Sunday, January 15, 2006

nursing homes, how to select, monitor, and evaluate

Generally, there are four main reasons for residing in a nursing home. These are: disturbances in thinking; illness that requires special medical attention not available at home; harmful behavior to one's self or others; and environmental factors that include not having people who can adequately care for the older person or nonaccessibility of special equipment, such as wheelchairs, lifts, and special tubs. Several factors should be considered when selecting a nursing home. The older person and/or family should understand how finances determine the options. They should know the amounts Medicare and Medicaid will pay for accredited facilities and then find out which facilities are accredited in the area. (At present, Medicare coverage is generally not available for nursing home stays unless they follow a hospitalization episode.)
There are several types of nursing-home care available and these should be matched to the individual's needs. If intensive care is needed, a 24-hour skilled nursing facility is necessary. This means that there are qualified nurses on duty 24 hours a day. If constant medical care is not necessary an intermediate- care facility will be quite satisfactory at about half the cost. In an intermediate care facility, care will be administered by unskilled staff under the supervision of at least one registered nurse. The older individual's doctor can be helpful in determining the type of care necessary. Frequently, the doctor can recommend a facility since he or she visits nursing homes with some regularity and knows how well his or her orders are followed. Another source of referral may be family clergy who can probably recommend church-owned facilities in the area.
Once the list of nursing homes that are available has been narrowed down by the type of care and cost, it is probably a good idea to check with the Better Business Bureau to determine whether all are reputable facilities.
At this point it is advisable for the older person and family to visit some of the prospective homes. If the older person is able, allow him or her as much input in the decision as possible.
Official statements of overall nursing home policy issued by operators and organizations have value because they define broad goals of nursing home care. The best of these include the following principles. The resident comes first; individual feelings, emotions, and wants are considered of utmost importance; the comfort and happiness of the resident is paramount.
Residents' rights desirably include:
1. Being fully informed of their medical condition
2. Participating in planning of medical treatment
3. Being transferred or discharged only for medical reasons
4. Being free from mental and physical abuse
5. Being free from drug and nonemergency physical restraints, except as ordered by a physician for a specified period of time, or to protect from self-induced injury
6. Being treated with consideration, respect, and dignity
7. If married, being assured of privacy for visits by spouse and if both spouses are residents, being permitted to share a room.
Three broad areas to assess when visiting prospective homes are medical, nursing, and therapeutic services; food and housekeeping services; and the social and psychological atmosphere.
When evaluating a specific nursing home, individuals should pay attention to the rapport between staff and residents, how clean the residents are, if there are enough bathrooms, if there is proper lighting and ventilation, whether there is sufficient storage space, and general appearance of the rooms. Nursing homes that are most readily accepted by both family and resident are those with pleasant environments. Some things that help to provide these types of environment include providing residents with safe patio areas so that they can enjoy the fresh air and sunshine and not feel "penned in," varying the colors of rooms and hallways, allowing residents to decorate their own areas, and having wall hangings, plants, and aquariums to give the facility a more homelike appearance. Other factors include providing enough living space to allow for group exercise, programs, crafts, and group interaction, and promoting opportunities for spiritual involvement by having a retired pastor or pastoral student in attendance regularly or having choirs or a hymn sing-along. It is important for the nursing home to provide enough opportunities and activities to enrich the residents' lives, instead of simply providing a place to exist.
It may be helpful for the family to carry a checklist on the nursing home visit so as not to overlook anything. The U.S. Department of Health and Human Services (HHS) has a prepared list, which may be helpful.
This list is as follows:
1. Does the home have a current license from the state?
2. Does the administrator have a current license from the state?
3. If you need and are eligible for financial assistance, is the home certified to participate in government or other programs that provide it?
4. Does the home provide special services such as a specific diet or therapy that the patient needs?
5. Location:
A. Pleasing to the patient?
B. Convenient for patient's personal doctor?
C. Convenient for frequent visitor?
D. Near a hospital?
6. Accident prevention
A. Well-lighted inside?
B. Free of hazards underfoot?
C. Chairs sturdy and not easily tipped?
D. Warning signs posted around freshly waxed floors?
E. Handrails in hallways and grab bars in bathrooms?
7. Fire safety
A. Meets federal and state codes?
B. Exits clearly marked and unobstructed?
C. Written emergency evacuation plan?
D. Frequent fire drills?
E. Exit doors not locked on the inside?
F. Stairways enclosed and doors to stairways kept closed?
8. Bedrooms
A. Open into hall?
B. Windows?
C. No more than four beds per room?
D. Easy access to each bed?
E. Fresh drinking water at each bed?
F. Drapery for each bed?
G. Nurse call bell by each bed?
H. At least one comfortable chair for each patient?
I. Reading lights?
J. Clothes closet and drawers?
K. Room for a wheelchair to maneuver?
L. Care in selecting roommates?
9. Cleanliness
A. Generally clean, even though it may have a lived-in look?
B. Free of unpleasant odors?
C. Incontinent patients given prompt attention?
10. Lobby
A. Is the atmosphere welcoming?
B. If also a lounge, is it being used by residents?
C. Furniture attractive and comfortable?
D. Plants and flowers?
E. Certificates and licenses on display?
11. Hallways
A. Large enough for two wheelchairs to pass with ease?
B. Hand-grip railings on the sides?
12. Dining room
A. Attractive and inviting?
B. Comfortable chairs and tables?
C. Easy to move around in?
D. Tables convenient for those in wheelchairs?
E. Food tasty and attractively served?
F. Meals match posted menu?
G. Those needing help receiving it?
13. Kitchen
A. Food preparation, dishwashing, and garbage area separated?
B. Food needing refrigeration not standing on counters?
C. Kitchen help observe sanitation rules?
14. Activity rooms
A. Rooms available for patients' activities?
B. Equipment (such as games, easels, yarn, kiln) available?
C. Patients using equipment?
15. Special-purpose rooms
A. Rooms set aside for physical examinations or therapy?
B. Rooms being used for stated purpose?
16. Isolation room
A. At least one bed and bathroom available for patients with contagious illness?
17. Toilet facilities
A. Convenient to bedrooms?
B. Easy for a wheelchair patient to use?
C. Sink?
D. Nurse call bell?
E. Hand grips on or near toilets?
F. Bathtubs and showers with nonslip surfaces?
18. Grounds
A. Residents can get fresh air?
B. Ramps to help handicapped?
19. Medical
A. Physician available in emergency?
B. Private physician allowed?
C. Regular medical attention assured?
D. Thorough physical immediately before or upon admission?
E. Medical records and plan of care kept?
F. Patient involved in developing plans for treatments?
G. Other medical services (dentists, optometrists, etc.) available regularly?
H. Freedom to purchase medicines outside home?
20. Hospitalization
A. Arrangement with nearby hospital for transfer when necessary?
21. Nursing service
A. R.N. responsible for nursing staff in a skilled nursing home?
B. L.P.N. on duty day and night in a skilled nursing home?
C. Trained nurses' aides and orderlies on duty in homes providing some nursing care?
22. Rehabilitation
A. Specialists in various therapies available when needed?
23. Activities program
A. Individual patient preferences?
B. Group and individual activities?
C. Residents encouraged but not forced to participate?
D. Outside trips for those who can go?
E. Volunteers from the community work with the patients?
24. Religious observances
A. Arrangements made for patient to worship as he or she pleases?
B. Religious observances a matter of choice?
25. Social Services
A. Social worker available to help residents and families?
26. Food
A. Dietitian plans menus for patients on special diets?
B. Variety from meal to meal?
C. Meals served at normal times?
D. Plenty of time for each meal?
E. Snacks?
F. Food delivered to patients' rooms?
G. Help with eating given when needed?
27. Grooming
A. Barbers and beauticians available?
28. General atmosphere friendly and supportive?
29. Residents retain human rights?
A. May participate in planning treatment?
B. Medical records kept confidential?
C. Can veto experimental research?
D. Have freedom and privacy to attend to personal needs?
E. Married couples may share room?
F. All have opportunities to socialize?
G. May manage own finances if capable, or obtain accountant if not?
H. May decorate own bedrooms?
I. May wear own clothes?
J. May communicate with anyone without censorship?
K. Are not transferred or discharged arbitrarily?
30. Administrator and staff available to discuss problems?
A. Patients and relatives can discuss complaints without fear of reprisal?
B. Staff responds to calls quickly and courteously?
31. Residents appear alert unless very ill?
32. Visiting hours accommodate residents and relatives?
33. Civil rights regulations observed?
34. Visitors and volunteers pleased with home?
Once a home has been chosen and the family member moved in, personal observation and visits are the best means of monitoring care. Visit the facility at different times of the day and week in order to observe different shifts.
If the resident is mentally competent he or she can frequently help to monitor the quality of care. If, however, the resident is unable to reason, it will be necessary to identify a responsible staff member to help monitor care and resolve problems. Remember to speak with the staff when pleased with the care as well as when displeased. Positive comments go a long way and will help when trying to work out problems in the future.
Some facilities plan regular "family meetings," which are held several times a year, at which senior staff, relatives, and the resident meet to share concerns, questions, and suggestions for new programs or care.
A few facilities have organized "resident councils" in which residents participate in some of the decision-making that affects their lives.
Deedy, J. Your Aging Parents. Chicago: The Thomas More Press, 1984.
Gillies, J. A Guide to Caring for and Coping with Aging Parents. Nashville: Thomas Nelson Publishers, 1981.
Lester, A. D. and Lester, J. L. Understanding Aging Parents. Philadelphia: The Westminster Press, 1980.


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