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SUB-PROBLEMS INCLUDING LEADING TO IMPAIRMENT AND BEST PRACTICES FOR SKILLED NURSING FACILITIES

There are many excellent skilled nursing facilities in the United States. They are well supervised and the patients are treated with great care and love. However, there are others which have fundamental problems of health and safety usually based on financing, poor training for inadequately paid personnel, and poor supervision throughout the 24/7 cycle.

A recent study by the Office of Inspector General, US Department of Health and Human Services indicates that there are numerous problems occurring in skilled nursing facilities or nursing homes used by Medicare patients. (See endnote 49.) An estimated 22% of Medicare recipients were involved: 79% of these individuals had prolonged stays at the facilities because of these problems; 14% required some form of intervention to keep them alive; and 6% were so affected that it contributed to their death. The adverse events are due to medication problems, resident care, and infections. The medication may cause induced delirium or change of mental status, excessive bleeding, and in some cases, contribute to falls. Poor residential care has led to falls, exacerbation of existing conditions, acute kidney injury, electrolyte imbalance, and pulmonary embolisms. Infections have included pneumonia, other respiratory problems, surgical site infection because of poor wound care, urinary tract infection, and infection with C. difficile. Patients have suffered low or significant drops in blood glucose, trauma with injuries, allergic reactions, and pressure ulcers. It was determined by physicians reviewing the patient charts that 69% of the adverse events were preventable. Most of the preventable problems were due to substandard treatment and inappropriate monitoring of the patient.

Infections are very common in long-term care facilities. Residents are usually in confined living situations and daily activity takes place in groups which promotes the spread of infections. Since many of the individuals are at least restricted in their cognitive abilities and others are senile, it is difficult to maintain an appropriate level of personal hygiene, especially hand washing, unless the staff works on a one-to-one basis with each individual. This gets to be very difficult when understaffing is a very common problem and improperly trained and poorly supervised individuals are hired to assist the residents. An increase in drug-resistant microorganisms adds to this complex situation. The most common infections found in nursing homes are respiratory, urinary, skin, soft tissue, and gastrointestinal. The most common diseases are: scabies, which is a mite infestation and is transmitted by person-to-person contact; influenza, which is a major source of illness and death in this high-risk population; C. difficile, which is a diarrheal infection ranging from mild to fatal; and MRSA, which is not only serious within the nursing home but also becomes a major risk factor when the individuals are admitted to hospitals. A re-emergence of tuberculosis has become a renewed healthcare problem. A serious communication problem exists between the nursing home and the acute care hospital, and often when the individual is moved to the hospital appropriate records and warnings of existing infections do not accompany him/her. (See endnote 50.)

Patient abuse, physical, sexual, and verbal, is increasing in a portion of the nursing homes in the country. Many of these facilities are understaffed, underfinanced, and improperly supervised, and unfortunately the patients are getting much older and feeble and there are increased levels of senility. In these situations, it is common to see patients with untreated bedsores, malnutrition, dehydration, and poor hygiene. Unsanitary conditions exist and medical care is spotty. Overmedication is a concern, especially with the use of psychoactive drugs. There may be excessive therapy services that are medically unnecessary or even harmful in order to increase the reimbursement from Medicare and Medicaid.

Approximately 1800 older adults who live in nursing homes die each year from fall-related injuries and those that survived the fall may have a permanent disability and have their quality of life affected. About 1.4 million people 65 and older live in nursing homes. This is estimated to increase to 3 million by 2030. Each year a typical 100-bed nursing home reports 100-200 falls. This is probably vastly under-reported. Patients frequently fall more than once. Falls may occur because of medications, the disease process, muscle weakness, balance problems, walking problems, environmental hazards such as wet floors, poor lighting, incorrect bed height, improper shoes or poor foot care, improper fitting, and use of wheelchairs, etc. The falls may also be the result of staff negligence. The routine use of physical restraints does not lower the risk of falls or injuries. (See endnote 51.)

 
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