Eric Carlson: On Elder Care—and Elder Law

All too commonly, the choice of a nursing home is made under duress—when a prospective resident and his or her family are already in difficult times. U.S. News asked Eric Carlson, a Los Angeles attorney with the National Senior Citizens Law Center, a nonprofit law firm that defends the interests of seniors, what to look for in a care provider and how to fight back if there's a problem. Carlson is the author of 20 Common Nursing Home Problems—and How to Resolve Them and coauthor of The Baby Boomer's Guide to Nursing Home Care (Taylor Trade, $14.95) Edited excerpts from the interview:

Eric M. Carlson, Director of the Long-Term Care Project at the National Senior Citizens Law Center.

What can consumers do to best protect themselves up front?
Be aggressive about questioning a prospective home about staffing and staff training. A nursing home generally receives $4,000 to $9,000 a month for the care of one resident, so it should be responsive to both residents and potential customers. Talk to residents and visitors without nursing home staff hovering nearby. Visit several times, at different hours and on different days. Make at least one visit at mealtime. Examine inspection reports. Each nursing home that accepts Medicare or Medicaid payment is inspected approximately once a year. And the National Citizens' Coalition for Nursing Home Reform offers a consumer guide to getting good care in a nursing home.

Are there special innovations to look for in Alzheimer's and dementia care?
Yes. Some nursing homes are trying a different approach, commonly called resident-centered care, that offers a homelike environment and that works to meet a resident's preferences, such as eating frequent snacks, waking up later, or being able to take walks. These homes work harder to try to get people up and find activities that work for them as individuals so they are not sitting around in wheelchairs watching The Price Is Right every morning. They stress intellectual and physical stimulation, exercise, calming music, and pets for therapy. And they pay attention to how the staff approaches and talks to dementia patients. Some examples: moving slowly when approaching a patient, approaching from the front so they do not get startled, and calling the person by name since even late in the disease they remember their own names.

What is the biggest factor when it comes to quality of care?
Staffing. Annual turnover for nurse aides runs at 100 percent or higher. Nurse turnover rates are also high at 50 percent annually. Existing staff winds up working double shifts. Seek out homes with low staff turnover and a high ratio of staff members to patients, particularly those for the nurse aides, who do the lion's share of the hands-on work. One staff member assigned to five or six residents is best. An administrator or director of nursing may not be willing to cite staff turnover rates but should be able to answer simple questions about how long employees have worked there.

Try to find a place where the nurse aides have been around for two or three years. The nurse aides are the ones waking people up and helping them get dressed and fed, and if they are staying, that probably means that the home is treating employees a bit better and the staff wants to be there. They, in turn, are apt to have a better attitude toward providing care.

Preferably, nurse aides will be assigned so that each resident generally receives care from the same aide, who is accountable for his or her care. In the worst homes, you'll see a resident cared for by one person on Monday, someone else on Tuesday, and someone else on Wednesday. Consistent staffing can make a huge difference in a resident's quality of life and behavior. Dementia and Alzheimer's patients often require consistency to enable the resident to recognize the person and build trust.

What are some other common problems?
Inappropriate use of behavior-modifying medication is a big one. It's easy to use sedatives and "psychoactive" medications, despite their side effects, to make residents more manageable. That said, it can only be administered with consent of the resident or his representative. If the medication is used solely for the nursing home's benefit—to keep the resident quiet and out of the way—you should likely refuse it. If the doctor recommends it, you must be told what the benefit is and then choose to accept or reject the recommendation. The family has to be real clear that the doctor does not have any unilateral authority.