Provider Guidance–Nursing Homes: It’s the Care, Not the Flare

Last week was quite a week. I attended the Illinois Department on Aging, Adult Protection and Advocacy Conference, and I viewed a Frontline and ProPublica PBS exposé on Assisted Living. Presentations at the conference and the Frontline program were harsh reminders of the bad things that can happen to residents in nursing homes and assisted living residences, even nice-looking ones.

Indeed, looks can be deceiving. The newest and showiest nursing home on the block is not always the best when it comes to long-term care. Bad things that happen in nursing homes—avoidable disease, injuries and death—occur due to poor care, not necessarily the age or “newness” of a facility.

So what causes poor care, you may ask. The answer is simple: Lack of good staffing. By that, I mean not enough well-trained and appropriately-supervised people. One presenter at the Illinois Department on Aging Adult Protection and Advocacy Conference talked about a nursing home where it was not unusual for one nursing assistant to be assigned 18 residents to care for on a shift (this is called a staffing ratio). Think about that. Daily care includes bathing, grooming, dressing, assisting with toileting or incontinence care, feeding, help with mobility, turning bed-bound patients and on and on. Good care is just not possible if someone is responsible for so much, for a lot of people.

It’s hard to get a handle on staffing ratios. Federal regulations say that nursing homes need to have enough staff to provide safe care—but they do not specify what that means. A number of states have established minimum standards. However, these are expressed as hours of care per resident per day. It’s hard to translate those numbers into an understandable standard of care. When I talk to professionals, attorneys, social workers, nurses and nursing assistants they tell me that more than a 10:1 ratio (i.e., 10 residents to one nursing assistant) on a day shift is bad news for residents who need skilled care, such as those in a nursing home. And less than 10:1 is better. Afternoon and night shift can have somewhat higher ratios because the need for hands-on care is less at those times.

So given that there are badly-run facilities providing poor care, how do you figure out which places are good on the inside, as well as on the outside?

It’s all about your evaluation process. Consider these steps:

Start your nursing home search by checking out the How To Evaluate A Provider pages on this website.

Read more about Best Practices and how to begin your search.

Visit Nursing Home Compare on the Medicare site. You can learn a lot about a nursing home from these pages. Be sure to review the staffing information, and compare staffing levels of several nursing homes to the state average and to others in your area. The more nursing/staff hours per day, per resident, the better.

Once you have narrowed your search to two or three nursing homes, download and bring our Nursing Care Checklist with you when you visit providers. It’s easy to forget things without a list as a guide.

With your checklist in hand, carefully observe how residents look and how they are treated. Probe, probe, probe about staffing, including credentials, training, turnover and ratios (as noted above). Talk to staff as you walk around. Ask one of the nurses or nursing assistants how many residents are assigned to them today, or in general. And remember that if the staff or the person giving you the tour is not open to your inquiry and forthcoming about staffing or any other question you have, this may well be the warning sign to look elsewhere.

So yes, there’s some work required and possibly some uncomfortable conversations, but in the end, you’ll find the right care for your needs. Stay tuned for Provider Guidance—Assisted Living next week, and learn about assisted living providers, including how to evaluate them and what criteria matters most.

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