Nurse Aide Turnover at Nursing Homes

We've talked a lot here about things you can look at when trying to choose a nursing home or assisted living facility for a loved one. 

This article in today's New York Times highlights an important factor to examine when you are looking at the quality of care in any given nursing home:  nursing aide turnover.  According to the article, more than 70% of nurse aides  change jobs within a given year. 

The work that nurse aides do is invaluable.  They provide the majority of hands-on care to nursing home residents, assisting them with eating, bathing, hygiene, and getting around.  Given the difficult nature of this work, it is important that the aides are well-trained, working in a supportive environment, and being paid adequately for the work they do. 

Unfortunately, as the article points out, this is very often not the case.  Most troubling, high nursing aide turnover usually results in poorer care for the residents. 

More Strategies for Choosing a Nursing Home

This week's New York Times' Health section offers suggestions for families choosing a nursing home for a loved one.  

The article recognizes that, unfortunately, the majority of nursing home placements come after a person has been hospitalized, and that families often have very little time to fully explore their options.  However, many of these suggestions are useful even if you do not have much time before you have to decide upon a particular nursing home. 

The article suggests that you visit medicare.gov, and use their Nursing Home Compare tool to help get a picture of the facilities in your area.  We covered this topic in more detail here

The article also emphasizes the importance of visiting potential nursing homes, preferably at different times of the day, and using this checklist to review basic aspects of the nursing home. 

Also important in choosing the right home for your loved one is the nursing home's guiding philosophy.  The article suggests that you ask about "person-centered care" and "consistent assignment," burgeoning trends in the nursing home industry that can increase the quality of resident care.  While person-centered care focuses on allowing the residents to make their own schedules and maintain a degree of autonomy, consistent assignment focuses on the staff of the nursing home.  In a nursing home which practices consistent assignment, the same caregivers, nurses, and doctors attend to the same person as regularly as possible--allowing them to create lasting relationships, which positively affects the resident's care.  High staff turnover, on the other hand, can mean that resident care suffers--which is why the article suggests that you avoid nursing homes with over 50% annual turnover. 

Finally, it recommends you call your local Ombudsman's program to learn more about facilities you may be considering.  In New Mexico, the Ombudsman's bureau is a division of the state Aging and Long-Term Services Department.  Information on this program can be found at its website.  In New Mexico, there are five local and regional ombudsmen, in addition to the State Ombudsman. 

Using Surveys to Learn More About a Nursing Home, Part II

As I mentioned in my last post, looking at state nursing home surveys can be a very helpful tool in your quest to learn more about a particular nursing home. 

Now I will walk you through the information you can find at the New Mexico Division of Health Improvement website

In Step 1, you choose your provider type from the drop-down menu.  "Nursing Homes" is the third entry from the bottom. 

For Step 2, you can search by city, county, or provider name.  If you are trying to look at all nursing homes in Albuquerque or Bernalillo County, the result list may be too long; if you have difficulties, you can narrow it to just one particular nursing home. 

Once you have the information screen for a particular nursing home, it will show you the facility's name, address and phone number.  It tells you its Medicaid, Medicare, License number, and License expiration date.  It also tells you the name of the nursing home's current administrator, who owns the nursing home, and how many beds it has.   

There are three icons directly below this information:  View Map, View Reports, and View Statistics.  For our purposes, we are going to focus on "View Reports."

Once you've followed that link, you will have a listing of surveys conducted at this facility.  Usually, the most recent survey appears first.  It will tell you the type of survey--"health" or "life safety code"; the event ID; the dates the surveyors were at the facility; and the highest citation code.  It will also let you look at the survey itself, via a link at the bottom of that section. 

For your purposes, the most important information is likely contained within the "highest citation code" section, and the most recent surveys themselves.

Next to the "highest citation code," if there is a code, you will see a link for the "Scope/Severity Grid" next to it.  (If there is no code, that means that no violations were found in that survey.)   

This grid is very helpful in understanding the severity of the problems that the surveyors noted at the nursing home. The letter that appears in front of the "highest citation code" will correspond to a letter on the grid.  An "A" code shows that the problem was isolated and did not actually cause harm to anyone, but has some chance of causing minimal actual harm to the residents.  At the other end of the spectrum, an "L" code violation means that there was widespread conduct that caused immediate jeopardy to the residents' health or safety. 

Once you've gotten a sense of the severity of the problems, you can view the survey itself.  "Health" surveys typically discuss resident treatment and resident rights.  "Life Safety Code" surveys typically discuss the physical condition of the facility, and whether it is in compliance with fire and other safety codes. 

The top of the survey  has administrative information.  What interests us, though, is the narrative in the left-hand column:  "Summary Statement of Deficiencies." 

Here, assuming violations were found in the survey, you will see a description of the violation.  First, the surveyor states the language from the regulation that they are using to guide them.  This is followed by what the facility did that was not in compliance with the regulation.  It will typically say that "this REQUIREMENT is not evidenced by...", and then describes the problem(s) the surveyors observed at the facility. 

On the right-hand side, the facility writes its "Plan of Correction," which includes a response to the survey's criticism, and a plan of action to remedy the deficiencies the surveyors cited. 

These surveys are often fairly dense and can be hard to read, but hopefully, they will help provide you with another tool when you have the difficult task of  choosing a nursing home for a loved one. 

Using Surveys to Learn More About a Nursing Home, Part I

We've spoken before about important factors to consider when choosing a nursing home for your loved one

You also have another tool, one that can be very useful, when you are looking at a particular nursing home or choosing from several nursing homes. 

The State of New Mexico's Division of Health Improvement conducts evaluations of nursing homes on at least a yearly basis, and more often when there is a complaint about a particular home.  These evaluations include a visit to the nursing home by a team of health care professionals, and usually last several days. 

These evaluations, called "surveys," seek to make sure that the nursing home is following the state regulations for nursing homes.  While the surveyors are at the nursing home, they observe conditions in the nursing home, and also review the medical chart of randomly selected residents.  They look at all aspects of the nursing home's care, from its food to its maintenance to its staffing levels.

When they have finished their observations at the facility, the surveyors fill out a series of forms, detailing any problems that they observed.  They state which regulations, if any, were not being properly followed, and discuss details of those deficiencies.  They then give a copy of this survey to the nursing home, which has to then come up with a "Plan of Correction," showing that they are taking steps to correct the problems the surveyors found.   

At this web site, you can search by the nursing home's name for its surveys. In an upcoming post, I will tell you more about how to use this web site, and how to interpret the information you find there. 

Brown University Study: Hispanics more likely than whites to live in nursing homes of poor quality

A team of Brown University researchers, led by Mary Fennell, a professor of sociology and community health, has concluded that Hispanic residents are more likely than whites to live in nursing homes of poor quality. These nursing homes are more likely to have structural problems, staffing and financial issues.  

“The most shocking finding is the pervasiveness of disparities in nursing home care that are primarily white, compared to nursing homes that are a mix of whites and Hispanic residences,” Fennell said.

Apparently, this study is a follow up on a 2007 study that concluded that African Americans are also more likely than whites to live in poor quality nursing homes. 

“People with resources can get into very good places or alternatives for nursing home care,” Fennell said. “Everyone else is left with not-very-good facilities that are not performing well.”

Notably, the study’s findings indicate a departure from a historical pattern. “Traditionally, the group has used formal long-term care services less frequently than any other U.S. ethnic group. They had also been less likely than white or black residents to live in nursing homes. In Hispanic households, elder care has traditionally been handled by adult daughters at home, but acculturation and financial issues have forced a growing number of young Hispanic women into work outside the home.”

The study notes that the number of Hispanics in nursing homes is expected to rise. The details of the study can be found in the January 2010 edition of Health Affairs.

New Report Examines Nursing Home Trends

The National Consumer Voice for Quality Long Term Care, NCCNHR, recently published an article summarizing a new report by the University of California, San Francisco, showing trends in U.S. nursing homes by state for 2003 through 2008. 

"These trends in nursing homes should be of concern to policy makers, nursing home providers, and consumer advocates because they do not show major improvements over the past seven years. Moreover, they show continued wide variations in staffing, residents, quality of care and enforcement across states."

Here are a few points I found particularly interesting:

  • The average number of deficiencies issued to nursing homes for violations of federal regulations, per facility, increased by 7.5 percent between 2003 and 2008.
  • The number of for-profit nursing homes increased while the number of non-profit and public homes decreased.
  • Staffing levels have increased slightly over the last decade.  Unfortunately, "[t]he average staffing levels are far below the level recommended by experts which is 0.75 RN hours per resident day and 4.1 total hours of nurse staffing per resident day."

Under New Mexico law, nursing homes must provide only 2.5 hours of nurse staffing per resident day, which is far below the recommended 4.1 hours cited by NCCNHR.  More importantly, however, under the Federal rules, nursing homes must provide a sufficient number of qualified staff to meet the needs of the residents

Choosing a Nursing Home: Where to Begin

Realizing that a loved one needs more care than you can provide is a difficult time families face every day.  Frequently, the decision to place a loved one in a nursing home happens quickly, perhaps after a traumatic event. I think many people do not realize they have access to so much information on the nursing homes near them.

A good starting place is the Centers for Medicaid and Medicare Services (CMS) Website. Here, you will find general information on nursing home resident rights, information about how to pay for nursing home care and other tools on what to look for in a nursing home. You'll also find the "Nursing Home Compare" interactive tool, which enables you to search for nursing homes near you and compare them to others.

CMS gathers data from State Department of Health Surveys and the nursing home itself and then comes up with a rating system. As the site indicates, "more stars are better."

You can ask yourself if this is a place that you would feel comfortable in. And here are a few things to look for and some questions to ask:

  1. Does staff seem attentive and patient . . . or rushed and overworked?
  2. Has the facility ever been cited for understaffing during an inspection?
  3. Do the residents get to choose when to get up in the morning and when to have breakfast?  How about lunch and dinner?
  4. Do the residents get to choose when and how to bathe?  Shower or bath at your preferred time?
  5. Can friends and family visit anytime - day or night?
  6. For a more extensive list of questions to ask and what to look for in a nursing home, download the Medicare Guide to Choosing a Nursing Home.

My suggestion is to concentrate on nursing homes near you. Make a list of potential homes and visit all of them. You wouldn't buy a house without going inside! Do the same when choosing a nursing home for your loved one. And for a more extensive list of questions to ask and what to look for in a nursing home, you may find the Medicare Guide to Choosing a Nursing Home (PDF) quite helpful.