of the factors that will cause a complaint to be unsubstantiated.
- What documentation does the facility show on her record. They have shown the patient is checked every two hours and dried when necessary. The argument can be, it is not our fault we go in to change her and she is not wet, and then after we have gone she wets on herself.
Unless you can prove beyond doubt that care was not provided. You can’t substantiate the complaint.
On the other hand let’s say mom developed a really deep bed sore from lack of care. The facility can be given a deficiency. They would be required to fix the problem for the person named in the complaint, and anyone else who could be affected. They would have to devise a plan to make sure it doesn’t happen again and who will be monitoring do make sure it doesn’t happen again. This is all put on a form on sent to the state and the federal government. Usually within thirty to sixty days someone will go back in and make sure the plan was put into place and everything is done appropriately. If it is not corrected then fines can be put in place by the government.
If it is never corrected to the satisfaction of the state, then the facility can go into the process of being shut down. Sometimes, facilities will sell and the name will change and all of the previous problems will be wiped clean. The new facility will have an opportunity to go through the whole process from start to finish. If they took care of it, then all is well.
The Nursing Home Association has a very powerful lobby in Washington DC. They keep a lot of rules and regulations from passing they feel could harm the industry. As you can probably surmise, the care of our geriatric population is very complicated. It is overrun with many problems and it’s a constant struggle.
I don’t want anyone to misunderstand my feelings here. I know there are some very good facilities in this country that take excellent care of their residents. They have loving caring staff that does what it takes to provide the needed care. I also know they are facilities I would not let take care of my dog, much less one of my loved ones.
I am fortunate in that I have a family of nurses and care givers and my parents or one of my immediate family will not go to a nursing facility. I know everyone does not have that choice.
Be planning ahead, and if you have to find a facility then look at it very seriously. The years previous survey has to be posted for public view, that is law. Look at the survey, go at different times of the day and observe what they are being served at meal time. If you enter the facility at 9:00 in the morning what does it smell like. You are always going to have some odor on the hall just because of someone being changed at any given time. It should not remain in the air consistently. How clean is the facility kept? Are people sitting around in wheelchairs parked in front of the nurses’ station? What type of activities do they have going on. Are they appropriate for the mental and physical abilities of the patients.
This is only the tip of the iceberg, and I hope and I have give you some information you can use, as well as educate you a bit. We have some major problems to overcome, when it comes to the care of our geriatric age group. It takes a very special person to go into long term care and stay. We have to do our best and keep striving to make things better for those who can no longer care for themselves.