Brian Capshaw, now 52, was a corporate cost accountant in Connecticut when a 1994 car accident left him paralyzed from the chest down. He continued working until 2005, and within two years it became apparent he would need ongoing care. At 45, he became a resident at the East Hartford nursing facility where he’s been living since.
When choosing a facility, Capshaw had two main criteria: instate location, and the capability to give him the services he required. That narrowed his choices to two facilities. Capshaw and family members talked to an admissions representative and took a tour while visiting each. Seven years later, Capshaw has become an advocate for nursing-home residents. Given what he knows now, he says he would have asked a much wider range of questions during those initial visits, and talked to a variety of staff members – while also seeking input from residents themselves.
Mitzi McFatrich has a different vantage point. As executive director of Kansas Advocates for Better Care, a statewide nonprofit that works on long-term care and elder abuse issues, she’s seen many nursing homes, dug into countless reports of deficient care and testified on issues affecting residents’ well-being. She and Capshaw recommend some key questions to consider when deciding on nursing homes to visit. And you can locate possible facilities and find inspection data by searching the U.S. News Best Nursing Homes rankings, as well as downloading a comprehensive checklist for visits.
Is the location realistic? “If you want to be able to visit your loved ones, you don’t want to be driving two hours a day,” Capshaw says.
When one spouse in an older couple is entering a nursing home, consider how longer distances may hamper that relationship, McFatrich advises, as well as a family’s ability to look out for a resident’s health and well-being.
What do nursing home surveys show? On an about-yearly basis, nursing facilities undergo inspections on behalf of the Centers for Medicare and Medicaid Services. Survey data, reports and ratings are available to the public. Annual survey reports should be posted in each facility – and if you don’t see that, ask.
Findings can be sobering, like the Kansas facility that received an “immediate jeopardy” rating because its hot-water heater was putting out scalding water. Such examples are not unique to any single state, McFatrich notes. Good nursing homes should have lower-than-average deficiencies, and none in the categories of mistreatment, actual harm or immediate jeopardy.
“It’s important for people to be armed with that kind of information, so they aren’t just getting the line that the marketing person, administrator or nursing director might be giving them,” McFatrich says. “They actually have a basis to go in and say, ‘I saw on your last inspection report that you were cited for these violations to health and safety standards. What have you done to correct that?’” From there, she and Capshaw recommend what else to ask and whom to approach:
To Administrators and Nursing Directors:
Which services do you offer? In Capshaw’s case, for example, the ability to give wound care was essential.
What are the staffing ratios? “We’re fortunate in Connecticut,” Capshaw says. “We have the law where you have to have an RN 24/7.” As for aides, he says, a good ratio would be one aide for eight or nine residents during the day.
How long do nurses and aides spend with residents each day? This is a critical component to getting the best care for your elderly or disabled loved one, McFatrich says.
In Kansas, she says, “the range in facilities is literally from two hours of care a day to 7.5 hours of care a day. So you can imagine the difference in people’s lives, in the quality of their care and all things that have to do with their functionality.”
What about staff turnover? Capshaw is in a union facility with low turnover. “So I’m comfortable with the people who’ve been caring for me quite a few years now,” he says.
Can I see your staffing schedule? Staffing information is self-reported by facilities, McFatrich says. To back it up, she says, “I would want to go to the administrator and I’d probably ask to see payroll records. Now they might or might not show me that, but I’d probably ask.”
How do you prevent pressure sores? “If someone is bed bound or not very mobile, they have to be moved every two hours in order to avoid development of pressure sores,” McFatrich says. In addition to care protocols, ask about on-site equipment, such as special mattresses that can relieve pressure points.
Are residents moved from room to room? “If you’ve been in the same room for a couple years and you’re comfortable and all of a sudden the facility decides, ‘We want to make some changes; you’re going to be moved,’ then I’d want to make sure they’d follow the state law, [and] go through all the procedures,” Capshaw says. Residents of Medicare-approved nursing homes must receive advance, written notice of proposed transfers and they have the right to appeal.
What if I run out of resources? McFatrich suggests asking: “If I come in as a private-pay [resident] and I run out of resources, are you certified to accept Medicaid? Am I going to have to move because I can’t live here if Medicaid is the entity that’s going to reimburse for my care?”
Do you provide special care for people with dementia? “Oftentimes, a facility will tell you they have a special-care unit, and what that means is they have a lot of people with dementia and they have a locked unit so those people can’t wander off,” McFatrich says. “That’s the bad definition of a memory care unit.” A good definition of dementia care: “You’ve got a staffing ratio of five to one and that’s nurses and aides,” she says. “And that’s all the time, not just during the day.”
Does staff have special training in dementia care? What does that training entail? “You want staff that have an awareness and a sensitivity and training in the best ways to address [residents’] needs,” McFatrich says.
What about physical and chemical restraints? Most facilities no longer use physical restraints. But so-called chemical restraint is another issue. McFatrich says she would ask, “How many of your residents currently receive antipsychotic, antianxiety or antidepressant medications as a means to control their dementia or related behaviors?” This speaks to whether antipsychotic drugs, meant to treat certain mental illnesses, are instead being used inappropriately, McFatrich says. Moreover, “anti-anxiety and anti-depressant [drugs] used to control elders, rather than providing adequate staff and attend to an elder’s needs is unethical,” she adds. Quality-of-life improvements and side-effect risks should be the top concerns when these drugs are considered.
What kind of food do you serve? Capshaw says diet didn’t occur to him when he was choosing a facility, but after seven years, he appreciates the impact meals have on residents’ quality of life.
Do you accommodate special diets? Residents come in with their own dietary preferences and restrictions. Some also may have medical orders for soft or puréed diets, for example.
Can I have what they’re having? “I used to visit my grandmother on a regular basis,” McFatrich says, “and I would always say at dinnertime at the facility, ‘Happy to pay for my meal, but I want to eat whatever she’s eating.’”
Are you happy here? McFatrich would let residents know she’s considering the facility before asking them things like, “Do you enjoy living here?” “If you could change anything, what would you change?” and “What do you like best about living here?”
Do you have freedom of choice? Capshaw wants to know how much control residents have over their lives: “What’s your daily routine? Do they offer resident-centered care? Are you able to get up when you want? Do you go to bed at the time you want? Or are you told, ‘I only have this amount of time to get up – I have to get you up now.’”
When you ask for help, how long do you have to wait? If you always have to wait beyond five minutes for help, you’re likely to try doing things on your own, which could set you up for falls, McFatrich says.
To Activity Directors:
What about activities? “I would ask, ‘What do you offer to keep my family member engaged?’” Capshaw says. “’I don’t want them sitting in their room all day, doing nothing.”
Are more traditionally male activities included? Some facilities have a garage or workroom where residents can build things and take them apart, McFatrich says.
Is transportation available? “A lot of times people end up in a nursing home because they can’t drive anymore,” McFatrich says. “But that doesn’t mean they should be captive in the building.”
How reliable is the transportation? “Sometimes nursing homes only provide transportation for certain medical appointments – and they don’t provide transportation for social [purposes],” McFatrich says. “Is there staff to help residents get to a granddaughter’s play?”