Karl Steinberg (Associate Medical Director, Sharp Mission Park Medical Group) gives expert video advice on: What services does a nursing facility provide?; How do I know if my parent needs to be placed in a nursing facility?; Do all nursing facilities offer 24-hour medical care? and more...
What services does a nursing facility provide?
A nursing facility, in contrast to a skilled nursing facility, provides general nursing care. They are a facility that is of a medical nature. They can provide medications and nursing care, including wound care, tube feeding and things like that, but they are not providing the types of skilled services that a skilled nursing facility would, including acute rehabilitation, things like IV drugs, things like that wouldn't be available in a typical nursing facility, the old fashioned nursing home that you would think of, or retirement home.
Do all nursing facilities offer 24-hour medical care?
In terms of the amount of medical care that is available in a nursing facility, if it's a skilled nursing facility, then yes, a skilled nursing facility that is contracted with Medicare to provide services under Medicare Part A, they will have medical services available. That doesn't mean there is a doctor on site 24-7, but there is at least a licensed nurse available around the clock. If a person's condition gets bad enough, they can always be sent to the emergency room to be seen. As far as a non-skilled nursing facility is concerned, there is also usually some degree of nursing present in the building 24-7, but the level of care that they are able to provide is less than a skilled facility.
Do I need to choose a nursing facility certified by the federal government?
As far as whether you need to pick a nursing facility that's certified by CMS or by Medicare, I wouldn't say it's an absolute necessity. There are still some nursing facilities that are not certified to get any dollars from Medicaid or Medicare, and these in some cases are very nice buildings. They're places that essentially only do private pay resident care. So I don't know whether its absolutely critical to have a certified building, but if you have the expectation that either your health insurance or Medicaid is going to pay for any part of it, then it does need to be a certified building.
What are the essential services a nursing facility must provide?
The basic services that a nursing facility has to provide are, first of all, assistance with general custodial care, whatever the activities of daily living that the person might need assistance with. They also have to provide care for incontinence, and any kind of wound care that might be necessary. They have to provide a whole array of services that include nutritional assessments, and this includes very comprehensive assessments. The nursing home industry is, probably next to the nuclear industry, as the most regulated industry. Every person that comes into a nursing facility, there's a form called the MDS that needs to be completed, and this gives the minimum data set. It is very thick; well let's just say it's many pages. It's tiny fine print, and it has to be filled out on every single patient, and it's very comprehensive, and that's basically a full-time nurse's job in almost every facility. All they do is fill out these forms about people. So they assess all of the patient's needs. It's sort of the whole physical, mental, and psychosocial assessment, and they're essentially trying to maintain the highest practicable level of function, physical status and emotional status that they possibly can in all of these residents.
What are the most important services to evaluate when choosing a nursing facility?
I think when you are trying to choose a nursing facility, it depends on the specific needs of your loved one. But you want to be sure that they have a good, competent nursing staff and really from a quality of life standpoint, the amount of time it takes to have... for example, when they hit their call button, the amount of time it takes somebody to get in. That is one of the biggest complaints that we hear from virtually all facilities is that "I hit my call button and they don't come right in" or maybe it takes ten minutes. People will say it takes an hour for somebody to get in, and if you are lying there and you have got to go potty, it feels like a long time even if it is only ten minutes. So I think that's really important. It may not be that important from a truly medical standpoint, but from a quality of life standpoint. Now you can not just go by staffing ratios because it really depends on how sick the people in the building are. But that is an important thing to look at. Whether or not a place can do I.V.s. Whether they have got a good wound care nurse. Things like that may be in important and specific cases depending on what your loved one's needs are. Also a rehab department if you are coming in after a stroke or after a hip fracture or something. You want them to have a good strong rehab department.
Why is the staff to patient ratio so important in a nursing facility?
I think the staff to patient ratio in a given building is an important parameter. I think you can't just go by the number itself. Some states have mandated numbers. For example, in California you have to have 3.2 nursing hours per patient day. That includes not just licensed and registered nurses but also nurses aids. You can't just go by that number, because there may be some residents in a nursing home that require five hours of nursing care a day. They have a lot of constant bedside assistance. Somebody who is incontinent and needs to get cleaned up many times a day can eat up a lot of nursing time. Whereas other patients require virtually no assistance, or just a little assistance with bathing a few times a week and obviously the meal preparation. So the number itself is not necessarily that important, although generally the higher the number the better. It has to do with issues like how long do you have to wait when you hit your call button, or if you are having pain how long does it take the nurse to bring the pain pill in? Those are really important qualities of life issues so it is an important thing to consider, not just as a number but in real life how does it actually work at the facility?
How important are recreational and social activities in a nursing facility?
I'd say if you're coming into a nursing home just for some rehab and you're going to be there short term, it's not really that important what the recreational activities are and what kind of social services are available and so on. If you're coming in for long term care, it's very important. When you're sort of stuck in a nursing home and that's where you're going to be for the long haul, it's really important. The day can last a very long time, 24 hours can be very long and these places can be noisy at night. You may not always get a restful night sleep and so things can be difficult. Life is not always simple in a nursing home. So if the facility has a good activities program and the food is good, these are things that will impact quality of life on a day-to-day basis. So I think those are very important.
What are the main concerns about quality of life in a nursing facility?
Some of the things that are really important are respecting a person's individuality, and that is sometimes easier said than done in a nursing home setting. A facility that values a person's individual characteristics and their own values is very important. Privacy is another issue, the ability to communicate with other people in the outside world, a feeling of empowerment. Typically, nursing homes have what is called a Resident Counsel where they can go and have a little gripe session, and in many cases they can actually affect some change within a nursing home if there are certain things that they don't like. Let's say they don't like the BLT's that they serve on a certain day or things of that nature. Respecting a person's autonomy is the big quality of life issue. Many people who live in nursing homes have chronic pain. Attention to pain and managing pain related issues is another important quality of life issue.
Is there an organization that 'ranks' nursing facilities?
There's a lot of good sources for information about nursing facilities and how they perform, thanks to the fact that it's such a highly regulated industry. There are quality indicators that are followed, that are required by Medicare as part of the MDS documentation, which is a very big form called the minimum data set. But it's really not minimal at all - it's quite extensive. Obviously, either somebody in the military or the federal government dreamed that one up. It's got information about things like how many people have a decline in their functional capacity, how many people develop bed sores, things that have to do with infections and continence, and a lot of things like that. There's also survey teams that come around. Usually the federal government contracts out to state agencies to do the actual inspections and they typically write deficiencies. A great majority of surveys do wind up with some deficiencies, so don't be alarmed if you're looking at a building and see that it got some deficiencies. There's a website on the Medicare website - it's called Medicare.gov/nhcompare. And that's a good website to go to just to show what the deficiencies were and some just general sort of demographics about certain buildings. And then many states have agencies that also do sort of ranking of nursing homes, but I'd say that 'Nursing Home Compare' from Medicare is a good place to start.
What does an ombudsman do?
The ombudsman is a position that in most states is a voluntary position. Typically it would be a person who is retired, but has some interest in elder care or maybe is a retired health care professional or social service type person. And they come out to the buildings, they do some on-site sort of inspections. They have to do with just walk-through, they're not formalized inspections, but they are also available to serve as a go-between when there are issues that arise between a facility's administration and the resident or their families, when there are concerns about the care, these are people that are very helpful, and typically the way to get a hold of the ombudsman is just post it up somewhere in the building or you can ask the staff.