Step 3, Part 1: Size Up a Nursing Home by Visiting

Ask the right questions, know the signs of good and bad care, use your senses. It's detective work.


The observations entered by the survey team on the 2567 forms will draw a picture far more candid and stark than one you're likely to see on a carefully guided tour. The surveyors may observe a pile of soiled linens in the hallway or perhaps food left out to spoil for hours. Ask about the specific deficiences that were noted. The details can also inspire more pointed questions about corrective actions; the nursing home has to describe on the same 2567 form how each of the problems identified will be fixed. An inspection report may indicate, for example, that nurses didn't wash their hands as they went from one resident to another. That's worrisome because infections travel fast in nursing homes, and the elderly are particularly susceptible to them. So you can ask whether the plan to increase handwashing compliance is working. Other red flags, says Wells, include untreated weight loss, which can lead to significant frailty; medication errors; untreated pressure sores, which can be painful and can send a resident along a bedbound trajectory; and use of physical restraints. While declining in popularity, "safety belts" that strap a resident into a wheelchair or bed, says Wells, may actually trigger harm if a person already prone to poor balance tries to get free and falls in the process.

A report that can run 100 pages or more may seem picky and obsessive, but inspections often don't go far enough. A 2008 report by the Government Accountability Office found that state surveyors frequently miss or understate serious care problems. Between 2002 and 2007, federal surveyors did follow-up inspections of nursing homes recently evaluated by their states. They found that 15 percent of the state surveyors had overlooked at least one problem carrying a risk of death or serious injury, such as untreated pressure sores or weight loss.

Discuss staffing with administrators. The National Citizens' Coalition for Nursing Home Reform, which has a helpful explanation of the ways in which nursing homes are measured, suggests a ratio of at least 1 registered nurse, licensed practical nurse, or certified vocational nurse, plus 1 certified nurse assistant for every 5 residents during the day, every 10 residents during the evening, and every 15 residents at night. A home's director of nursing should be able to give you these numbers, and the Best Nursing Homes page displays ratios of nurses to patients, although they are not broken down by time of day.

High staff turnover is a special challenge for nursing homes. "Three out of four staff leave every year," says Charlene Harrington, professor at the University of California, San Francisco, and an expert in long-term care. "That's a new staff person about every three months." Studies show that high turnover rates lead to generally poorer care. One study suggests that families should look for a turnover rate below 30 percent for registered nurses, below 50 percent for licensed practical nurses, and below 40 percent for nurse assistants. Until CMS begins providing turnover data, all you can do is ask a home for its turnover rates. You could also chat up some of the nurses and aides about how often employees seem to come and go.

Even if turnover is low, scheduling can hamper care. "Does the facility tend to have the same caregivers day after day, or do they randomly assign...or rotate staff?" asks Phillips. The more consistent the contact between your mother and her nurses and aides, the better they will understand her needs and be her intelligent advocates.

As part of selecting trustworthy staff, nursing homes are required to run a state background check before a hire, but some facilities are broadening their due diligence by also conducting a national background check. The more thorough, the better.

Not all nurses are the same. Some homes make frequent use of temporary or "agency" nurses; others do so only occasionally, and still others have a policy against using them at all. Ask. "If they're doing it regularly," says Wells, "it probably means they're desperately understaffed."

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