The use of physical restraints can be problematic, but it has dropped dramatically, and many nursing homes now function completely restraint-free. Ask about the policy regarding the use of restraints (physical or medication-related), and be observant on visits for residents in chairs with lap trays and waist restraints or someone that looks sedated. Alternatives always exist.
Can a nursing home evict a resident for being difficult?
Nursing homes often attempt to evict residents with dementia who exhibit difficult behaviors and require more staff time. In almost all such situations, the nursing home is the right place for an individual with aggressive dementia, and nursing homes are obligated by the federal Nursing Home Reform Law to provide comprehensive dementia care. In general, a nursing home can evict a resident if the resident needs a level of care that cannot be provided in a nursing home, or if the resident's presence endangers the health or safety of others in the nursing home. If there's a problem with someone merely being difficult, the nursing home should identify an aide who works well with the resident and permanently assign the aide to work with him.
Generally, a nursing home must give 30 days' written notice before a planned eviction that lists the reason for the eviction along with the facts. The notice must list the telephone number for the state agency that inspects and licenses nursing homes along with instructions on how the resident can request an appeal from the agency. An administrative law judge will hear both sides and rule. My experience is that residents win the vast majority of appeals.
How big an issue is a removal to a psychiatric unit to get the resident out?
If somebody has a heart attack, it's a clear medical decision to move him to a hospital. In nonemergency situations, transfer requires the informed consent of the resident or the resident's authorized representative. But it's not unusual for hard-to-manage nursing home residents with Alzheimer's and other dementia to be committed from nursing home facilities to psychiatric units against their will. This also can happen in assisted-care facilities.
When the nursing home decides to send the person out for a pysch evaluation, state law governs the process. Generally, there's a short hold period of, say, 72 hours, which varies state to state. The individual is placed in the care of the county or state where he or she resides. That is followed by some kind of adjudication, which allows the person to be held against his or her will for a longer period or be returned to the care of his family.
Some cynical nursing home administrators try to evade the eviction requirements by transferring the resident to a hospital or psychiatric unit, then refusing to take him or her back. When this happens, the resident and family have to be very persistent in demanding readmission. Most states allow a resident to hold a nursing home bed for a certain period of time, and federal law says that a Medicaid-eligible resident has the right to be readmitted to a nursing home's next available bed, no matter how long the hospital stay. If the nursing home refuses to comply with these laws, it's necessary to file an urgent complaint with the state inspection agency and/or consult with an attorney.
You have to be really persistent because a cynical management figures it can just outlast consumers. Inspection agencies need to step up and assess meaningful fines so the calculus will change for nursing homes when they think about doing this in the future.
I'm frequently asked whether a resident should even want to go back to a nursing home that doesn't seem to want her. My answer is a strong yes. When a resident wins one of these disputes and returns to the nursing home, she gets treated with more respect. Management and direct-care staff get the message that they need to work with the resident and the resident's family to plan and provide appropriate care. Also, nothing's worse than searching for a nursing home while a hospital is rushing to discharge you from a short-stay psychiatric evaluation. Too frequently, residents in that situation end up being sent to one of the area's worse nursing homes.