Ensuring your loved one has the best care in a nursing home.
This was a comment I left for an article about falsification of patient records in a California nursing home. It turned into a blog post :)
As a hospice nurse I had the opportunity to visit with many patients who were residents in nursing facilities in a major western city (not in CA). In "good" nursing homes I routinely found bowel movement logs that had not been filled out for days. When I expressed concern (ok, raised hell) about one patient who had no BMs charted for 5 days, which I charted in my patient notes, I returned the following day to find the records completely filled out and indicating BMs every day....and initialed with different initials. Needless to say this was also charted in my notes. I then informed the administrator that a small problem with recording BMs had now become a really big problem with falsifying medical records.
Bottom line, in my experience visiting (and assessing weekly or more often) patients in a wide variety of nursing homes from medicaid "warehouses" to very, very expensive private pay facilities:
- The patients or residents who get the best, most frequent care are the patients with visitors. Nothing is better than involved family members. Patients with family, friends or outside nurses/therapists who staff are aware will be visiting regularly are kept cleaner, turned more frequently, have meds given more accurately, and tend to be cared for earlier rather than later.
- When you visit, ask questions of the nurses! When was Mom's last BM? How is she tolerating her medications? Offer to bathe your family member - this helps overworked staff and gives you a chance to do a skin check! Look at heels, back of head, ears, tailbone, buttocks, shoulderblades - pressure sores start as reddened areas that do not turn white when pressed. If you find a spot, alert the nurse supervisor. If you find an open sore, also alert the physician. Coordinate your help with when the nurse is doing rounds for skin assessments.
- Unresolved constipation becomes a fecal impaction which can become a bowel obstruction, which is often fatal in elders. Ensuring regular bowel movements in those who are debilitated is really vital. Ask each visit to see the BM log for your family member. Ensure that there is a protocol for laxatives to be given after more than 2 days maximum without a BM. Since muscle tone is often decreased, ask the doctor if a stimulant/softener combination is a good choice. Impaction/obstruction by stool is completely preventable (barring tumors,constrictions, etc), and any hospitalization for this is a big red flag to find a different facility.
- When choosing a nursing home, certainly do your homework and research. Ask some home health or hospice nurses which ones they especially like (grin) - I have seen some awesome care given in facilities that were not the top end most expensive facilities. After all that, do the nose test. Visit the facility unannounced on a weekend, and a weekday evening. Walk down the halls - what do you smell? If you smell several unchanged adult diapers - look elsewhere. This is not to say walk into rooms, but look around and use your nose. Weekends, especially weekend evenings/nights, are when staffing is probably lowest and will be the least desirable shifts.
- Be realistic! If your dad had frequent falls at home, he is not going to fall less in the nursing home. The purpose of being in a care facility is to ensure that he is as safe as possible, and that he will be found promptly when he does fall. Bedrails are not fall prevention - the opposite in fact. Bedrails are proven to increase the severity of injuries/deaths from falls. Patients get arms or legs through bedrails while climbing over, they climb over and the bedrail acts as a fulcrum - causing them to land headfirst rather than sliding to the floor. Low beds are your best defense - think mattress on the floor or the special beds (some made from PVC) that are low to the floor with mats next to them. This is the BEST injury prevention.
- Communication is vital, and making staff a part of "mom's team" is the very best way to ensure that your family member is getting great care while you are not there. Being pleasant, persistent, and grateful goes a long way. Most nursing homes are staffed with very caring and incredibly overworked people. Negligence is not malicious, it is simply a matter of not having enough time or staffing to do everything needed and required.
As a hospice nurse I had the opportunity to visit with many patients who were residents in nursing facilities in a major western city (not in CA). In "good" nursing homes I routinely found bowel movement logs that had not been filled out for days. When I expressed concern (ok, raised hell) about one patient who had no BMs charted for 5 days, which I charted in my patient notes, I returned the following day to find the records completely filled out and indicating BMs every day....and initialed with different initials. Needless to say this was also charted in my notes. I then informed the administrator that a small problem with recording BMs had now become a really big problem with falsifying medical records.
Bottom line, in my experience visiting (and assessing weekly or more often) patients in a wide variety of nursing homes from medicaid "warehouses" to very, very expensive private pay facilities:
- The patients or residents who get the best, most frequent care are the patients with visitors. Nothing is better than involved family members. Patients with family, friends or outside nurses/therapists who staff are aware will be visiting regularly are kept cleaner, turned more frequently, have meds given more accurately, and tend to be cared for earlier rather than later.
- When you visit, ask questions of the nurses! When was Mom's last BM? How is she tolerating her medications? Offer to bathe your family member - this helps overworked staff and gives you a chance to do a skin check! Look at heels, back of head, ears, tailbone, buttocks, shoulderblades - pressure sores start as reddened areas that do not turn white when pressed. If you find a spot, alert the nurse supervisor. If you find an open sore, also alert the physician. Coordinate your help with when the nurse is doing rounds for skin assessments.
- Unresolved constipation becomes a fecal impaction which can become a bowel obstruction, which is often fatal in elders. Ensuring regular bowel movements in those who are debilitated is really vital. Ask each visit to see the BM log for your family member. Ensure that there is a protocol for laxatives to be given after more than 2 days maximum without a BM. Since muscle tone is often decreased, ask the doctor if a stimulant/softener combination is a good choice. Impaction/obstruction by stool is completely preventable (barring tumors,constrictions, etc), and any hospitalization for this is a big red flag to find a different facility.
- When choosing a nursing home, certainly do your homework and research. Ask some home health or hospice nurses which ones they especially like (grin) - I have seen some awesome care given in facilities that were not the top end most expensive facilities. After all that, do the nose test. Visit the facility unannounced on a weekend, and a weekday evening. Walk down the halls - what do you smell? If you smell several unchanged adult diapers - look elsewhere. This is not to say walk into rooms, but look around and use your nose. Weekends, especially weekend evenings/nights, are when staffing is probably lowest and will be the least desirable shifts.
- Be realistic! If your dad had frequent falls at home, he is not going to fall less in the nursing home. The purpose of being in a care facility is to ensure that he is as safe as possible, and that he will be found promptly when he does fall. Bedrails are not fall prevention - the opposite in fact. Bedrails are proven to increase the severity of injuries/deaths from falls. Patients get arms or legs through bedrails while climbing over, they climb over and the bedrail acts as a fulcrum - causing them to land headfirst rather than sliding to the floor. Low beds are your best defense - think mattress on the floor or the special beds (some made from PVC) that are low to the floor with mats next to them. This is the BEST injury prevention.
- Communication is vital, and making staff a part of "mom's team" is the very best way to ensure that your family member is getting great care while you are not there. Being pleasant, persistent, and grateful goes a long way. Most nursing homes are staffed with very caring and incredibly overworked people. Negligence is not malicious, it is simply a matter of not having enough time or staffing to do everything needed and required.