Finally, after ticking off the last item on a lengthy list of must-haves, you think you've found the best nursing home for your Dad. The staff seems caring and professional. It's comfortable, homey, and Dad is OK with it. He might even come to like his new life.
The best ways to make sure your loved one gets the care that was promised
By Kurtis Hiatt, US News
But your work isn't over. You want to make sure Dad gets the care you were told he'd receive—and the care he deserves. "The resident's needs should be met by the facility, rather than having the patient meet the facility's needs," says Barbara Messinger-Rapport, director of the Cleveland Clinic's Center for Geriatric Medicine.
How do you make that happen?
What to ask:
Start with your loved one. Isn't Dad going to be your best source of information on his own care? "Ask the questions you would want to be asked if the roles were reversed," says Cornelia Poer, a social worker in the Geriatric Evaluation and Treatment Clinic at Duke University Medical Center in Durham, N.C. Questions such as:
- Are you comfortable?
- Is anything worrying you?
- Do you feel safe?
- Do you feel respected?
- If you need help and you push the call button, how long before somebody comes?
- Have you gotten to know any of the other residents?
- Do you like the staff—and any staff member in particular?
That last point may seem small, but whether your loved one clicks with a specific caregiver is important, says David A. Nace, chief of medical affairs for UPMC Senior Communities, a long-term care network in western Pennsylvania that is part of UPMC-University of Pittsburgh Medical Center. It shows he's making connections, growing in new social relationships. The trust that develops may also mean Dad takes his medication more reliably, or if behavioral issues stemming from dementia are a concern, it may be easier for one nurse than for another to manage them, says Nace.
Show interest and concern and identify major problems, but don't go overboard. "Inquiries are important, but try to avoid turning every phone call into an interrogation," Poer says. "You will be able to determine if there are areas of concern in normal, everyday conversation."
Some questions will be better directed at staff members, particularly if your loved one has a cognition problem such as dementia or Alzheimer's disease. In the first days and weeks, the focus should be on the initial adjustment. Does Dad's nurses see any signs of depression? Does he appear to be making the transition smoothly? If not, what, specifically, is being done to help him?
Then drill down to his day-to-day routine:
- When does he get up?
- Are his meals appropriately prepared—soft or pureed food if he has trouble chewing, low in fat and salt if he has a heart condition?
- Is he taking his medications when and as often as he should? (The timing of each medication should be documented.) If there's been a consistent problem, how is that being addressed?
- Is there a reason to change any of his medications?
- Is he exercising or participating in other physical activities?
- Is he social?
"I like to see if the patients are usually in their rooms," says Susan Leonard, a geriatrician at Ronald Reagan UCLA Medical Center. "Not being in their rooms means they are participating in activities, dining, or in the hallway socializing with others, which may suggest a better social environment for residents." But you'll want to see for yourself whether empty rooms might only mean residents are parked on sofas and in wheelchairs elsewhere in front of TVs.
Don't be afraid to broach more sensitive topics. If you were recently alerted of a behavioral issue or medical emergency, talk to both Dad and the staff to figure out whether it was handled properly. You want to know what the staff did and what changes in care they've made.
It's helpful to have a main point of contact during the day's various shifts. You should feel like you can call at any time, but Nace observes that it's good to know up front what the best times are for getting general updates. And don't settle for less than you need to know. If you don't get an answer, head up the chain of command to a unit supervisor, assistant director, or director.
What to inspect
Getting a feel on your own for the overall environment goes a long way, says Audrey Chun, associate professor of geriatrics and palliative medicine at Mount Sinai Medical Center in New York. Are common areas, rooms, and residents' clothes clean? What about lighting and temperature? These are especially important to older adults, says Poer. Does the room feel homelike? If you send cards, are they hanging on a bulletin board in the room? If cards and drawings are up and Dad couldn't put them up herself, that's a great sign. "It means the staff took the time to do it for the resident," Nace says. "The staff cared enough to do this."
Look around. Do you see any safety hazards—a hanging TV that isn't strapped down or blocked exits? What about bruises, such as on the upper arms where staff may have handled Dad too roughly? Watch the staff—are they affectionate, genuine, and helpful?
Use your nose. Are there odors in the hallways and rooms? "Yes, bowel movements happen—this is a long-established fact of life—but it should not be the thing that greets you every time you are in the hall," says Nace.
Listen. Do you hear birds, music, laughter? Or do you hear creaky floors and clanging pipes? Constant small annoyances can affect a person's mood and eventually her day-to-day demeanor.
How often to check in—and what to do if you can't
Some homes have a "care conference" shortly after admission and then quarterly to give you and your loved one a regular time to talk with staff, says Nace. But stopping by on various days and at various times is smart. You can ensure Dad isn't "over-medicated or spending time sitting in front of the TV," says Messinger-Rapport. When you do check in, swing by the nurses' station to signal to the staff that you're actively involved in Dad's care. If distance keeps you apart, staff might be able to send you photos or videos of Dad or set up a video conference with Dad and his caregivers. If you're abroad, staff might be able to print out an email for Dad if he doesn't have a computer, Nace says.
10 Warning Signs of Bad Care:
It's frustrating to discover that the care Dad is receiving in his new nursing home falls short of expectations—yours and his. It's frightening to think that it might be bad.
But how would you know?
"There are literally dozens of warning signs," says Dan Sewell, director of the senior behavioral health unit at the UC San Diego Medical Center. Here are what he and other experts consider especially serious red flags:
- Marked emotional or physical changes. Look first to your loved one. You should be concerned if he is less able to function as usual, has stopped taking part in activities, or has become withdrawn and uncommunicative. If Dad is experiencing emotional abuse—such as being ignored or talked down to—he may be agitated and withdrawn, fearful, or experience loss of weight or appetite and sudden changes in mood or sleep pattern. Physical abuse or neglect may be a concern if Dad has unexplained bruises, pressure ulcers, or skin tears, particularly in areas that are not regularly visible, like the upper back, hips, and thighs.
Careful, though: These are potential clues, not proof, of bad care. "The problem is that some of these changes represent the inevitability of the underlying disease, and not poor care," says Josh Uy, assistant professor of geriatric medicine at the University of Pennsylvania's Perelman School of Medicine. Dad might think a staff member was condescending when he was just using a term of endearment. Bumping the nightstand can cause an alarming bruise on an elderly person using a blood thinner like Coumadin. You'll need to observe the staff with Dad, stop by unexpectedly on various days and at different times, and ask staff to explain anything you find worrisome.
- Unanswered or deflected questions. "I don't know, but I will find out" is an acceptable response—but not regularly, and you shouldn't get the feeling there's something to hide. "If staff are evasive with your questions, unable to answer your questions, or refuse to discuss your loved one's care with you, this is a big red flag that care may be sub-optimal," says Amy Jo Haavisto Kind, an assistant professor in geriatrics at the University of Wisconsin School of Medicine and Public Health.
Some questions, such as, "My Dad is losing weight, what is the plan?" should always have a ready answer. "If all a person gets is blank stares or a dismissal—'Old people just do this, don't worry about it'—then that is concerning," says Uy.
What's the ultimate wrong answer? "I get more concerned when someone says, 'This is how we do things here,' and has no desire to help," says Jatin Dave, a physician at the Brigham and Women's Hospital's Center for Older Adult Health.
- Frantic, discordant, or inadequate staff. A busy, thin-stretched staff may be unavoidable at times, experts say. But does it always feel chaotic when you visit? Are staff working well together, or do they seem to have bad attitudes? At meals, do they talk only among themselves or do they mingle with residents? Does important information get lost between shift changes?
Don't overlook the leadership. Is the director nowhere to be found and unknown to residents? "I have never seen a place with strong, involved leadership that had bad care," says Barbara Bowers, associate dean for research at the University of Wisconsin-Madison's School of Nursing, who researches long-term care delivery.
- High staff turnover. "Some regular staff turnover is an unfortunate reality at most nursing homes," says Kind. "However, if you notice that your loved one's nursing home constantly is training new staff to the point that no one on the staff knows your loved one—well, it is time to look for a new nursing home." Consistent staff-resident pairing is important in the quality of care Dad gets.
- "I don't want so-and-so to care for me." Your loved one should never feel distressed or uncomfortable around any staff member, experts say. Even if Dad suffers from cognitive problems, "take these statements seriously and investigate them thoroughly with the nursing home leadership," says Kind. "They may be signs of mistreatment or neglect."
And even if Dad doesn't say anything, observe him when staff enters the room. Does he seem happy? Or is he anxious, fearful, or uncomfortable?
- Constantly ringing phones and unanswered call lights. It should raise an alarm if the nursing staff doesn't have the time to pick up the phone, says Elisa Gil-Pires, section chief of geriatric medicine and palliative care at Saint Francis Hospital and Medical Center in Hartford, Conn.
And if Dad says he's waiting a long time after pushing the call button, "find out for yourself," says Erin Hilligan, a licensed nursing home administrator at Ebenezer Ridges, a long-term care facility in Burnsville, Minn. "Put the light on. Note if the delay is during a specific time of day—shift change or a meal time, maybe. Then bring up your concern to a staff person and note how it is handled." Of concern, adds Sewell, is if Dad says something like, " 'I waited as long as I could for someone to help me to the bathroom and then I just could not wait any longer, and so I got up on my own.'"
- Dehydration and undernourishment. "One of the most frequent and insidious signs of neglectful nursing home care is dehydration," says Kind. "If a nursing home does not have the adequate number of high-quality staff, residents in that home may not receive all of the food or fluids they need to remain hydrated and nutritionally sound. Meals may even be completely missed." Act immediately if you suspect this is occurring, Kind says.
- Status quo reigns. Ask staff what improvements the nursing home has recently put in place, especially since your loved one moved in. In particular, ask about anything they told you would be updated by now. "It is easy to identify nursing homes that are trying to improve and ones that are trying not to get shut down," says Uy.
- Continuity of Care Some facilities use outside staffing agencies to supplement their own nursing staff. Agency nurses often do not get the opportunity to develop a relationships with your loved one because they move from one facility to the next. Because of this, the quality of care your Dad receives is likely to be lower than someone he sees every day and develops a working relationship. Some nursing homes also shift their staff around from one area to another. You want the staff to be able to identify changes in your father’s health which only occurs with continuity of care.
- A bad feeling. Ultimately, your gut knows. "Most of these warning signs will be the family member's concern that something is not right, or a feeling of uneasiness when they visit," says Gil-Pires.