We all know the most important thing a family can do is to visit their loved one in a nursing home. Unfortunately visiting isn’t enough. Even if it is several times a week, it simply is not enough to protect your mother, father or loved one from abuse or neglect.
Why is that? How can someone be a victim of neglect even if they have a near constant stream of visitors? If visiting was enough to protect our loved ones, why are there still so many problems?
The answers are straight forward. Here are a few factors that come into play.
Family members aren’t trained to monitor nursing home care – Even if you are a doctor, it’s not likely that you have sufficient training or the experience to detect problems early on in a nursing home. In fact, most neglect occurs as a result of poor communication and failure to properly provide or document needed nursing care. Since a nursing home resident is seen by so many different providers and may only be seen by a doctor once a month or less, it is important to know exactly what each provider has done or seen. Since there are very particular ways in which this needs to be documented in the chart, someone who is not intimately familiar with how the chart or records are managed in a nursing home is not likely to discover a problem until it is too late.
An example of such a problem might be incontinence. Oftentimes, a nursing home resident will refrain from telling a family member when they are experiencing incontinence. They may be too embarrassed or they may not even be aware. Sometimes the incontinence occurs at night when families are not visiting. The night time staff may simply be too busy to note the incontinence in the chart. Even if they do, it may not be seen by the doctor. Read Susan’s Story for an illustration of this problem.
Visiting can create a false sense of security – Just because a home doesn’t smell or mom hasn’t been physically abused doesn’t mean she is getting appropriate care. Many of the problems in a nursing home are subtle or slow to develop. It’s not until they have reached the crisis state that a visitor becomes aware of them.
Falls are a good illustration of this issue. Frequently, after a catastrophic fall, a family will learn that their loved one had fallen before. Since previous falls were minor and there were no injuries, the CNA who discovered or witnessed a fall may not have taken the time to report it accurately and completely. The resident themselves often does not tell their family for a variety of reasons.
Visiting mom, asking if she’s fallen and/or looking for cuts or bruises can give a false sense of security. Oftentimes, there are no bruises or marks visible, even for the most vigilant family member. As a result, no precautionary action is taken to prevent further falls until it’s too late. Additionally, few visitors, even with the best of intentions know how to properly document falls or know what precautions and interventions should be taken.
Another frequent problem in nursing homes is pressure sores, (also called) pressure wounds or decubitus ulcers and previously known as bed sores. These wounds occur when the skin breaks down over time due to unrelieved pressure. When they are identified early and treated quickly, these horrible wounds can often be cured easily. However, when they are allowed to progress, they can cause catastrophic pain, suffering and even death. A pressure sore often begins as a small patch of redness on the sacrum, elbows, ankles or anywhere there is constant pressure. Often, the staff fails to note these small changes in the proper part of the chart. As a result, chances for early intervention can be easily missed. Merely visiting frequently does relatively little to help prevent this.
Nursing home residents have complex medical issues and it’s not enough to know that the correct orders have been entered by the physician. – A conscientious and sophisticated visitor may have a deep understanding of their loved one’s medical conditions. They may be active participants in meeting with doctors and may visit their parent or loved one frequently. Regardless, far too often the doctor’s orders are simply not followed.
View a good example of this problem. The Abramson Center is a highly regarded, non-profit home in suburban Philadelphia. They have long been at the cutting edge. They even have their own gerontological research group – the Polisher Research Institute, founded in 1959. An inspection done by the Pennsylvania Department of Health found that in the charts that the Department reviewed, “the facility failed to follow physician’s orders for four out of the 30 residents reviewed.” That means that even in one of the best facilities the State Department of Health found that doctor’s orders were not being followed for over 13% of the residents. 1. For example, one resident was an insulin dependent diabetic. The doctor had ordered additional insulin when the blood sugar rose over 179mg./dl. The records showed that despite blood sugars of 300, 218, 278, 262, 262, 322 and 358 the insulin was not given as ordered! Another resident was having problems swallowing their food. A doctor ordered a special soft diet to keep the resident safe. But the change was never carried out since the dietary department was not properly notified. Another resident’s psychiatric medication was not reduced in accordance with doctors’ orders. The last resident had fallen. Their doctor ordered “that a physical therapy consult was to be obtained for safe ambulation.” That order was never carried out. Just visiting these residents would not have made a difference in these cases.
Many of the preventable problems occur because of under staffing or poor communication – It’s no secret that care in nursing homes would be improved if there were more staff. Many times, there are simply too few people available to care for all the needs of nursing home residents in a timely fashion. Invariably when this happens, certain things are put off, done poorly or not done at all. Many CNAs and nurses say they are far too busy sometimes to write certain basic items in the chart.
Consider the following. It is important that input and output of each resident be noted on a daily basis. For example, if a resident is suffering from a urinary tract infection, the amount of fluid they are getting, as well as the quantity and appearance of their urine output can be significant. Far too often, though, the residents’ chart will not be fully noted or completed. A doctor caring for such a resident simply won’t have the information needed to give that resident the care they deserve.
Nursing homes know how to manage a family – Many homes understand that keeping the family happy is important. But providing customer service and providing quality care are not the same thing.
Many visitors feel reassured if they walk into a facility that smells clean: in other words, does not smell of urine or feces. Unfortunately, that is a very superficial assessment of cleanliness and is certainly no substitute for assessing whether the facility has proper infection control protocols in place, and if staff is following them!
When families are trying to monitor, they are not able to do their real job – Not only are family members unable to effectively prevent neglect by merely visiting, trying to monitor care takes them away from that all important job that only they can do. Close family members provide love and emotional support. No healthcare provider, no matter how well meaning, can truly reminisce with your parent about the family vacation 30 years ago. Only you can talk and laugh about the good times in a life well lived. Tracking down the RN or speaking with the director of nursing or checking with the dining service means you are not there providing the love that only YOU can give.