The Culture of Long-Term Care
by Tyra Phipps, Ed.D. (tyra.phipps@gmail.com)
Mr. Paul Taylor of the Pew Research Center recently published his book, The Next America (2014). He reports that there are 76 million Baby Boomers, and there are 80 million people in the Millennial Generation. There has been a major demographic shift with 40% of them going back home to live with parents. There are now only two people to support each member of the Baby Boomer generation living on Social Security, compared to the 20th century with 150 people supporting each person living on Social Security. Mr. Taylor calls for the need to rebalance the social safety net, because the Millennial Generation graduates from college with too much debt to move forward. While the author talks about the Millennial Generation as a force to be reckoned with because of their numbers and characteristics, what is the impact for the elderly or disabled residing in nursing homes and assisted living?
This is the generation of younger employees in assisted living, skilled nursing, dementia units, and hospitals. Culture is about people. Normative behaviors address how people should behave or ought to behave in groups. What is happening? What I see as an educator is not unique, but pervasive in industry and business alike. Taking care of the aging population is a business. Even 50% of the hospice units in the nation are now for-profit. My main concern is with assisted living and nursing homes. What is the culture or behavioral norms in these facilities?
It is interesting to note that senior nursing aides who work with new trainees tell me that what they hear is unbelievable. One nursing aide said that the trainee told her she would never work an overnight shift, so is it, “Okay if I get out my Kindle?” There was a complete lack of understanding that a nursing aide could be mandated to work overnight and everyone needs to know what to do on every shift. Even the manager of assisted living told me of an LPN who worked in skilled nursing simply quit her job, because that way she and her husband would have less earnings and qualify for a subsidized home at the lake in Oakland, Maryland paying just $200 a month. The manager also told me the home the LPN and her husband got at $200 a month overlooks a golf course and is beautiful inside and out. I have noticed in assisted living that calling off a shift is frequent without any regard for the nursing aide who has already been on duty for eight hours. This means the nursing aide works sixteen straight hours. With the four training classes that I have seen during the two years in assisted living at Goodwill Retirement Community, only a minority of people who train actually move into a position. I have frequently heard nursing aides say that my family comes first and if something happens with one of my children, then, I am out of here. I have also heard nursing aides say, “I can’t wait to get the hell out of here.” Appalling? Is this part of the normative behavior? Even more important, how do these attitudes affect residents? How do they affect other members of the team in a healthcare setting?
The culture appears to be one of doing less work and frequently looking for ways to get disability, assistance with an Independence Card or food stamps, energy assistance, and medical cards. While management can weed out these types of workers, there is a problem of diminishing returns or who is left to hire. Recently in dealing with a nurse surveyor who inspects nursing and assisted living facilities in Maryland, I listened to her grammar and was astonished. The surveyor said to me, “Axed me any questions.” As a professor in communication, I have helped many students with substitutions of words (axed for ask), but this was a senior state nurse surveyor. She earned a bachelor’s degree in nursing. The state coordinator she reported to, left a message on my answering machine also had very poor grammar. These people held bachelor degrees and I found them to be woefully incapable of doing state work. The high-ranking nurse surveyors could not even understand the complaints I filed. What about the ability of a nursing aide with a high school education or less to understand complicated medical jargon and instruction?
Perhaps it is simply a self-fulfilling prophecy that people who come into a nursing facility or assisted living are part of the population in decline. It is easy to think that the room filled today in a short while will be emptied and then filled by someone else. With the average age of resident in their late 80s at most of these places across the nation, medical transports to the hospital are frequent as well as moving bodies to funeral homes. Mr. Granger Cobb, CEO with Emeritus, met with Mr. A. C. Thompson on the program “Life and Death in Assisted Living.” He talked about human error occurring with this population. There was a female resident who got out of the window in her room and fell to her death at an Emeritus facility. Granger Cobb spoke with a tone of voice that was more businesslike than compassionate and explained that the window was open twelve inches. He clarified that a twelve inch opening followed state regulations. In listening to him, it was almost as if no error occurred because there was a regulation that was met, so Emeritus was in the clear. However, a mother died and the death was premature! Could this death have been prevented? It most likely could have been prevented if there had been adequate staffing.
There appears to be great acceptance of nursing homes and assisted living units working with inadequate staff. The culture has a way of accepting minimal staffing to meet state guidelines. In the skilled nursing area, there are more regulations and more staff required which means more nursing aides on the floor. In assisted living which is largely unregulated, there can be one nursing aide on the floor for as many as sixteen people. That becomes very problematic when half of the people are dementia patients or maybe two thirds and even more of the people are using assistive devices to ambulate. In the recent US News report that ranked states for the quality of their nursing homes, the best five-star facilities had 4 ½ hours of staff caring for a resident each day. I reside in a facility in Maryland, which does not even rate in the top twenty states for nursing. In all likelihood, this means that assisted living facilities provide even less resident time with staff. The US News report follows this entry.
While the top twenty states were ranked in the US News report, that means a lot of states have very poor nursing facilities. Is our national culture simply indifferent to the struggles of the aging population? Eventually, if one lives long enough, palliative care will be necessary. Psychologists talk about the concept of open awareness. Sometimes it is difficult to look at the prognosis of dying and death. It is a fortunate person to have family all around during the final months and days of life. However, many lives end in assisted living, or nursing homes without family or friends. This makes a caring, supportive, and even loving culture inside assisted living and nursing homes even more important.
More and more families are making those decisions only to meet with disappointments in the way their loved ones were cared for by staff. The following represents a few of the summary statements I have received from readers of the blog who shared similar family problems:
Ms. Tina Anderson January 3, 2014:
"I agree, more people need to be made aware of what goes on in those homes. I hated to put my mother in law in one and even after doing a lot of research still was not an ideal place to live."
Ms. Tina Anderson June 28, 2014:
“I just read your post ....An insider opinion ~ I feel the same way as you. We had my mother in assisted living for 8 months and I didn't think for one minute they were not taking care of her cause she was paying 4,000 a month to stay there. Her care was a little more because she was in the dementia unit. I can't speak too much to the food menu, because we were never there during meals. She never complained, but she didn't have much of an appetite. She probably didn't eat $400.00 worth of food a month.
The staff was fairly friendly especially the arts and crafts instructor, however one of the head nurses, was just ugly no matter what you were discussing with her. (I realized they are busy I feel they are understaffed also) It just doesn't make sense to me, WHY they are understaffed.....they received 4,000 a month to take care of her.
They had some turnovers, but she was only there 8 months. She needed lots of water because of the medications she was on so we bought her a large plastic cup with a lid on it. All they had to do was FILL IT UP. She became dehydrated in 6 months. By Thanksgiving, we had to take her to the hospital and she was there for 5 days. We talked with staff and a head nurse about the fact that she needed lots of water, and to keep her cup filled. Then in early January, she had a stroke and passed away. She was trying to get to the water fountain and she forgot her walker (dementia patients don't remember those things)
My husband wanted to go after the facility but it had been a rough couple of years and I just wasn't up for a court battle. My husband paid all of her bills at the facility, looked over every insurance claim, checked the pharmacy bill two and three times, because they overbilled quite a few times.
It’s like you have to stay on the assisted living facility every minute to make sure everything is done correctly......so frustrating to think we have to worry every minute because we aren't sure they are doing their jobs. After all that's what they are being paid for !!!!!!
My dad was in assisted living for 25 years, but my mom handled all of his affairs then. He always complained about the food. Said the staff didn't listen to him. He was NOT in an expensive facility but he lived thru it.
I'll always be thankful that we brought them both to live with us in Debary, Fl. in 2003 to try and give them a better quality of life (my mom had Parkinson's) However they both were gone by 2006.”
Ms. Andrea Dennison December 3 2013:
“Great information. Managing medical seems to be a big rabbit hole for so many.”
Ms. Terry White December 18, 2013:
“I would love to see a facility in this county that would foster independence when possible and is better equipped for the younger generation-the baby boomers. You have had quite a struggle. Facilities are so regulated in an attempt to prevent abuse and this new younger generation of residents do have different needs and are far more active in mind and/or body than the typical resident. Maybe your concerns will help to make changes in the way we provide services.”
Ms. Terry White January 24, 2014:
“’Things’ sound good in theory, but not so in practice. Not all facilities are created equal. I’d like to see more changes made; ‘culture change’ means making a facility more home like and resident directed care.”
Reverend Bill Carpenter February 10, 2014:
“Tyra, I read with interest (and frustration) your blog revealing your recent experiences in assisted living. I hope your report and counsel serve many families and individuals in managing their own health care situations, both now and in the future. My parents lived in assisted living facilities for four years and I experienced a range of service/responsiveness from more-than-adequate to feeling like the only way I could ensure their safety and care would be to be present 24/7.”
Summary:
I find it interesting that the comments I have received coincide with what Mr. A. C. Thompson of Frontline ProPublica discussed as problematic with assisted living. Mr. Jeffrey Brown was the interviewer. Mr. Thompson states, “You know, first off, a lot of these facilities are great. But what we also found was that there was a pattern of problems that spanned the country. What we kept seeing were allegations and citations for a lack of staffing, not enough workers, a lack of training, workers who weren’t trained enough, medication errors, people getting the wrong drugs over and over again. These were the kind of things that we saw, and these were the things that worried us about the industry as it evolves.”
As the industry keeps evolving, it appears to revolve around two words of correct and right which can sometimes be contradictory. I find nursing aides and management frequently saying that they were correct meaning they followed policy or regulations. The tone of their voices echoes that of Granger Cobb, CEO Emeritus. I know a resident who received the wrong medications from five different nursing aides and yet nothing was done to correct the situation. It appears to be human error and that is to be expected with limited staff that has only minimal training and education. Despite state regulations that are written with such ambiguity and lack of clarity that anyone can interpret words in any way, problems prevail.
It is always comforting to me that there are nursing aides who do what is right to help a resident regardless of some policy or regulation. The word, “right” implies a values judgment which many nursing aides exercise on a regular basis. These decisions revolve around what can make a resident feel more at home, or comfortable in their surroundings despite the newness of schedules for mealtimes, or activities of daily living and very important hygiene rituals. It is especially heartwarming to see a resident smile because a nursing aide took the time to offer another cup of coffee or warm-up coffee that may be cold.
Questions for Consideration:
1. What does it feel like when you walk into one of these facilities? For instance, a library feels a lot different than a grocery store. That may be an exaggeration, but do people seem friendly? Watch the interactions. Did the staff smile at family members, but have a different nonverbal expression when interacting with a resident? Is there an atmosphere of respect? What did the members of the staff look like? Are these people well groomed and is there a dress code policy?
2. Make unannounced visits. Try to visit during the night hours as well as surprise visits during the day shift which is generally 7 AM until 3 PM. Observe what is going on during the second shift and what happens during early evening hours. Make every effort to see what happens during activities such as bingo or balloon tennis.
3. Notice if there is an atmosphere of indifference among the members of the staff. In some assisted living facilities, there is a white gate that residents can use at their doorway. This is similar to the gate that you use for pets to keep them in a room, only this is used to keep residents from wandering into a room. The resident can still have the doorway open, but protect the entryway. While I was in rehab at the Frostburg Nursing and Rehab Center, I saw a resident confined to a wheelchair and propelled himself with his feet wander into the bathroom area where a female resident was using the toilet. This kind of embarrassing situation can be prevented if there is enough staff, but the gate also helps to protect privacy of the resident.
4. Watch the usage of cell phones, androids, and other electronic devices. During your unannounced visits, see if members of the staff are using Facebook instead of helping residents. A favorite pet peeve of mine is to watch staff use cell phones and then see if they wash their hands afterwards. The cell phone is one of the most bacteria ridden items, and yet I have observed nursing aides making a peanut butter and jelly sandwich for someone without first washing their hands.
5. Listen to the tone of voices. Do people yell at one another? Even with elderly residents, who have very little hearing, does the staff member get down closer to the good ear and speak in more normal tones? Do the members of the staff sit in central locations and yell, or do they make every effort to get closer to the resident who needs assistance? Is there a calming sound to the voices, or are they agitated and irritating? Keep in mind that while you may be able to leave the facility, your loved one will hear irritating sounds day in and day out.
6. Are members of the staff patient? Oftentimes, the staff cannot take a lot of time because of the heavy workload. However, they can be patient. Patience is not only a virtue, but it is conveyed in nonverbal language by a nodding of the head and a posture that is relaxed along with a reassuring tone of voice.
7. Is there an atmosphere of tolerance? Not everything about getting older is pleasant. While the staff needs to be tolerant and residents need to be tolerant of one another, there needs to be a line drawn. In other words, everyone has our own boundaries. Is it really right to let someone sneeze, wheeze, and even spit at the dining table? Are members of the staff tolerant yet respectful of the rights of other individuals residing in the facility?
8. Do members of the staff look tired? Are employees complaining to one another about how much they have to do? I have always observed with my students that they could write the paper in the time they are sending me email and complaining about how they cannot get it done. It is better to see an atmosphere of, “Just Do It.” The morale gets really low in these facilities when members of the staff leave work for the next shift. This is not the kind of job where employees can watch the clock. Additionally, does there appear to be teamwork? The spirit of teamwork or having someone as a backup really helps morale stay high regardless of workload.
9. Does the administration micromanage employees? Is there a threatening atmosphere? To put it another way, are there threats of QA or Quality Assurance reprimands that go in the nursing aide file? What concerns me is the nurse aide that is truly helping a resident, but may not be following a code of regulations that frequently are outdated and do not address individual needs. Are there threats to have the nursing aide license revoked? Alternatively, is there a sign designating the employee of the month? Is there a reward system in place for someone who goes “The Extra Mile” or some other designation for outstanding performance among employees?
10. Try to observe the relationship between administrators and nursing staff. Is there an air of superiority displayed by management? Is there a condescending tone of voice, or patronizing actions directed toward women? Does it appear that the employees are essentially disposable, or are the employees valued? Ask someone who works there how she or he feels about the job and I am guessing you will get an earful. Be sure to make notes about everything. You cannot be too cautious when making a decision to move into assisted living, skilled nursing, or helping a loved make the transition.
The following report provides additional information and supplemental reading:
U.S. News' best nursing homes - 2014
U.S NEWS
Health inspections, nurse staffing, and quality of medical care determine each home’s star ratings by Avery Comarow and U. S. News staff
On any given morning this year, roughly 1.4 million individuals, among them one person in every 34 age 65 and up, will wake up in a U.S. nursing home. U.S. News wants to help families find a good and caring facility for those they cherish. To lend a hand, U.S. News has collected meaningful data and ratings on nearly every nursing home in the country and built a search tool designed to highlight the facilities that both match up with a family’s priorities and carry good ratings besides.
The data behind Best Nursing Homes come from the federal Centers for Medicare & Medicaid Services. CMS sets and enforces standards for nursing homes enrolled in Medicare or Medicaid, as almost all are. The agency also collects information from states and individual homes, and on its Nursing Home Compare website it assigns each home (other than a few too new to have enough data) a rating of one to five stars in each of three categories:
Deficiencies in state-conducted health inspections
Nursing staff time with residents
Quality of medical care provided to residents
In January 2014, 3867 nursing homes earned an overall rating of five stars from the federal government. Around the country, the number of nursing homes in a state has little relation to how good they are. Texas, for example, has nearly 1,200 nursing homes, more than three times as many as Minnesota’s 377. But 30 percent of Minnesota's homes earned a top overall rating of five stars; just 15 percent of Texas nursing homes earned that distinction.
All of the following states have at least 300 nursing homes. They are ranked by their percentage of homes with the top five-star overall ranking.
States with the biggest shares of best nursing homes:
Massachusetts (35.9 percent)
California (34.0 percent)
New Jersey (33.0 percent)
Michigan (30.4 percent)
Minnesota (30.2 percent)
Florida (30.1 percent)
Wisconsin (28.9 percent)
Kansas (26.4 percent)
Pennsylvania (24.8 percent)
Iowa (24.1 percent)
New York (23.1 percent)
North Carolina (22.4 percent)
Illinois (21.9 percent)
Missouri (21.6 percent)
Indiana (21.5 percent)
Ohio (21.3 percent)
Tennessee (20.4 percent)
Georgia (18.9 percent)
Texas (15.2 percent)
Oklahoma (11.8 percent)
The fundamental approach to the star ratings has not changed since U.S. News began publishing Best Nursing Homes in 2009. Nor has the number of rated facilities moved significantly. The 2014 results, however, reveal a tectonic shift in just five years in the share of top- and bottom-rated nursing homes.
In 2009, 11.8 percent of all nursing homes earned the highest possible overall rating of five stars. In 2014, the percentage has more than doubled, to 24.9 percent. Most of the difference can be found in the shrinking number of bottom-rated one-star homes, which accounted for 22.7 percent of the total in 2009 but only 10.1 percent in the 2014 tally. The percentages of facilities receiving four, three and two stars, by comparison, have changed by a handful of percentage points or barely at all. The bulge in the performance curve has steadily shifted to the right, and the trend seems to be speeding up.
Why this has happened is unclear. CMS is investigating. But no one should be selecting a nursing home entirely on the basis of star ratings. Long, carefully planned unannounced visits and candid discussions with staff members should be a given and should be heavily weighed in the decision.
Here are the details of the elements that determine each facility’s star ratings:
Health Inspections:
Because almost all nursing homes accept Medicare or Medicaid residents, they are regulated by the federal government as well as by the states in which they operate. State survey teams conduct health inspections on behalf of CMS about every 12 to 15 months. They also investigate health-related complaints from residents, their families and other members of the public. "Health" is broadly defined. Besides such matters as safety of food preparation and adequacy of infection control, the list covers such issues as medication management, residents' rights and quality of life, and proper skin care. A rating in this category is based on the number of deficiencies and their seriousness and scope, meaning relatively how many residents were or could have been affected. Deficiencies are included if they were identified during the three latest health inspections and in investigations of public complaints in that time frame. State inspectors also check for compliance with fire safety rules, although their findings are not factored into the CMS ratings. Best Nursing Homes displays all health and fire inspection results online.
Nurse Staffing:
Allocation of staff time or the amount of time per day patients receive from the nursing staff, because even first-rate nurses and nurse aides can't deliver quality care if there aren't enough of them. The information is self-reported by each nursing home. Facilities report the average number of registered nurses, licensed practical nurses, licensed vocational nurses and certified nurse aides and assistants on the payroll during the two weeks before the latest health inspection. The number of hours they worked is also reported. Agency temporary employees do not count. That information is compared with the average number of residents during the same period and crunched to determine the average number of daily minutes of nursing time. To receive five stars in the latest CMS ratings, the nursing staff had to provide nearly 4½ hours of care a day to each resident, including about 43 minutes from registered nurses. The time for each home is shown in the ratings. CMS also provides the average time physical therapists spend with residents, but it isn’t factored into the staffing rating.
Quality Measures:
CMS requires nursing homes to submit clinical data for the latest three calendar quarters detailing the status of each individual Medicare and Medicaid resident in 18 indicators, such as the percentage
of residents who had urinary tract infections or who were physically restrained to keep from falling from a bed or a chair. Best Nursing Homes, like Nursing Home Compare, displays all 18 data points for each home. The ratings, however, are based on nine of
them — seven for long-term and two for short-term residents - that are considered the most valid and reliable, such as the two above and other measures related to pain, bedsores, and the ability.
June, 2014
July 2018