Photo by Alexandra Boulat/VII/Corbis
The answer, says experts, is simple: You must stay vigilant to make sure that he is getting the kind of care you want him to get.
“Every person in a nursing home needs an advocate,” says Maryglenn Boals, a former nursing home administrator in Arizona. “When you are serving that many people, there are going to be mistakes. There is always going to be little things that happen. So every resident needs his own ‘squeaky wheel.’ ”
A panel of experts and former nursing home workers offers these 10 questions to ask to detect signs of improper care.
1. How does the food look and taste?
Dining with your parent in the nursing home cafeteria is a great way not only to bolster your parent’s spirits, but also to give you an idea of how well he or she is eating. “When people are aging and losing a lot of sensory sensitivity, food is a huge issue,” says Boals. “The meal might meet the dietary requirements, but is it palatable? Is it visually encouraging, especially to someone who doesn’t have much interest in eating?”
Standard protocol is to record how much food a resident eats at each meal, Boals says. If you see that your parent is not eating much of the home’s food but will heartily eat food you bring in for him or her, mention that to the staff. Changes to their meal restrictions might be possible. Keep in mind that if your parent is on a special diet, such as low-salt or pureed foods only, you might not have much say over taste and appearance. But if someone can’t eat because the food is unpalatable, it’s not necessarily worth maintaining a special diet.
2. What sounds do you hear?
Residents moaning or yelling “help” might be unsettling, but they are rarely signs of poor treatment, says Boals. More likely it’s part of the dementia spiral. Instead, listen for how staff members address their residents.
Staff should address residents by their names, instead of “Mama” or “Grandpa,” says Marion Somers, an elder-care advocate and former nursing home administrator. “You’re talking about a generation that is used to being called Mrs. So-and-So,” Somers says. “Staff should ask a resident how they want to be addressed. If they’re not taking into consideration what the resident needs to feel respected, then they are diminishing that client and they are going to have problems with that client.”
3. What does it smell like?
Nursing homes can foster some funky odors, says Boals. There are unavoidable reasons for this: certain medications and diets make residents more gassy. And as people age, they’re more likely to lose control of their bladder and bowels. So a faint whiff of something unpleasant isn’t something to complain about. However, if the home reeks of stale urine, it could be a sign that the facility is not cleaned properly. “Urine can penetrate into floor wax, and if someone is having a lot of accidents on the floor a room can get a very intensive smell if they’re not stripping and rewaxing the floors regularly,” says Boals.
4. Is the staff overworked?
Ask the nursing assistants and other staff if they work a lot of overtime and double shifts. If so, that’s a sign of short staffing that can affect patient care.
“If the staff are overworked, then they are overstressed,” says Boals. “It’s a lot of giving, and they’re working in a difficult situation.”
Ask the director of nursing for the home’s staffing ratios or check their staff ratio rating on the Nursing Home Compare tool at Medicare.gov. If you believe your loved one is being neglected because of poor staffing ratios, file a complaint with your state agency that regulates nursing homes.
5. How do residents spend their afternoons?
Don’t be alarmed by the crowd of residents circling the nurses’ station or watching people come and go through the front door. This is actually a good sign, says Boals. “I’d rather see that than see people tucked in their rooms, the television on, no one with them,” says Boals. A quality nursing home is going to have a daily calendar of activities in which your parent can participate. If your parent is room-bound, activities should be brought to his or her room.
6. How does the staff interact with each other?
Eavesdrop on the aides and nurses, says Somers. “If the staff is rude to each other, they’re going to be rude to your parent,” says Somers. Also listen for what music is on the radio or programs are on the television. “The music should be for the clients who are there, so if you’re hearing hip-hop or hard rock then you know the administrator doesn’t have a clue as how to deal with old people,” says Somers.
Also be aware of how staff spends its time once all the charting and direct care has been finished for their unit. “Are they gossiping with each other or are they making time to sit and talk with the patients?” says Debra Stang, a former nursing home social worker. “That’s something that I would always look for. Any time you come in and you’ve got three nurse’s aides giggling over a book and a bunch of residents sitting around in wheelchairs looking bored — that’s not a good environment.”
Next: Check for bruising. »
7. Do you see bruising?
Don’t assume that any black-and-blue mark you see on your parent is a sign of abuse. As people age, their skin becomes more fragile and certain medications make the skin more sensitive. But some bruises should not be ignored. “A finger-shaped bruise around the upper arm is a very suspicious injury,” says Stang. Also look for handprint-shaped marks on the face or stomach or bruises on the back, areas which are unlikely to be bruised by a fall.
8. How does the home handle a fall?
Falls can happen under even the best of circumstances, says Stang, but it’s important to watch how the staff reacts to one. Did they check for injuries? Did they help your parent get up off the floor safely? Was he or she checked later in the shift for injuries that weren’t apparent at first, such as a closed head injury that would make a person act more confused than normal? And how did you find out about the fall? After any fall, the staff should call you immediately and meet with you to determine why the fall happened and whether any changes should be made (such as a chair alarm that alerts staff when your parent gets up, or a lower bed) to protect your parent from future falls.
9. Are there unexplained bedsores?
Bedsores are often unavoidable, especially as a parent becomes more sick and frail, says Stang. “My concern would be if my loved one were capable of being up and around and hadn’t shown any signs of refusing food, yet all of a sudden he’s developing bed sores,” says Stang. “That’s when I’d talk with the staff about, ‘Why aren’t you getting him up? Why is he spending so much time in the same position?’ ”
If your parent is confined to a bed, ask how often he or she is being rotated. This should correspond to the doctor’s orders, which can be every hour or two, and rotations should be marked on your parent’s medical chart.
10. Are personal care needs being met?
If your parent is incontinent, ask how many times a day her adult diapers are changed. “If a memo goes out to the staff saying, ‘nobody is to have more than six changes a day,’ for instance, that is a problem,” says Somers. “If you don’t change a diaper and keep the area dry and clean, that can lead to wounds.” At Workmen’s Circle MultiCare Center in New York City, diapers are changed every two hours. “But if the resident needs more changes, the certified nursing assistants would know the different routines of that resident and would check them more frequently,” says Eva Marie Fabian, Workmen’s director of nursing.
If you have issues with your loved one’s care, your first conversation should be with the unit manager for your parent’s floor, says Fabian. If that conversation doesn’t resolve the issue, continue up the line of command. “If it’s an issue that is persistent and it’s something that is reoccurring, then we have always encouraged family to write a grievance form or complaint form,” says Fabian. The issue should then be addressed within 48 hours. If it’s not, talk to the nursing home administrator. And if you are still unsatisfied, file a complaint with the state agency that regulates nursing homes.