The Minnesota Star-Tribune reported that an assisted-living facility is being held responsible for the death of a resident who suffered head injuries from a fall and received no medical attention for days afterward.

The Health Department’s investigative report says that Lighthouse of Columbia Heights “failed to report changes” in the resident’s condition to a nurse and “failed to seek medical attention in a timely manner” after the resident fell in November 2011 and developed a sizable bump on one side of her head and a smaller one on the other side.

The resident was hospitalized three days later before dying on Dec. 5.  Her death certificate concluded the fall caused her death.  In citing the center for neglect, the report noted that the facility had no registered nurse available for unlicensed staffers to call after hours in the event of changes in residents’ conditions.

An interesting article in The Atlantic explained that traditionally nursing homes have operated in a fashion similar to asylums, with their primary purpose to serve as residential medical institutions. Even though this is still too common in most nursing homes, there is a gradual “culture change” towards a more personal resident-centered care and a more home-like facility.  In these new facilities pets and children are welcome to visit and residents are encouraged to take part in voluntary, every-day tasks such as maintaining a plant, selecting and “ordering” their meals like in a restaurant, and preparing their own snacks. Also, the resident and their family members are more involved in creating their own personalized care plan. All of these improvements aim to give the residents a greater sense of empowerment and an improved quality of life.

This shift focuses on building strong relationships between the residents and care givers and making the facility’s environment as welcoming and personal as possible.  Most national for profits chains have not adopted this cultural change especially in Southern states.  According to The Alliance for Quality Nursing home care, more than half of the nation’s nursing homes are participating in this change of culture where facilities consider individual residents’ needs instead just operating in an uniform, institutionalized style.  See article in Senior Housing Newshere.

However there are encouraging developments for this positive shift in nursing home “culture.”  The new Medicare/Medicaid Quality Indicator Survey is very resident-focused rather than focused on the facility as a whole.  For example, the Survey concentrates more on if the individual residents are being served food that meets their personal nutritional needs and taste than general facility details such as what time meals are being served.

It is important to for nursing homes to continue to look past their outdated traditions and seek more innovative ways to care for residents and improve their quality of life.
 

The Minnesota Star-Tribune reported the sad case of a resident who died when the nursing home staff  failed to recognize the obvious signs of a cardiac arrest.  State investigators concluded that the staff failed to act quickly enough to save the life of a resident whose condition was rapidly deteriorating. Sunwood Good Samaritan Society of Redwood Falls was found negligent in the death.  Specifically, the investigation found, the home failed to have formal processes in place for monitoring and reacting to significant changes in a resident’s condition.

 

The report states:

 

On Oct. 31 during dinner, the resident coughed and gasped while eating. A nurse sent a fax to a doctor saying that the woman was having breathing problems. There was no evidence that the doctor responded to the fax or that staff followed up with the doctor that day.

 

The next day, the resident’s breathing problems continued, she was lethargic and her appetite was poor.

 

That evening, the woman’s “condition further declined.” She exhibited symptoms of respiratory distress: Breathing became more difficult, her pulse was erratic and her fingertips turned dark blue. With a grimace on her face, she curled herself into a fetal position.

 

A nurse put her on oxygen and gave her a drug to ease her discomfort.

 

Additional faxes were sent to the doctor starting at 4:15 p.m. and marked “urgent.” The doctor responded at 5 p.m. after the third one.

 

At 5:15 p.m., a nurse called for an ambulance but did not say it was an emergency situation. At 6:25 p.m., a second call was made for the ambulance by the same nurse, again without mentioning the situation’s urgency.

 

By the time ambulance arrived at 6:30 p.m., the woman was in cardiac arrest. She died 26 minutes later. Her attending physician listed cardio-respiratory failure on her death certificate.

 

The physician said in an interview with the state that staff should have been quicker in notifying a doctor and in obtaining emergency medical assistance.

 

 

Greenwich Times had an article discussing Greenwich Woods Health Care Center’s approach to caring for residents with Alzheimer’s dementia. Changes such as music and activities are among many that make up a new approach in caring for people with dementia.  Greenwich Woods staff have been trained by the Alzheimer’s Association Connecticut Chapter to provide more personalized care.

"It’s culture creation," said Shipe Hajdari, director of staff development for Greenwich Woods, who has worked on what has been dubbed the Alzheimer’s Ambassador program.

There are 5.3 million Americans with Alzheimer’s, and that number is only expected to grow as the population ages, according to the national Alzheimer’s Association. With 75 percent of nursing home residents having some form of dementia, the shift in care is one that many facilities are making.

One of the key aspects of the change in care is staff really knowing the residents, including their likes and dislikes, and routines — whether they usually get up early, or like to sleep in and eat a little later in the morning. Staff gather information from family members, and the particulars for each resident are extensively documented.

Weight loss is also common in people with dementia, so the food services staff has included some new ideas, such as using red place mats to stimulate appetite, and making pureed food, for the residents who require it, look much more appetizing.

The physical environment is also important. Showering can be traumatic for people with dementia, so the shower room on the Redwood unit was painted and decorated with soothing blues and tans, and rechristened the "Spa Room."

 

 

The Associated Press had an interesting article about the nursing home industry’s attempt to recruit younger residents.  For decades, the mission at Miami Jewish Home and Hospital was simple: To care for the old. But like nursing homes around the country, the facility is changing how it does business because of consumer demands and the economic realities of selling a service nearly no one wants.  "This is a place of life. This isn’t a place of impending death," said Blaise Mercadante, chief marketing officer at Miami Jewish. "And that’s fundamentally the mindset change."

"Nursing homes are waking up more and more to the reality that their old model of doing business is not going to hold up in the 21st century," said Elinor Ginzler, an expert on long-term care at AARP.

Even as the number of older Americans surges with the aging of the massive baby boom generation, demand for nursing homes is decreasing. The Centers for Disease Control and Prevention estimate that the number of nursing home residents fell from 1.63 million in 1999 to 1.49 million in 2004, the last year for which data is available. Meanwhile, the number of nursing homes decreased by nearly 16 percent over the two decades ending in 2004.

Demand for services like assisted living, in-home care and adult day care, meanwhile, is booming. Nursing homes have expanded their offerings to cope with shortfalls after finding that in many cases they cannot make enough profit Medicaid, the main governmental provider of long-term care.

Brian Williamson, an analyst for Standard & Poor’s who follows nursing homes, said facilities have been branching out to deal with lower occupancy rates. "Where before you may have been able to keep your facility 97 percent full, now maybe it’s 92 percent," he said. "You have to figure out how do I compensate for that lost percentage of beds."

Neil Kurtz, CEO of Golden Living, one of the largest nursing home operators in the U.S., said the emphasis has shifted from providing a place where seniors can grow old and die, to a place where seniors can recover from illness or surgery before moving back home or elsewhere.

 

Other companies whose core business has been caring for the elderly are also coming up with new ways to make money, but Miami Jewish has taken the innovation further than most. While similar providers have expanded senior-related offerings like in-home care or assisted living, the South Florida home took a gamble in recent years by hiring specialists in fields that attract younger patients. 

Another provider that’s changed its mix of services is Ecumen, which operates 70 senior communities in Minnesota, Wisconsin, Iowa, North Dakota and Idaho. In 2004, Ecumen derived more than 80 percent of its $99 million in revenues from traditional nursing homes. Five years later, revenues climbed to $126 million while nursing homes’ share fell to less than 60 percent, as Ecumen markedly expanded assisted living complexes that allow seniors to be more independent. A $2.5 million loss in 2005 became a $937,000 profit last year.

At Miami Jewish, the broadening of services began when its executives’ saw a market for services such as pain management and biofeedback, which uses electrodes to increase mobility in paralyzed limbs. The hospital built a staff of experts in those areas mostly from scratch, adding more than 50 specialists to staff its pain, biofeedback and rehabilitation centers.

 

 

 

Chicago Tribune had an article about the transformation of the culture at nursing homes.  The article discusses Bethesda Home and Retirement Center. Traditionally, the world of nursing homes have been run like highly regimented mini-hospitals. Bethesda made a change two years ago taking its first step to join a movement that hopes to transform the nation’s nursing homes.

The "culture change" movement seeks to get these facilities to alter their physical layout and their caregiving practices to create homelike environments where residents are seen not as passive recipients of care but as individuals with control over their lives. Nursing homes that embrace the new philosophy are letting residents decide when to bathe, eat and sleep; allowing them to organize their own activities; and redesigning nursing units into small "households."

Advocates say residents in such homes are happier and healthier; the employees have more job satisfaction; and giving care this way even costs less. The idea is not new. The Pioneer Network, a national umbrella group of nursing home providers and consumer advocates, has been promoting it since it was formed in 1997.

Yet only 25 percent of the nation’s nursing homes say they have "for the most part" embraced culture change, according to a 2007 survey by the Commonwealth Fund, and only 5 percent say they have done so "completely."

Nursing home operators, who are under tremendous pressure to cut costs, are often afraid that culture change would cut into their profits.  However, flexibility is more cost-efficient.

The experience of the Bethesda Home illustrates the challenges. Janet Meyer, the home’s director of nursing, had proposed a single change: letting residents sleep late. But "that’s a bigger deal at a nursing home than you might think," she said.

Mealtime practices had to be changed to accommodate late risers. Housekeeping had to be done more flexibly to avoid waking residents for vacuuming.

Most challenging, the morning medication system had to be changed. Nursing homes traditionally give out medications during a two-hour period. But if residents were allowed to sleep late, Bethesda could no longer give morning medications only between 8 and 10.

So the home made another change: Residents could get their morning medications any time between 6 and noon, by individual request.

Other practices were loosened too. At staff meetings, administrators told employees that they needed to be flexible and perform caregiving tasks like bathing when residents wanted them.

The Health Reform Act passed in March calls for conducting demonstration projects at nursing homes to establish the best ways to effect culture change. So many organizations and government agencies are now working toward culture change that "everything is in place for widespread dissemination," said Bonnie Kantor, executive director of the Pioneer Network.

 

A group of nursing organizations released a list of 10 nurse competencies for nursing home culture change. The new list is the result of a joint effort by the Hartford Institute for Geriatric Nursing, the Coalition of Geriatric Nursing Organizations and the Pioneer Network. See Pioneer Network website here with the list of 10 competencies.

The organization convened a panel of 31 experts in nursing and other areas to explore the role of nurses in the culture change movement. The competencies include effective communication skills, creating a system to maintain consistency of caregivers for residents, and including residents and families in shared problem solving, decision-making and planning. Here is a summary of the list:

1. Models, teaches and utilizes effective communication skills such as active listening, giving
meaningful feedback, communicating ideas clearly, addressing emotional behaviors,
resolving conflict and understanding the role of diversity in communication.
2. Creates systems and adapts daily routines and “person-directed” care practices to
accommodate resident preferences.
3. Views self as part of team, not always as the leader.
4. Evaluates the degree to which person-directed care practices exist in the care team and
identify and addresses barriers to person directed care.
5. Views the care setting as the residents’ home and works to create attributes of home
6. Creates a system to maintain consistency of caregivers for residents.
7. Exhibits leadership characteristics/ abilities to promote person-directed care.
8. Role models person-directed care.
9. Problem solves complex medical/psychosocial situations related to resident choice and risk.
10. Facilitates team members including residents and families, in shared problem-solving,
decision-making, and planning.

 

McKnight’s site had an article and Science Daily also ran an article about how nurses and relatives routinely fail to detect the severity of chronic pain among nursing home residents, especially those with cognitive impairments, according to a new study in the September issue of the Journal of Clinical Nursing.

The five-year study from The Netherlands followed 174 nursing home residents at six different facilities. A total of 171 nurses and 122 relatives also took part in the study. Researchers conducted interviews with the non-cognitively impaired residents to determine how much, if any, pain they had reported in the week prior to the interview. Relatives and healthcare staff find it hard to diagnose pain levels in nursing home residents accurately, especially if they are cognitively impaired with illnesses such as dementia or unable to speak, according to a study .

The findings have led experts from The Netherlands to call for nurses to be given more education about how to assess and treat chronic pain and encouraging greater mobility and providing soothing massages, to alleviate pain.

Previous studies have shown that some people with mild or moderate cognitive impairment are still able to use simple zero to ten scales, where zero is no pain at all and ten is the worse pain imaginable.   "When the team interviewed the residents without cognitive impairments they found that all of them reported pain in the last week, but that only 89 per cent of the caregivers and 67 per cent of the relatives were aware of that pain" says Dr Rhodee van Herk. "However, if they were aware that the patient had experienced pain, the nurses and relatives gave it a median score of six out of ten, with the same score reported by the patients."

Nurses and relatives were less unaware of pain levels when the patient was at rest. They gave their pain levels a median score of zero, compared with the patients, who gave it a median score of four out of ten. However relatives were more aware of pain issues than nurses, with their median scores ranging from zero to five, compared with nurses, who reported a median score of zero to two. 

In general, there was more agreement between residents and relatives on pain levels than between relatives and nurses.

The Tracy Press out of California had an article about the death of a nursing home resident caused by the neglect and negligence of the nursing home.   New Hope Care Center which is owned by the for profit corporate owner Evergreen Healthcare Companies, LLC failed to properly monitor her medication and failed to check her into an emergency room fast enough when her brain started bleeding.  Caregivers failed to keep a close eye on the condition of the patient after a doctor ordered an increase in medication to prevent blood clots. A possible side effect of the medication is excessive bleeding. Because the nursing home staff didn’t monitor a change in the woman’s condition after the doctor upped her anticoagulant prescription, the state said they missed warning signs that could have saved the woman’s life.  Days after the doctor-ordered increase in her blood-thinning medication, the woman started slurring her words and complaining of a headache.  Even though the woman woke up just a couple hours earlier, she started nodding off, waking up only to vomit.

The facility was fined $100,000 after the nursing home ignored the worsening condition of a patient.  State investigators concluded that New Hope caregivers “failed to ensure that the resident’s medications were monitored and failed to fully assess the resident or promptly notify the physician when there was a change in the resident’s condition, which resulted in the resident’s death,” according to Al Lundeen, a spokesman for the state agency. The fine levied on the nursing home is the maximum penalty the agency can impose for a “AA” citation, the harshest assessment for hospitals and nursing homes in California.

The article mentions several other complaints and investigations into New Hope.

 

 

The Charlotte News & Observer had a great article on how the culture of nursing homes are changing.  Hopefully, for the better. This culture change is long over due and is desperately needed in most nursing homes.  Instead of a hospital-style nurses’ station, staff members talk with residents in an area that looks like a comfortable office, den and kitchen in someone’s home.  The physical and organizational structure of facilities is made less institutional. Large, hospital-like units with long, wide corridors are transformed into smaller facilities where small groups of residents are cared for by a consistent team.   All this means that the center has adopted the long-term care approach known as culture change.

What does culture change mean?  In the culture change model, seniors enjoy much of the privacy and choice they would experience if they were still living in their own homes.  Residents’ needs and preferences come first; facilities operations’ are shaped by this awareness.  To this end, nursing home residents are given greater control over their daily lives — for instance, in terms of meal times or bed times, and frontline workers — the nursing aides responsible for day-to-day care — are given greater autonomy to care for residents.

A symposium in Raleigh on Tuesday will examine facets of the movement’s main tenet: that residents’ preferences should guide the way nursing homes are run, not what’s most expedient for owners and staff.   The label "culture change," or "resident-centered care," may give the approach a touchy-feely sound, but it’s serious business to the several facilities in central North Carolina already adopting the changes. Some are even spending millions in building renovations to make it all work.

Changes at Hillcrest include:

Allowing residents more choice in schedules and dining choices, a move away from the structured regimes of many facilities.

Creating "neighborhood" halls with an approachable nurse’s work station, small kitchen and den to service 16 or so residents. Carpeting, wall sconces and light wells that bring in sunshine create a homier appearance.

Having frontline workers such as certified nursing assistants take on some housekeeping and food-preparation duties so that residents get consistent care from fewer staff members.

Taking soiled laundry outside — out of living areas — as soon as it’s gathered, avoiding waste smells not usually evident in homes.

Getting medicine and housecleaning carts off the halls when not in use, making for easier walking and less of a hospital-corridor feel.

Advocates for older people have pressed for better conditions in nursing homes for decades, but the specific improvements grouped as culture change have gained momentum during the past 10 years. A survey in 2007 by the Commonwealth Group, a national nonprofit, showed that about 30 percent of homes have adopted the approach, with an additional 25 percent striving toward it.  Hopefully, this kind of change will become madatory throughout the country.