Nursing Facilities
Spot Potential Problems Early
While most people can easily recognize outright abuse and neglect, it is sometimes difficult to identify substandard care in a nursing facility. Health care experts have identified some common telltale signs, which are described here along with advice on how to prevent them and correct poor care.
Increased Need for Help with Daily Activities
Because of physical or mental limitations, most nursing facility residents have difficulty carrying out activities of daily living such as eating, moving about, and getting to and from the toilet. But the less a resident does, the worse their abilities may become.
Nursing facility staff should strongly encourage residents to be out of bed as much as possible and assist them with activities, exercise, and walking at least once a day, but preferably more often. Only residents who are unresponsive or in severe pain should be left in bed — and they should be assessed for pain and depression and also assisted with turning and moving at least every two or three hours.
What you can do. Visit the facility at breakfast time or mid-morning. If a large number of residents are in bed during breakfast instead of eating in the dining room, or if many are still in bed mid-morning, this may indicate that residents are spending too much time in bed — and may be at risk for physical decline and loss of function.
Ask the staff what they do if a resident does not want to get out of bed. And ask whether there are policies for getting residents out of bed at specific times each day and for maintaining and improving daily functioning.
Bedsores
A pressure ulcer, also known as a bedsore, is caused by constant pressure on the skin and muscle when a person does not move around enough or get out of bed. Bedsores usually develop on bony parts of the body such as the tailbone, hips, buttocks, ankles, or heels. Residents who are confined to bed or who have difficulty moving by themselves may suffer from bedsores. If left untreated, bedsores may cause pain, infection, decreased social interaction, a decline in self-care activities, a longer stay in the nursing facility — and even death if complications arise.
Most bedsores can be prevented if residents are turned or repositioned every two to three hours, eat adequate amounts of food and liquids, and are kept clean and dry. The chances of developing bedsores may also be reduced by using air pads, gel flotation pads, or other special padding on beds and wheelchairs.
What you can do. Visit the facility and ask to see the types of devices used in beds and wheelchairs to relieve pressure ulcers. Ask nursing staff if they do a risk assessment for pressure ulcers when residents are admitted to the facility, and periodically after that. Also ask how often they reposition residents who cannot move themselves and how that activity is monitored. If a resident develops a pressure ulcer, ask the licensed nurse or attending doctor at the facility for a weekly report about the location, size, appearance, and stage of healing of the wound.
Use of Physical and Chemical Restraints
Physical restraints are any device or method that restricts or prevents freedom of movement and normal access to the body. Physical restraints include: hand mitts, ties or vests, chairs with lap trays, bedside rails, belts, and wheelchair foot pedals that cannot be released by the resident. Such devices do not necessarily provide security or safety to residents — and they may have negative effects that far outweigh any possible benefits. The risks may include: less mobility and dignity with more agitation, falls, pressure sores, social isolation, and accidental death.
Chemical restraints include four classes of psychoactive drugs: antipsychotics, anti-anxiety drugs, anti-depressants, and sedative/hypnotics. Nearly 60% of all California nursing facility residents regularly receive some type of psychoactive drug. Many such drugs are safely and legitimately used to treat medical symptoms. But a growing number have been found to be used simply to make residents more docile and easier to manage. Possible side effects of these drugs include tremors, over-sedation, toxicity, anxiety, confusion, delirium, and insomnia. In rare cases, the effects of these drugs alone or in combination with others can be fatal.
By law, a restraint cannot be used unless a physician has ordered it. Any restraint should be used only on a short-term basis, to protect the resident — for example, to prevent him or her from pulling out tubes essential for medication or nutrition — rather than for the staff members’ convenience.
What you can do. Visit the facility in the middle of the day and observe how many residents are using wheelchairs, lap trays, seatbelts, foot pedals, or some other restraint device. Ask the nursing facility staff how often they remove and reposition residents who are restrained and what alternatives are available. If your family member seems drowsy or unresponsive, ask to review the resident’s care plan to learn exactly which drugs are being used and why. Request a medical reassessment based on the specific behaviors you have observed. If physical or chemical restraints are being used, ask about less severe alternatives.
Frequent Incontinence
Incontinence is the inability to control the flow of urine or feces. Nursing facility residents may develop incontinence if they are dependent on others for moving around, suffer from severe memory problems, or are physically restrained. Incontinence can cause problems such as skin rashes, falls, isolation, pressure sores, and odors. Perhaps the most serious problem with incontinence is a person’s loss of dignity.
What you can do. Residents who are incontinent should be checked to determine if they have a urinary infection or a bowel impaction and if so, this should be addressed. Then they should be put on a scheduled toileting plan of every two or three hours.
Ask staff how they decide whether a resident is a good candidate for a scheduled toileting program. If the program seems ineffective, talk with the director of nursing or nursing administrator about changing it.
