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10 Things Nursing Homes Won't Tell You

SmartMoney Magazine
by Lisa Scherzer and David Stires
April, 2010

Updated and adapted from the book "1,001 Things They Won't Tell You: An Insider's Guide to Spending, Saving, and Living Wisely," by Jonathan Dahl and the editors of SmartMoney.

1. "We're careless about the drugs we give out."

"The primary goal of nursing homes," according to the American Health Care Association (AHCA), an industry trade group, "is to rehabilitate residents so that they can return to the community." It's a worthy aim, certainly. And many nursing homes-both public and private-do an excellent job of caring for the elderly and infirm. So why is it that so many people not only have a negative view of these facilities but live in absolute dread of entering one?

One reason, critics say, might be the misuse of drugs. According to the Centers for Medicare & Medicaid Services (CMS), which enforces federal rules affecting these facilities, 19% of nursing home surveyed were cited for unnecessary drug use in 2008, up from 13% in 2006. (CMS attributes the uptick in the citation rate to "new survey protocols" in 2006.)

The use of antipsychotic medications in the treatment of nursing home residents is of special concern to critics. California Advocates for Nursing Home Reform (CANHR), a nonprofit advocacy group, says the problem is rampant in that state. Nearly 60% of all California nursing home residents are given psychoactive drugs, a 30% increase since 2000, according to a recent report published by the group. The concern is that many psychoactive medications have dangerous side effects, including tremors, toxicity and delirium. And "despite legal requirements, the informed consent of residents or their representatives is often ignored," CANHR says.

A spokeswoman for the American Health Care Association (AHCA), a trade group representing nonprofit and for-profit assisted living and nursing facilities, says she isn't aware of a widespread problem with administering drugs to patients inappropriately.

2. "We're woefully understaffed."

By far, the biggest problem at nursing homes is a shortage of nurses, nurse aides and other workers. "We have a crisis in direct care," Donna Wagner, a professor and the director of the gerontology program at Towson University. According to the AHCA, as of 2007, the vacancy rate for registered nurses at nursing facilities was 16.3%. And the need will only grow: the population of Americans aged 65 and over is expected to reach 72 million by 2030, from 37.2 million in 2006.

Ideally, says Jeanie Kayser-Jones, a professor at the University of California, San Francisco who researches nursing-home issues, a nurse's aide - the person tasked with providing the bulk of the care, including feeding, bathing, and clothing residents - should be in charge of no more than three people during a meal and no more than five to six (depending on the resident) at other times. (At overnight that ratio can go to one aide per 15 residents.)

Yet, some nursing homes have only one registered nurse for 50 to 70 patients, notes Charlene Harrington, a professor of sociology and nursing at the University of California. The shortage often stems from budget issues. In California, for example, just 53% of a nursing home's budget typically goes to paying for direct patient care, including nursing costs, Harrington says. The result is not only too few employees but also high turnover rates.

"Unfortunately, most health-care providers nationwide face a problem with having enough registered nurses available to provide care," says AHCA spokeswoman Susan Feeney. And it's not a new situation. She says the shortage, in part, is due to the lack of nurse educators needed to train new registered nurses.

3. "Mr. and Mrs. Smith, meet Sticky Fingers Louie."

Nursing-home fees aren't cheap. In 2009, one year of care in a nursing home cost over $70,000 for a semi-private room, or $198 a day, according to the Department of Health and Human Services (18% of that was covered by out-of-pocket spending).

But critics say there's also often a hidden price tag to a nursing home stay: the value of stolen personal belongings. Cash, jewelry-even wedding rings-and clothes are commonly swiped items. "The problem is that people have accepted this - 'Well, that's what happens in nursing homes,'" says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform. "Theft and loss is so prevalent, that a lot of times people don't even bother reporting it."

The just-passed law includes a provision that mandates long-term-care facilities nationwide to provide better protections for patients. The bill contains the Patient Safety and Abuse Prevention Act, which will create a national system of background checks, to keep nursing home workers with criminal histories out of the long-term care setting. The AHCA has been supporting criminal background check provision for a long time, says Feeney. "We need to make sure the database is strong enough and accurate enough and timely, so we're hiring the right people," she says.

4. "What you don't know about your checkbook can hurt you."

Nursing-home theft isn't just about lifting jewelry from unsuspecting residents. It can also be institutionalized.

In fiscal year 2008, the Office of Inspector General (OIG) for the Department of Health and Human Services reported that the State Medicaid Fraud Control Units recovered more than $1.3 billion in court-ordered restitution, fines, civil settlements, and penalties. In North Carolina, for instance, a former clerk admitted to taking money from a nursing home's patient fund account and manipulating the facility's patient rosters to conceal the embezzlement. The OIG's investigation of the home revealed a total of 165 forged patient trust fund checks resulting in more than $292,000 in stolen funds. Similar incidents of theft from patient funds occurred in New York and Oregon in 2008.

Such cases of institutional fraud are not rare. "The problem is that's the tip of the iceberg. Those are just the people that got caught," says McGinnis. Again, the AHCA says it supports criminal background checks.

5. "If it's not in the care plan, we're not gonna do it."

The creation of an individual patient care plan -- essentially a blueprint for how nursing home staff are supposed to tend to a particular resident -- is mandated by federal law. Failure to provide comprehensive care plans was among the top 10 most frequently cited deficiencies in nursing home facilities in 2008, according to a November 2009 report co-authored by Harrington of UC San Francisco.

"It's supposed to be directed to that particular resident - if my mother is subject to falling, what are you going to do to prevent falls?" says McGinnis. But, facilities sometimes don't adhere to the care plan. Within a certain period of a patient's admission to a facility, the staff must meet with family members to discuss the care plan. Everyone who will be involved in the resident's care should be there. The problem is "they don't always do the care plan meeting. And even when they do, sometimes the doctor isn't there," McGinnis says.

Not all facilities are remiss, however. "I think the majority of long-term-care facilities do an OK job, and are working hard to keep the quality of care high. It's really the outliers that have serious issues come up," says Towson University's Wagner.

How to help protect your loved ones? Get involved in both their preliminary health assessment and the development of a care plan right from the beginning. And if you're not satisfied that the plan does enough, call your state's long-term care ombudsman. The National Long Term Care Ombudsman Resource Center lists contact numbers on its web site.

6. "'Neglect' is our middle name."

In January California's Department of Public Health issued a citation with a fine of $85,000 to Orange Healthcare & Wellness Centre, formerly known as Kindred Health Care Center, of Orange, Calif., for negligence. According to the citation, a resident died in July 2009 after suffering a fall and fatal head injuries. The patient had a history of falls before and after entering the nursing home, and also had a history of brain injuries that put him at high risk of injury due to falls. Kindred planned preventive measures, but they were not in place at the time of the fall. The department found that the violations were a cause of the patient's death. A Kindred spokesperson says the facility worked with the state to address its concerns, but couldn't comment further because of patient confidentiality.

Patient neglect can cause a range of problems, from pressure sores--areas of damaged skin caused by staying in one position for too long-to dehydration. In a November 2009 report on nursing facilities co-authored by Harrington, 21% of facilities received deficiencies for failing to ensure residents don't develop pressure sores in 2008, up from 17% in 2003. Malnutrition is also a serious threat, affecting anywhere from 4% to 50% of residents, according to John Morley, a professor of gerontology at St. Louis University.

Again, the trouble can begin with inadequate staffing. If a nurse's aide has 15 residents to take care of - some of whom need assistance with their meals -- corners are likely to be cut. Some patients can't be rushed, "and if you feed them too quickly, they'll aspirate and can get pneumonia," Kayser-Jones says. While these instances are not the norm, says Feeney, any time you have this, "abuse or neglect should not be tolerated."

7. "We use physical restraints on your loved ones."

While the law allows for the use of physical restraints-belts or vests that bind nursing-home residents to a chair or bed to prevent falls and wandering-the concept is to use them as a last resort to protect a resident's health or ensure the safety of others. Critics argue restraints shouldn't be used at all, saying they can not only can make residents agitated or depressed, but can result in a host of physical problems as well.

"We should aim for restraint-free care. It's inhumane. There are other ways to handle people who might be confused, wander or who might fall," says Kayser-Jones. Unfortunately, the practice still goes on. While 10.97% of facilities received deficiencies for restraints in 2008 - lower than 2007 - the number is still slightly higher than it was in 2003, according to Harrington's nursing home report.

AHCA's Feeney says the entire profession has made a concerted effort to address the use of physical restraints. In fact, a campaign to improve quality in long-term-care facilities, called Advancing Excellence in American's Nursing Homes (participants include long-term-care providers, advocacy groups, nurses and other health care professionals), makes restraint-use reduction one of its eight stated goals.

8. "Take our report cards with a grain of salt."

How to tell if the long-term-care facility you're considering is any good? Well, you could rely on its health- and safety standards compliance survey, which, in accordance with federal regulations, is updated annually by a state inspection agency. Nursing homes are checked for things such as unsanitary food conditions and patient neglect, and cited for any code violations.

But a clean record may not mean much. Why? Some facilities "prep" for the surveys by hiring more staff during the inspection periods. Kayser-Jones recently heard from a nurse who had worked at a nursing home that would call in nurse's aides on their days off when surveyors came in. "There are ways for nursing homes to make things look better than they are," she says.

Others say surveyors charged with assessing quality of facilities often get it wrong. A surveyor can be in a nursing home for as little as a few days - "They see [one patient] gets transferred inappropriately, and they cite the facility for a deficiency. But is that really the measure of the care being provided?" says Barbara Miltenberger, an attorney and partner with Husch Blackwell Sanders LLP in Jefferson City, Mo., who is also chair of the long-term care practice group of the American Health Lawyers Association.

With the new health-care reform legislation, consumers will be able to get important information about nursing homes they didn't have access to before on CMS's nursing home compare web site. Most importantly, CMS will have more accurate data regarding staffing, including retention and turnover rates, says Janet Wells, director of public policy at NCCNHR, formerly the National Citizens Coalition for Nursing Home Reform, a nonprofit consumer advocacy group. "A nursing home that retains much of its staff is probably better than one that doesn't," Wells says.

9. "Fines? Go ahead- give us your best shot."

When a nursing home fails to meet state standards, it's supposed to get fined, right? At least in California, it looks like only a portion of the fines are collected. For the fiscal year 2008-09, California assessed long-term care facilities with $4.6 million in fines. Of that, just $1.2 million has been collected to date.

One way to bypass the penalties is through an administrative hearing, whereby a facility can choose to appeal both the type of citation and its accompanying fine. The Class B citations, for offenses that affect the health, safety, and/or security of a resident, generally carry a fine of up to $1,000. "If you don't appeal your B citation, you can pay 65% of the fine. So you get a 35% discount right off the bat," says McGinnis. And when nursing homes do appeal these citations, fines are sometimes reduced. "The idea that you can use fines as a stick isn't working. If you're not going to collect them, it's not a penalty," she says.
There could be various reasons why a fine would be reduced. Some measures allow facilities that pay promptly to get a reduced fine, says Feeney. "It's not them shirking their responsibilityĆ  they're complying with the law," she says.

10. "We can kick a resident out anytime we want."

The No. 1 complaint received by the State Long Term Care Ombudsman for New York in 2009 involved discharge issues. Critics say nursing homes sometimes force a resident out when the person requires too much staff attention or is otherwise considered a problem. "A lot of people complain that the process wasn't done correctly," says Mark Miller, New York's ombudsman, who works as an advocate for residents of nursing homes in the state. Any discharge notice is supposed to indicate where the resident will be moved to and has to make sure the new facility is an appropriate setting, he says.

Typically, the process is subtle - a resident's family member, for example, might be pressured into "voluntarily" removing his or her loved one from the facility. If the nursing home isn't adequately staffed or trained to deal with patients with, say, dementia or Alzheimer's, they may "call the family and say, 'we can't provide care for your relative,'" says Miller.

Such tactics are a way around the formal discharge process, says Toby Edelman, senior policy attorney with the Center for Medicare Advocacy. While state and federal laws allow nursing homes to discharge residents under special circumstances - for example, if the patient's health improves and he or she therefore no longer requires the facility's care - they generally must provide 30 days' written notice, stating the reasons for the discharge. Even then, residents have the right to appeal.

Feeney says there could be legitimate reasons why a facility isn't able to tend to a particular patient - for example, they may not have a ventilator for someone who needs one. "As long as a facility has the ability to meet the needs of the individual, they should continue to do that," she says. "Unfortunately, there might be cases where [a nursing home is] not taking [a resident] back for reasons that are not appropriate, and that's not acceptable."