Is Your Parent Safe in the Nursing Home?

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Safety is one of several reasons people decide that elders with chronic health problems are better off in nursing homes than in their own homes. Unless a family is able to afford a private duty nurse or around-the-clock home health care, skilled nursing facilities offer greater safety and supervision for seniors who need a high level of care compared to living alone or with a family caregiver.

The obvious point of safety in nursing homes has always been that there are trained health care professionals on duty round-the-clock in case a senior falls, experiences a medication reaction or has another health issue. Skilled nursing facilities have gotten a bad reputation in the past. Fortunately, additional government regulations, advances in technology, and a strengthened commitment to residents and their families have significantly improved the safety measures in long-term care facilities and the quality of care they provide.

Background Checks for Nursing Home Staff

First, good nursing homes are very careful about who they hire. They do thorough background checks on their employees to head off concerns about elder abuse, neglect and theft in residential care settings. While these anxieties are understandable, the truth is that the quality of care an elder receives in a nursing home is dependent upon the quality of the employees working there.

When I had several loved ones living in a local nursing home, my mother and I often commented on the incredible quality of the staff. It was obvious that this home's administration worked very hard to hire qualified employees that met their high standards. Of course, education, training, licensing/certification, and work history also factor into this, but background checks are critical in ensuring quality care.

In 2010, the Centers for Medicare and Medicaid Services (CMS) established the National Background Check Program to conduct background checks on all direct patient access employees of long-term care facilities and providers. Currently, 26 states and the District of Columbia participate in this voluntary program. A study conducted by researchers at American University in Washington, DC, examined records from 16,000 public, nonprofit and for-profit Medicare and/or Medicaid certified nursing homes and found strong evidence that increased spending on criminal background checks for employees was associated with higher care quality. Fingerprinting specifically was linked to fewer health deficiencies and higher star ratings in Medicare’s Nursing Home Compare database.

When looking for a nursing home, it’s important to ask about a facility’s hiring process and how they vet employees. Even if a senior lives in a state that does not participate in the National Background Check Program, nursing homes do have the option to set their own screening requirements. Inquire about a nursing home’s background check policies and whether they conduct both state background checks and fingerprinting crosschecked with the FBI’s fingerprint database.

Fall Prevention Measures in Nursing Homes

The trouble with falls is that they can happen instantly and without warning—even if a family caregiver or nursing home staff member is present. While some seniors who fall incur minor or no injuries, the Centers for Disease Control and Prevention (CDC) cites falls as a leading cause of fatal and non-fatal injuries among people age 65 and older. Aside from the risk of broken bones and traumatic brain injuries, falls can also rob seniors of their independence, mobility and quality of life.

Years ago, restraints were used to prevent nursing home residents from getting up unsupervised and/or unassisted and risking injury. However, studies have proven that both physical and chemical restraints can pose serious health risks to elders and damage their self-esteem. CMS regulations now state that residents have the right to be free of restraints except where they are deemed medically necessary, in which case this need must be regularly documented and reevaluated. Nursing homes eventually transitioned to using bed and chair alarms, lowering beds to the floor and placing padded fall mats in residents’ rooms to prevent falls and minimize injuries. But in 2017, CMS issued a new guideline discouraging the widespread use of bed and chair alarms because “these devices can startle the resident and constrain the resident from normal repositioning movements, which can be problematic.”

As a result, skilled nursing facilities are embracing evidence-based strategies for reducing falls like improving staffing levels, establishing individualized care plans and routines for each resident, and training staff to better recognize and meet residents’ needs in a timely manner. Not all falls can be prevented, but reputable nursing homes utilize falls management programs that take a multifaceted approach to assessing and minimizing fall risk for each patient. The Agency for Healthcare Research and Quality recommends screening at admission, quarterly, annually and following a change in condition for identifying residents at an increased risk of falling. An interdisciplinary team of staff members then engages in personalized care planning to devise fall interventions for each resident.

Strategies might include adjustments to a senior’s medication regimen to minimize side effects like dizziness and drowsiness, responsible management of chronic and acute medical conditions, scheduling bathroom breaks, discouraging unsafe behaviors, and even physical therapy to help maintain or improve gait, balance and strength. Fixing or eliminating environmental hazards, such as clutter, defective or dangerous equipment (e.g. nursing home beds, mobility equipment and furniture), and ensuring each resident’s personal items are safely within reach can help minimize fall risk even further.

Preventing Medication Errors and Adverse Events

The rise of digital medical records has made it easier than ever for nursing home staff to check a senior’s chart for detailed information on their current medication regimen and notes regarding allergies and past adverse drug reactions. Customized medication packages are often used so nurses have all a resident’s pills pre-sorted and ready to dispense in a sealed packet. Proper education, training and attention to detail are crucial for avoiding medication errors, but these tools help to eliminate much of the human error that is inherent in administering medications to many people at once.


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Infection Control Measures in Nursing Homes

Seniors move into nursing homes to receive higher levels of care in a safe and supervised environment, but, like many other health care settings, the spread of infectious diseases can be problematic in long-term care facilities. When many people live in close quarters and use the same common areas, diseases like the flu, the common cold, pneumonia and Clostridium difficile (C. diff) can spread quickly among residents and staff alike. In addition to proper hygiene practices like regular hand-washing, sneeze/cough etiquette, and environmental cleaning policies, vaccination is key.

Seniors are a high-risk group for many of these conditions, especially influenza and complications like pneumonia. It makes sense that the CDC, the Advisory Committee on Immunization Practices (ACIP), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that all health care workers receive annual vaccinations against influenza. Some states have even developed vaccination laws for documenting the vaccination status of residents and/or employees, requiring that health care facilities provide or arrange for vaccinations each year, and even mandating vaccinations (with the option to refuse due to medical contraindication, religious/philosophical objection or by choice). Individuals who aren’t vaccinated must usually wear a surgical or procedural mask around patients.

Another important infection control measure during times of illness inside and/or outside a nursing home is to limit person-to-person contact with sick individuals as much as possible. This includes keeping ill seniors in their rooms, limiting group activities and meals, and restricting non-essential visitors. Outbreak policies in nursing homes can be very difficult for residents and their loved ones to endure, but it is crucial for preventing the spread of contagious diseases. Understanding how these measures work and why they are important as well as using alternate methods of “visiting,” such as phone calls and video calling programs, can help residents and families get through visitation restrictions during an outbreak. While these temporary policies can have a significant effect on a senior’s mood and quality of life, they are aimed at keeping residents safe and healthy over the long term.

Security Measures in Nursing Homes

Cameras in entrances and security systems keep nursing home staff informed about people who come and go. Good nursing homes want to encourage visitors and keep security as unobtrusive as possible to offer a home-like atmosphere while still maintaining a secure environment for residents. Cameras and check-in protocols for all visitors can help keep seniors safe without alarming them. In addition to monitoring communal areas, individual facilities usually have their own policies governing the use of cameras in residents’ apartments/rooms as well.

Wandering is another security concern for seniors with Alzheimer’s disease or other types of dementia. Again, a good home should not seem like a prison, yet dementia patients must not be able to leave the premises unattended for their own safety. Many skilled nursing facilities have cleverly disguised secure exits in their locked memory care units so that the doors can't be opened without codes, yet the coming and going of staff and visitors isn't hindered or accompanied by the jingle of “jailer's keys.”

Emergency preparedness is another issue for families of loved ones who are living in long-term care facilities. Every nursing home should have an evacuation plan in place in the event of a fire. Depending on the location of the facility and the hazards that are common in the geographic area, nursing homes may also have emergency plans in place for severe weather events like winter storms, floods, tornadoes or hurricanes. Inquire about these and other security concerns you may have to ensure you understand the procedures the home uses.

Balancing Safety, Independence and Comfort

Trying to maintain a home-like atmosphere for vulnerable elders while keeping them safe is not an easy task. Yet, the public has increased their expectations of modern nursing homes, forcing them to examine their approaches common problems and concerns. Many skilled nursing facilities have fostered a culture of safety among their employees and found ways of using technology and person-centered care to improve the quality of care and quality of life for their residents. Perfection may never be reached in these settings, but the happiness and security of elders in nursing homes is becoming a requirement instead of an added benefit. To me, that's great news.

If you have any questions or concerns regarding a loved one’s safety, never hesitate to contact nursing home administrators or your long-term care ombudsman. You can use the National Consumer Voice for Quality Long-Term Care website to locate an ombudsman who can help you resolve problems and advocate for a resident.

Sources: CMS National Background Check Program (https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/BackgroundCheck); Criminal Background Checks Improve Quality of Care in US Nursing Homes (https://www.american.edu/spa/news/criminal-background-checks-improve-quality-of-care-in-us-nursing-homes.cfm); 42 CFR § 483.12 - Freedom from abuse, neglect, and exploitation. (https://www.law.cornell.edu/cfr/text/42/483.12#a_2); State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf); The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities (https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man1.html); Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities (https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm); Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) (https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf)

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