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If you’re looking for a safe nursing home for your loved one, the federal government’s new comparison tool is helpful starting point, but long-term care experts advise digging a bit deeper.
The Centers for Medicare and Medicaid (CMS) in October introduced an eye-catching alert icon on their online Nursing Home Compare tool to signal that a particular facility had recently been cited for abuse or neglect. Before the icon’s debut, consumers could learn about a nursing home’s history of abuse by looking through its health-inspection reports, which are also available on Nursing Home Compare.
The icon, a white hand within a red circle, appears for facilities cited in the past year for abuse that led to harm of a resident and/or those cited in each of the past two years for abuse that could potentially have led to a resident’s harm. CMS said that the symbol, updated monthly, is meant to supplement its five-star rating system and help consumers “develop a more complete understanding of a facility’s quality.”
The Wall Street Journal reported last month that 760 of the database’s 15,262 Medicaid- and Medicare-certified facilities — nearly 5% — had been marked as such.
“Our new abuse icon helps patients make the best choices for their care, incentivizing nursing homes to compete on quality,” CMS administrator Seema Verma said in a statement emailed to MarketWatch. “While fewer than 5 percent of the more than 15,000 nursing homes participating in Medicare and Medicaid will be subject to the icon, CMS nevertheless urges all providers to focus on preventing abuse.”
Robyn Grant, the director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, said she thought the new icon would serve to grab public attention. It also serves as an important incentive for nursing homes to examine their policies and procedures and work to prevent, respond to, and report abuse and neglect, she told MarketWatch.
“Abuse is just a persistent and pervasive problem in nursing homes,” Grant said. “I just think we do need something that’s startling enough to get people’s attention.”
But the warning drew complaints from the American Health Care Association (AHCA) and LeadingAge, two nursing-home industry associations. The groups argued that the icon gave the wrong impression — the visual urges consumers to avoid a facility altogether rather than investigate it further, they said — and didn’t account for facilities having taken corrective action after a citation.
“We feel that that icon is not helping a consumer, and that there’s much more information about an organization either being compliant or noncompliant,” Janine Finck-Boyle, LeadingAge’s vice president of regulatory affairs, told MarketWatch. She questioned whether consumers would actually look any deeper to learn about a facility after seeing the bright-red icon.
Mark Parkinson, AHCA president and chief executive, suggested in a statement that the icon had the potential to create “unnecessary worry” and “decrease access to care.”
A deeper problem
Icon controversy notwithstanding, abuse in nursing homes frequently goes unreported. The Health and Human Services Department’s Office of Inspector General this year estimated that one in five high-risk hospital emergency-room claims for Medicare beneficiaries living in nursing homes in 2016 “were the result of potential abuse or neglect.”
“We determined that [nursing homes] failed to report many of these incidents to the Survey Agencies in accordance with applicable Federal requirements,” the OIG review added.
If you’re looking for a nursing home for a parent, grandparent or other loved one, you might be preoccupied with any number of safety concerns: abuse and neglect, falls, infection or even unnecessary use of antipsychotic medication. But experts say there are steps you can take to help minimize risk. Here’s what you can do:
Check Nursing Home Compare, but seek additional context. The government site lists the 15,000-plus nursing homes nationwide that participate in Medicare and Medicaid. Some 97.5% of nursing homes in the U.S. were Medicare-certified in 2016, while 95.2% were Medicaid-certified, according to a February report from the National Center for Health Statistics.
While the database can help narrow down possibilities, there are lots of other factors to take into consideration, Grant said. For starters, read the facility’s actual survey report and then ask the facility what it has done to correct any problems and ensure they don’t happen again, she said.
Lisa Laney, an Asheville-based aging life care professional and board member for the nonprofit Aging Life Care Association (ALCA), agreed that Nursing Home Compare was a “starting point.” “There’s nothing better than firsthand knowledge from someone who’s had a family member in that community recently,” she said. “What that facility was like last year may be totally different from this year.”
Visit the facility — and not just during its optimal moments. “You should always set up a tour with an admissions person, and then you should go back without the admission person, because you want to see what really goes on,” said Debbie Fins, another aging life care professional based in Worcester, Mass., who also sits on ALCA’s board. Late morning on Saturday or Sunday will give you a sense of a facility’s “weakest point” in terms of staffing, Laney said.
Observe how staff and residents interact; whether residents seem engaged in activity or just slumped over with nothing to do; whether residents appear well-groomed; and how long it takes for staff to respond when a resident needs help, Grant said. At mealtime, pay attention to whether residents have a choice in what they eat, how food is served, and whether aides are assisting those who need help eating, Fins said.
Use your nose, Fins added: People have accidents, but is there a strong odor of urine or staleness in the air? Do people smell like they haven’t been cared for?
Research how well a facility is staffed. Ask about staff turnover rate, Laney said. “The biggest complaint we hear, bar none, is that there aren’t enough staff to take care of residents,” Grant said. Nursing Home Compare provides staffing charts for comparison.
Staffing can have a big impact on safety, Grant added: Neglect can stem from an inadequate number of people — often overworked and overwhelmed — available to provide care. Abuse, however unjustified, can occur when staffers are under tremendous pressure due to workload.
Experts recommend 4.1 hours of “direct-care” nursing time per resident a day, a number that includes time spent with nursing assistants, licensed nursing staff and registered nurses, Grant said. The New York-based Long Term Care Community Coalition offers state-by-state data on facilities’ direct-care staffing levels.
Meet with the nursing-home administrator and director of nursing. “They’re the two most important people for establishing the culture of that entire workforce,” Laney said. Take notice if the higher-ups seem unapproachable or cold, she said, as that could provide a window into how they treat staff.
Assess the potential for abuse. Ask about the facility’s policy for male staff members providing intimate care for female residents, Laney said, and how it handles such situations on short-staffed days. Ask what staff members’ anti-abuse training entails, Finck-Boyle added — as well as how exactly abuse allegations are reported and investigated, how family members are notified of an incident, and what preventive measures the facility takes.
Check CMS’s list of special focus facilities (SFFs), or nursing homes with “a history of serious quality issues” that receive extra attention from CMS. The government lists nursing homes that have been recently added, have or haven’t improved, and qualify as SFF candidates, among other categories. “All things being equal, if you have a lot of candidates in an area, I would probably stay away from the special focus facility,” Grant said.
Contact your national, state or local long-term care ombudsman program, a network that advocates for nursing-home residents. Ombudsmen can provide information on their experiences with various facilities, Grant said, and give you a general sense of the types of complaints they’ve received and how responsive a facility has been.
Consider a facility close to family and friends. “Finding a place that’s geographically convenient for people to visit regularly is something to keep in mind,” said Fins. “The more family or friends are visible in a facility in general, the better care people get.” Facility staff will know that “someone’s watching,” she said, and a family member can also pick up on subtle changes like weight loss or behavioral shifts.
If you wind up choosing a facility far away from family, try to enlist help from a care manager (who can act as an advocate for folks caring for aging family members), neighbors or fellow churchgoers, Laney suggested. And consider that pairing your loved one with a roommate could potentially provide “another set of eyes and ears,” particularly if she or he has conditions like memory impairment or trouble communicating.
Seek insight from a nursing home’s family council, a voluntary group composed of residents’ family members who voice concerns and advocate for improvements. Ask during a tour of the facility whether there is an active family council and who its leaders are, Finck-Boyle said.
Don’t be seduced by bells and whistles. “For someone living in those four walls, the only thing that matters is the quality of the staff that’s taking care of them — period,” Laney said. “The beautiful landscaping outside your window doesn’t matter if there’s nobody to help you pee in a timely fashion, and with dignity and compassion.”
If your loved one has dementia or Alzheimer’s disease, ask whether staff are trained in the basics of Alzheimer’s and dementia care, and provide care based on a person’s individual needs, said Doug Pace, the director of mission partnerships for the Alzheimer’s Association. “It is about balancing safety and autonomy for those folks,” he said.
Ask about the facility’s policy on using antipsychotic medications and its non-pharmacological approaches to care, Pace added. Patient advocates today warn about the dangers of misusing antipsychotic medications to treat dementia patients’ behavioral symptoms.
To the extent possible, start your research in advance. “If you have a loved one who is declining, and you are concerned that in the future they’re going to need nursing-home care, now’s the time to be looking — not when they’re in the hospital and you have to make a decision in 24 hours,” Fins said.
