Nursing Home

Advice from the Texas Attorney General's Office

WHERE DO I START? Many people simply choose the closest facility. Before making this decision, however, you should do a little shopping. Some facilities are better than others. Unfortunately, there are facilities that consistently violate state standards and subject their residents to poor care. You should start by asking friends with relatives in nursing homes for their recommendations— good and bad. Ask your physician and nursing staff if there are places close to you that stand out as very good or very bad.

Pick three or four facilities close to home and prepare to visit. Ask to talk to the Administrator or the Director of Nursing. The following questions will help you decide whether a facility is right for your family. Pay attention if you feel that you are not getting a straight answer. Notice when the answers are inconsistent with what you observe at the facility.

Call the Texas Department of Human Services at 1-800-458-9858 and ask about the places you are considering. Although the TDHS employees cannot designate a facility "good" or "bad" or recommend one facility over another, they can answer the following questions about any facility:

Have there been any proposed license terminations in the past two years?
How many complaints have been filed in the past year?
How many complaints in the past year have been found to be valid?
How many deÿciencies have been cited in the past two years?
How many "quality of care" violations have been cited in the past two years?
When was the last visit by TDHS, and what was the purpose of the visit?
Has the owner of this facility had other facilities recommended for license termination?

YOUR VISIT-- WHAT TO ASK AND LOOK FOR. When you first walk in, take a deep breath. How does it smell? As you walk down the halls, take another deep breath. How does it smell? Look at the floors. Are the floors clean? These simple observations will alert you to conditions that residents live with daily. A facility that does not keep residents clean will smell bad. A facility that allows floors to stay dirty does not put a high priority on cleanliness.

"Please show me the most recent survey report, and any resulting follow-up reports." Every year, the State inspects each Texas nursing home and prepares a survey report. This report cites deficiencies found by state surveyors during recent inspections of the facilities. It describes these violations in detail (left column) and facility efforts to correct problems (the "plan of correction," right column).

If the documented problems show poor care of residents, incompetent staff, a callous attitude by management, or if a facility took too long to correct problems, you probably do not want your loved one there. Sometimes, poor care creates new problems. For example, unanswered call lights can lead to urinary incontinence when a person needs help going to the bathroom.

By law, nursing homes must make this and other compliance reports available to you. The facility must provide an accessible and well-lit place for you to review the documents. The facility must also post a notice informing you that these documents are available. If the facility fails to meet any of these requirements during your visit, notify the Texas Department of Human Services. Remember, facilities are often at their best when the State inspects them.

Most facilities have some violations; this does not necessarily mean the facility provides poor care. You will be more concerned about some violations than others. Standards exist for several areas, including nursing care, quality of life, dietary services, physician services, rehabilitative services, infection control, pharmacy services, facility management, and observation of resident rights. Violations of these standards are labeled by "F-tags" on the survey report. Read the speciÿc allegations. Following is a brief summary of the violations to look for in a facility's survey reports:

F-223, 224, or 225 - Physical, verbal, sexual, mental abuse, and involuntary seclusion and misappropriation of resident property are unlawful; the law specifies proper staff treatment of residents, and proper investigation and reporting of abuse allegations.

F-241 - Residents' dignity and individuality must be respected.

F-246 - Residents' needs and individual preferences must be accommodated.

F-253 - Housekeeping and maintenance for a sanitary, comfortable, orderly environment must be maintained.

F-254 - Beds and bath linens must be clean and in good condition.

F-272 - Each resident's needs must be assessed to determine an appropriately tailored care plan.

F-279 - Each resident should have a comprehensive care plan for meeting his or her medical, nursing, mental, and social needs.

F-309 - Each resident must receive quality care necessary to attain the highest practicable well-being and prevent avoidable decline.

F-310 - A resident's abilities in activities of daily living (bathing, toilet, eating, dressing, grooming, moving) should not be allowed to deteriorate unless this is clinically unavoidable.

F-312 - A resident unable to carry out activities of daily living must receive help to maintain good nutrition, hygiene, and grooming.

F-314 - A resident should not develop pressure sores unless they are clinically unavoidable, and a resident who does have pressure sores should get treatment to promote healing and prevent new sores.

F-315, 316 - In cases of urinary incontinence, no catheters should be used unless clinically necessary; infections should be prevented; normal bladder function in incontinent residents should be restored when possible.

F-317, 318 - Residents should be helped, with active or passive exercise, to maintain range of motion in order to prevent the decline of their ability to move.

F-319, 320 - Residents should receive help with mental or social problems; residents who enter a facility without mental or social adjustment problems should not become angry, depressed, or withdrawn.

F-321, 322 - No nasogastric tubes should be used to feed residents unless unavoidable; residents fed by tubes must not develop problems related to poor nasogastric care (ulcers, pneumonia, dehydration).

F-323, 324 - The facility must provide adequate help to prevent accidents and minimize accident hazards.

F-325, 326, 327 - Adequate diet and hydration must be provided to each resident.

F-328 - Residents' special medical needs must be met (injections, colostomy, prostheses, foot care, for example).

F-329, 330 - Residents must not be given unnecessary drugs.

F-332, 333 - Residents must not be subjected to significant medication errors.

F-353 - The facility must provide sufficient staff to meet resident needs and maintain or attain the highest practicable physical, mental and social well-being.

F-354 - There must be a registered nurse at the facility eight hours a day, seven days a week.

F-363, 364 - Food must be nutritious and palatable.

F-441, 442 - A facility must have an infection control program to prevent development and spread of disease.

"What is the ratio of nurse aides to residents for the day, evening and night shifts? Is there a facility policy about this? How often do you call temporary employees?" Most of the day-to-day direct care that residents receive is from nurse aides, with licensed nurses supplementing this care in good facilities. Walking with residents to the dining room; helping with eating, going to the bathroom, bathing, and dressing; cleaning up after accidents; or just saying a kind word—this assistance will probably be given by a nurse aide. When a facility does not have enough aides, residents have to wait for attention. Often, they give up and get no help.

A nursing facility is required by law to maintain "sufficient staff to provide nursing and related services (1) in accordance with each resident's plan of care; and (2) to obtain and maintain the physical, mental, and psychosocial functions of each resident at the highest practicable level, as determined by the resident's assessment and plan of care."

While no specific number or ratio is required, the National Citizens' Coalition for Nursing Home Reform has concluded that minimally acceptable ratios of direct care givers to residents, for three daily work shifts, are as follows:

Day One direct care giver to five residents
Evening One direct care giver to 10 residents
Night One direct care giver to 15 residents

When you ask about this, be sure the answer is for how many aides or direct care givers actually work, rather than how many are scheduled to work. A good facility will ensure adequate stafÿng and will make provisions for staff absences.

"How many complaints have been filed against this facility in the past year? What have they been for? Can I see the reports?" The Texas Department of Human Services (TDHS) investigates complaints against nursing homes. Unless an immediate threat is described, however, TDHS does not investigate right away. Keep in mind that, although a problem may have existed at the time a complaint was filed, when TDHS arrives at the facility, the problem may not still exist, or there may no longer be any evidence. For this reason, pay attention not only to the complaints that are "substantiated," but to the total number of complaints. (For example, a caller may complain that her father is constantly wet and dirty; but when TDHS arrives to investigate, the resident is clean and dry. TDHS cannot substantiate the complaint, though it may have been based on the caller's true statements.)

"What kind of turnover do you have for nurses and nurse aides?" Staffng is an extremely important factor in the quality of care people receive at a nursing facility. Personnel costs are signiÿcant, and a facility looking to improve its bottom line may try to cut corners on staffing. Competent, loyal, caring employees are unlikely to stay at a facility that imposes impossible workloads, pays poorly, offers no beneÿts, and does not offer training.

More important, if the number of nurse aides and nurses at the facility is too low, those who do work will be constantly stressed, in a hurry, and unable to provide the care residents need. In addition, high turnover means that there is no continuity—a resident will not know the people taking care of him or her, and the staff won't be familiar with the resident's needs. This is an important indicator of the value placed by the facility on providing good care. Talk is cheap, but good staff is not.

"What is the ratio of registered nurses to residents for the day, evening and night shifts? Is there a facility policy about this? Have you asked TDHS for a waiver from the nursing standard? How often do you call temporary employees?" Studies have shown that higher nursing staff levels are consistently associated with better care, and the presence of RNs turns out to be most important. The law requires a nursing home to have an RN eight hours a day, seven days a week, and a licensed nurse serving as charge nurse (the nurse in charge during a shift) on each shift. In addition, the facility's Director of Nursing should not serve double duty as a charge nurse unless a facility has fewer than 60 residents. Many nursing homes ask for, and receive, a waiver from these requirements.

When you ask this question, if the facility representative won't tell you how many RNs typically work on each shift, or suggests that RN services are not necessary, or tells you only that the facility complies with current regulations, you may want to consider another facility, especially if their "compliance" is accomplished through a waiver. You might also want to reconsider if the facility does not have enough RNs and licensed nurses on staff, but uses temporary employees frequently. Permanent staff members who can get to know residents and their individual needs can serve these residents much better than temporary staff who have never met them.

"Is there an independent resident family council at this facility? Please give me the name and telephone number of the president." Residents and their families have a right to meet with each other without facility staff being present. Each facility is required to provide a private meeting place, and the facility must help residents attend the meetings. Often, these councils discuss problems and substandard care received by the residents. Unfortunately, some facilities discourage these councils, interfere with meetings, or fail to set aside meeting rooms. Worse, some facilities retaliate against residents whose families are outspoken advocates—a tactic that is against the law. Find out whether the facility you are considering encourages a family council and a resident council. Talk to the president of each council to see how the facility responds to complaints and concerns expressed by the group. Ask if there is a problem with adequate stafÿng
of nurses and nurse aides.

"Are all the nurse aides certified? If they are not certified, are they paid for working while they get trained here?" Nurse aides must be certified to take care of residents. An aide becomes certified after completing a training program and demonstrating competence. An untrained aide might not know, for example, how to avoid spreading infection from one resident to another, how to bathe a resident with delicate skin, or how to recognize when a resident needs emergency intervention. A nursing home may hire uncertified aides and provide training, but you should be aware that some facilities actually prefer to hire uncertified aides because they cost less—not only are salaries lower for uncertified aides, but some facilities actually charge them for the "training"
they get while working.

Often, a nursing home competes with minimum wage businesses for employees from the unskilled labor pool. A nursing home, therefore, shows a commitment to quality care by doing whatever is necessary to attract employees who (1) have a choice and (2) choose to work as a nurse aide. If the answer to your question is that many of the facility's aides are "in training" or not certiÿed, consider looking elsewhere.

"Please tell me how you take care of residents who are incontinent—how often do you check them and clean them up? Is there a written facility policy about this? May I see it?" Sometimes a person loses control of bowel and bladder functions in a nursing home. This can occur when a resident needs assistance to get to the bathroom and has to wait too long, too many times. Eventually, the person becomes "incontinent" and has little or no control. In that case, the resident must be kept clean and dry after each episode of incontinence; otherwise the skin breaks down from constant exposure to the waste. Once the skin surface breaks, the person is vulnerable to infections and further breakdown, especially if the skin is not kept clean and allowed to heal. Unless a resident is unable to communicate, he or she will probably activate a call bell or light to ask for assistance. If a facility places a high priority on responding to calls, residents are less likely to become incontinent in the ÿrst place. In a good facility, a resident will receive prompt assistance before or after an incontinent episode. How long would you want to sit in a soiled undergarment, waiting for a nurse aide to help clean you up? Go to the nurse station where call lights are, and see for yourself how the staff responds when a light comes on.

"How many residents are physically or chemically restrained? Does each one have a doctor's order? Is there a written facility policy about this? May I see the policy?" By law, each resident has a right to be free from chemical or physical restraints unless the restraints are necessary to treat the resident's medical symptoms. In that case, they may be used only with a doctor's authorization. The only other instance when restraints may be used is in an emergency, to protect the resident or others from injury. Discipline and convenience are improper reasons for restraining a resident. In the past, some facilities found it easier to sedate residents, or tie them to chairs, than to provide adequate supervision for active, mobile, alert residents.

Improper use of restraints is often linked to short stafÿng. Look around the facility, visit the public areas, and look for residents who are tied or strapped into chairs, or who appear to be sedated with drugs. Ask why these people are restrained. Are you convinced by the answer?

"How many residents here have pressure sores? How many of these residents developed the pressure sores in the facility? What do you do to prevent pressure sores? How do you treat pressure sores?" Pressure sores (called decubitus ulcers) are one of the most serious problems faced by nursing home residents. Skin breaks down when there is unrelieved pressure on a point, preventing circulation. Elbows, ankles, heels, and tailbones (coccyx) are common places for these sores to develop. The most severe sores penetrate skin, tissue, and muscle—through to the bone. Skin also suffers from exposure to urine or feces, as when residents are incontinent and are allowed to lie in their waste. Although a few pressure sores may be unavoidable, most pressure sores are preventable if bedfast residents are kept clean and dry, and if they are turned at least every two hours.

A resident with a pressure sore is vulnerable to infection and has higher nutritional needs because healing requires more calories and protein. In addition, dressings must be changed frequently by a nurse who has been trained not to spread infection. If the facility has a history of pressure sore problems, consider looking elsewhere. Pressure sores can be an indicator of other serious deÿciencies in the quality of care residents receive.

"What administrative steps must be taken before a resident can be taken to the hospital for an emergency? Is there a written facility policy about this? May I see it?" When a resident has a medical emergency, a nursing home should (1) recognize the need and (2) send the resident to the hospital. Unfortunately, some facilities fail at both responsibilities. If the nursing staff is not competent or is unfamiliar with a resident's medical history, or if a resident's need is not noticed because staff are too busy elsewhere, then a resident could suffer a medical emergency and receive no attention until it is too late. A nursing home is generally not paid by Medicaid for the time a resident is in the hospital. Some facilities allow a resident to suffer severe medical emergencies before calling an ambulance to send the resident to the hospital. Some require cumbersome administrative procedures before a resident can be sent to the hospital. If your loved one has a medical emergency in the nursing home, you want facility staff to be calling the ambulance and notifying you, not trying to get authorization from a manager who is away from the desk.

"What kind of help do you offer to keep people mobile, to prevent muscle atrophy and rigidity?" When you do not move, you get stiff. If you did not move for a whole day, you would get very stiff. Sometimes people in a nursing home, if they are conÿned to their beds or wheelchairs, lose the range of motion they used to have. They need to receive passive exercise or use a roll (a piece of foam or cloth that is placed in the hand). Simple daily attention can help prevent deterioration. When you are visiting the facility, notice whether the residents you see appear to suffer from muscle atrophy or rigidity. When you ask, notice whether this appears to be a matter of concern for the facility. (Is anyone assigned "range of motion" responsibility, or is it left for who ever has time?) Although loss of mobility may not be life threatening, it has a significant impact on the quality of a person's daily life.

"Do you keep adequate staff at the facility? How do you decide what's adequate? Is there a written facility policy about this? May I see it?" Adequate staffing—quality and quantity—is one of the most important differences between a good nursing home and a bad one. See what the facility's written policy is. A good policy will address quality of care. A bad policy is one that is vague or refers only to numerical standards without reference to quality of care. The facility policy should be to have enough nurses and nurse aides to provide good care and prevent avoidable deterioration of each resident's health. Sometimes "average" staffing numbers for an entire facility hide the fact that less profitable units (often Medicaid) are understaffed while more profitable units (Medicare and private-pay) are fully staffed.

"How many lawsuits have been filed against this facility or its employees in the past two years? Were they filed by the State or by private parties? What were these suits for?" A nursing home that gets sued frequently should not be your first choice. If lawsuits are based on improper nursing care, consider talking to the families who brought the suits. You do want to know how residents are treated, and how the management responds to problems.

"How do residents spend their time here? Are there planned activities that are mentally and socially engaging? What are today's activities?" Nursing home residents are like the rest of us. They like to be engaged in interesting activity. A good facility will plan music, games, exercise, lectures, movies, local outings, shopping, crafts, and other activities in which residents with varying levels of physical and mental ability can participate. In a poor facility, staff will turn on the television, set some playing cards or dominoes out, and leave residents alone.

Ask to see the activity calendar, but also look around while you are there, and see what people are doing. Are they bored? Socially engaged? Sedated? Apathetic? Depressed?

"Are Medicaid residents kept separate from other residents? How does a Medicaid resident's treatment and level of service differ from that of a non-Medicaid resident?" Chances are high that even if your loved one does not enter a nursing home as a Medicaid recipient, he or she will eventually become eligible for Medicaid. A nursing home may not legally discriminate between Medicaid and non-Medicaid residents, but subtle differences may nevertheless exist. Is there a "Medicaid wing?" Is there any difference in the food service? Is the staffing level different? Are different linens used for Medicaid residents? Are any parts of the facility off limits to Medicaid residents? Is the nursing staff aware which residents are Medicaid recipients? If so, why?

"How many people have moved out of this facility in the past year? How many were asked or forced to leave?" Moving into or out of a nursing home is often traumatic. People usually do not leave one facility for another without a strong reason. Sometimes, an outspoken resident, or a resident with an outspoken family, will be asked to leave a facility. Although it is illegal for a nursing home to retaliate against any person for complaining about abuse or neglect, it happens. Poor facilities would rather get rid of "problem" residents than address the deÿciencies that are causing complaints. In such facilities, residents and their families are intimidated and afraid to complain. If you are in such a place, the facility staff certainly will not tell you. Residents and their families may not tell you.

"What do you do when a resident doesn't like the meal on the menu? Do you have good substitute choices, as opposed to just cereal, for example?" Resident autonomy is a very important consideration. We take for granted the freedom to eat what we want, when we want, where we want. A good nursing home will recognize individual tastes and make it easy for a resident to choose from at least two nutritious meals. A poor facility will offer one meal and, for those who do not like it, the facility may serve cereal, toast and jelly, or a "snack" that is not a balanced meal. Besides the nutritional concerns, treating a resident's food choices as an inconvenience adds to the feeling of living in an institution.

"Are the residents aware of their rights under the law? May I see your written policy to protect these rights?" Moving into a nursing facility does not mean giving up your rights. Texas law lists 21 speciÿc rights of nursing home residents, including the right to be free from abuse and exploitation, to live in safe, decent and clean conditions, to privacy, to hire their own doctor and be fully apprised of their medical condition, and to manage their own ÿnances. Each facility must implement written policies to protect these rights. The policies must be given to all residents, next of kin and staff, posted in the facility, and made available to the public, together with any citations the facility has received for violating residents' rights. Ask the residents if they are aware of these rights—beware of any facility that keeps its residents in the dark about their legal rights.

Reporting Medicaid Fraud or Abuse of a Medicaid Recipient:
Medicaid Fraud Control Unit
Phone (512) 463-2011 or Fax (512) 320-0974
E-mail: mfcu@oag.state.tx.us

Reporting Suspicions of Neglect or Abuse to a Disabled or Elderly Person:
911 or local law enforcement if the person is in immediate or severe danger or

Texas Department of Protective and Regulatory Services
(800) 252-5400 24-hour abuse hotline

Complaints About a Nursing Home:
Texas Department of Human Services
(800) 458-9858 long-term care

selecting a nursing home