Choosing A Nursing Home

Choosing a nursing home can be an overwhelming experience. Although the quality of care should always be your first concern, most people will also need to focus on the cost of nursing home care, which currently averages over $50,000 per year in North Carolina. When considering a nursing home placement, remember that people who are admitted into nursing homes still have basic human needs for respect, encouragement, dignity and friendship. Also remember that finding a nursing home that provides the right services in a pleasant and comfortable atmosphere often requires hard work! Here are some suggestions to assist you with making a placement decision:

1. Find out about the facility’s track record.

You should always review the nursing home’s survey (inspection) reports. The best way to evaluate the quality of a nursing facility is usually to review survey reports over a period of time. We recommend that you look at the survey reports for the most recent three years. All facilities are required to maintain the most recent survey report and make it available for public inspection. Therefore, you should be concerned if the facility seems hesitant to show you its most recent survey report. Make sure you are looking at a report that says "recertification" on it. This means that the report is from the annual inspection of the facility. If the report says "Post survey review" or "post certification review" you are looking at a follow-up report.

In addition to checking with the facility, you can obtain survey information by contacting your local long-term care Ombudsman Program, an advocacy program for nursing home residents. If you don’t know the number of your local Ombudsman, you can call the North Carolina Division of Aging. In addition, North Carolina’s Division of Aging operates a web site which has a link to the most recent government surveys for every Medicare and Medicaid Certified nursing home in the United States.

2. Make Visits to the Facility!

The worst mistake you could possibly make is to admit your loved one to a facility without ever visiting it first. Remember, you are choosing your loved one's future home! You wouldn't buy a house sight unseen and you shouldn't make a major commitment like choosing a nursing home without careful investigation as well.

All facilities provide guided tours for prospective residents’ families, but it is critical for you to spend some un-chaperoned time in the facility. We recommend visiting at least times at different times of day. Good times to visit are early mornings, late evenings or weekends. Think twice about any facility that does not want you visiting on your own.

Consider the location of the facility in relation to friends and family members. All nursing home residents benefit from regular visits from friends and family. Just as importantly, nursing home staff members usually know which patients have regular visitors and attentive family members checking on their quality of care. There is a strong correlation between nursing home neglect and infrequent visits from family.

3. Make full use of your senses!

Smell: Good facilities don’t have lingering smells of urine or feces. You should be suspicious of overpowering “cover scents” such as strong bleach or ammonia.

Taste: Ask to eat a meal in the dining room to sample the food. Are residents given a choice of foods at mealtimes? Are nutritious snacks available outside of scheduled mealtimes? Ask to see a menu of the meals for the month. Review the list prior to a second visit and see if the facility is really following the menu.

Listen: Talk with the residents and their family members. Ask them about their experience with the nursing home. Find out if there is a resident council or family council. If so, talk with members of these councils. These groups communicate directly with the facility's administration about problems or concerns. Ask about any concerns they had in the past and how those issues were addressed.

Look: Carefully observe the interaction between staff and residents. Does the facility staff treat residents in a respectful and polite manner? Does the staff knock before entering the resident’s room? Are residents aimlessly wandering the halls of the facility? Does the staff acknowledge residents when they pass by? Are the residents clean, well-groomed and appropriately dressed? Are the facilities well lit? Make sure that you visit at least one room like the one your loved one will reside in. There are major differences between "private" rooms for a single person and the more-common "semi-private" room shared with a roommate. While physical surroundings are important, elegant decor has little meaning in evaluating the daily quality of life your loved one will enjoy.

Touch: Does the floor seem sticky when you walk on it? Is it slippery? Is there dust on the furniture? Poor housekeeping can be an indicator of other problems.

4. Ask about staffing:

Staff Turnover: You should always inquire out about staff turnover. Ask how long staff has been there, from the Administrator and Director of Nursing (DON) to the nursing assistants. Turnover of nursing assistants is very important since these people provide most of the direct care that residents receive. High turnover of aides can erode the quality of care in a nursing home and may indicate other lurking problems. You should be particularly concerned about turnover if your loved one suffers from dementia. A constant parade of new faces greatly increases confusion for dementia patients.

Staff to Resident Ratios: Ask about the ratio of nursing assistants to residents for each of the different shifts during the week and the weekend. Don't take the facility's word for it; go out on the floor and observe. Does the number of aides correspond to what you were told? Try to visit the home at different times, including a weekend. Many authorities claim that nursing assistants can only provide reasonable care to 8 residents during day and evening shifts and12 to 15 residents at night. You should be concerned if you see a larger number of residents per each CNA. If you are looking for a special care unit, check the guidelines developed by your local Alzheimer’s Association for recommended ratios of staff to residents and compare them to what you see on the special care unit.

Staff Training: Inquire into staff training. Ask how many hours of training staff members receive each year. If your loved one has dementia, inquire if staff members have specific training for working with patients with diminished mental capacity.

Are there clear policies regarding resident abuse and neglect? Ask about the use of physical restraints. Quality facilities work hard to reduce or eliminate the need for physical restraints. Remember that physical restraints can have harmful physical and psychological effects on your loved one. High usage of restraints often indicates staffing shortages or other problems with quality of care.

Physician Visits & Emergency Care: Most facilities have contract physicians who visit the home on a regular schedule. Ask how often the physicians visit. Find out if these physicians actually review the care plans of the residents. Make sure that you understand where your loved one will most likely be taken in the event of emergency.

5. Investigate the Safety and Security of the Facility.

Ask if employees are screened or given a background check before being hired. How does the home protect residents' property? Are there safety devices such as sprinklers, fire extinguishers, and smoke detectors throughout the building?

6. Ask about activities.

Look at the activities schedule and see what types of activities are offered. How does that compare with what your loved one likes to do? What activities are provided in the evening and on the weekends? What activities are available for bed-bound residents or those who don’t like group activities? Remember that people can become confused and depressed when life long patterns are disrupted.

7. See how the facility accommodates individual needs and preferences.

Can residents get up or go to bed when they want? How are bathing times scheduled? Ask what control residents have over their schedules and their day. What factors are considered in pairing roommates? How are conflicts between roommates resolved?

8. Discuss payment terms with the facility.

Nursing home payment systems are often quite complicated. Relatives are frequently told that they are responsible for payment from their own funds for any unpaid bills or told that the resident must pay privately for so many months before she or he can convert to Medicaid. Federal law prohibits these practices, but they are commonly used with those who are uninformed about their rights.

What happens if your loved one starts paying privately, but then converts to Medicaid. Can she or he remain in the facility? Can she or he remain in the same room and bed?

9. Review all documents carefully & seek assistance if needed.

Get copies of all documents such as facility policies, admission contracts and written statements of residents’ rights and read them carefully. These are important documents for determining your rights and responsibilities. Nursing home contracts are usually many pages long and often contain terms purporting to take away your rights.

If you have any concerns about the contract, tell the nursing home that you want to review the documents with your lawyer. Doing so may prevent you from putting yourself or your loved one in legal jeopardy. It also conveys the message that you will be informed about your legal rights. A visit to an attorney who regularly deals with nursing home residents can be a valuable opportunity to discuss residents’ rights, standards of good care, Medicaid eligibility, as well as the documents to be signed. Most importantly, remember you should never sign any document that you don’t understand!

Important Facts about Nursing Home Contracts:

• Never sign a contract as the attorney-in-fact/power of attorney or guardian without writing “Attorney-in-Fact” or “Guardian” after your signature.

• Unless you are married to the nursing home resident, you cannot be forced to pay for your relative’s nursing home bill.

• You are not required to use the resident’s assets to privately pay for his or her care, even if the contract requires you to list the resident’s assets. You and the resident have the right to do Medicaid estate planning.

• You are not necessarily financially responsible for your relative’s nursing home bills, even if the nursing home contract refers to you as the “responsible party.”

• The nursing facility cannot seize the resident’s Social Security, except to the extent that the resident must pay the facility under the Medicaid program.

• If you have been unfairly misled by the terms of the nursing home contract, you may have a claim under North Carolina’s consumer protection laws.

• Nursing homes can only discharge residents for certain limited reasons and they must give the resident advance written notice of discharge in almost all cases.

• The nursing home must arrange for proper, safe discharge planning and orientation before a discharge can take place.

• You have the right to appeal a nursing home discharge.

• Medicaid-eligible residents have the right to priority readmission, even if they aren’t able to pay to “hold” the nursing home bed.

• Even if the contract says the nursing home is not responsible for personal injuries to the resident, you or the resident may have the right to recover for damages if an injury or death occurs.

• The nursing home may be responsible for losses or damages to the resident’s property, if the home was careless.

Remember, nursing home contracts are written by nursing homes for nursing homes and often do not accurately or completely describe the rights of the resident. If you have questions about a nursing home contract or feel that a nursing home resident’s rights are being violated, you should consult with an attorney.

10. Get your loved one actively involved in the selection of a facility.

Respect your loved one's wishes. Remember that people who are involved from the beginning are better prepared when they move into a nursing home. If your loved one is not alert or able to communicate well, keep his or her values and preferences in mind.

Moving into a nursing home is usually a difficult time, but many residents adjust to the change after a month or so. Keeping your loved one involved in the process can make the adjustment smooth and greatly increase his or her quality of life.

A nursing home placement is a major commitment, both emotionally and financially. Investing your time and seeking expert advice before the placement may avoid very costly and traumatic mistakes.

For more information, contact:

Attorney V. Tate Davis**

Member, National Academy of Elder Law Attorneys (NAELA): An association of attorneys who are dedicated to improving the quality of legal services provided to the elderly. Some of the issues that NAELA members assist their clients with include, but are not limited to: public benefits (i.e. Medicaid), probate and estate planning, guardianship, and health and long-term care planning. ◙

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