Articles Posted in Staffing

It is no secret that taking care of the elderly in a nursing home is an incredibly important role that carries with it responsibilities of magnanimous proportions. In addition to offering physical aid to avoid falls and encourage mobility through physical exercises, nurses must also build rapport with their residents so that they may offer them emotional support through their caretaking process. However, the daily routine of caring for several residents often becomes exhausting for these nurses, leaving them burned out. Such exhaustion often results in a nurse leaving the facility and the relationships he or she has built with the residents. This common phenomenon among nursing home caretakers causes either a high turnover rate amongst nurses, or leaves the facility constantly understaffed.

A recent study published by The Gerontological Society of America explores the relationship that exists between nurse turnover and nursing home resident re-hospitalization. They find that many hospital readmissions may be prevented if the quality of nursing home care is improved through the hiring of more licensed nurses and licensed practical nurses. As it stands, they estimate that about 28% to a staggering 40% of re-hospitalizations may be avoided. In order to improve the quality of care, nursing homes must hire enough licensed nurses and keep them for long periods of time so that the care may be consistent. The study found that higher licensed nurse staffing correlated with lower licensed nurse turnover rates. More importantly this showed that increasing a nurse retention rate by 10% would reduce hospital readmission rates by 19%. This occurs because a long term stay at a nursing position fosters specialized knowledge which better equips nurses to provide a higher quality of care for residents.

In order to promote higher nurse retention rates in nursing homes, these facilities must invest time in constructing strategies to encourage long-term job retention. A nursing home’s priority must be to provide the highest quality of care to their residents. This includes ensuring that their residents’ needs to be hospitalized are minimized by maximizing the assistance they receive from professional nurses at the facility. In addition to the benefits conceded to residents from increasing nurse retention, there is also an economic incentive derived from it. Many nursing home administrators mistakenly believe that staff turnover is a money-saving strategy. However, nursing homes with higher performance levels on staff turnover, retention, and avoidable hospitalizations receive extra money from the CMS Nursing Home Value-Based Purchasing. Additionally, those that have an increased rate of Medicare hospital readmissions are actually sanctioned by receiving lower Medicare payments.

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A 2013 study conducted by BioMed Central Geriatrics found that there is a strong positive correlation between pain and disruptive behaviors displayed by the elderly suffering from dementia. It explains that such behavior is often expressed through aggression or agitation, which increases these patients’ risk for injuries and hospitalizations. In fact, agitation is a common behavioral symptom which occurs in up to 80 percent of nursing home patients suffering from any type of mental deficiencies, not simply dementia. However, because dementia is characterized by a decreased ability to verbalize pain due to memory impairment, it causes the sufferer’s pain to manifest itself through destructive behavior.

This discovery is significant because it emphasizes the need for nursing homes to address troublesome behavior by dealing with the root of its cause, rather than simply attempting to manage the symptoms. Many nursing home caregivers often attempt to deal with these symptoms by using psychoactive restraints which not only lead to falls and decreased mobility, but also offend the personal dignity of the elderly. Such practices are common because a sedated patient does not need to be checked on for long periods of time, allowing a chronically understaffed nursing home to continue running with their limited staff. Therefore, this unethical practice bolsters understaffing, which is an important cause of elder neglect.

The BMC Geriatrics study also found that 30% of the cost of care associated with dementia is attributed to the cost of controlling disruptive behaviors. In other words, learning how to adequately cope with elderly pain would significantly help to reduce the overall cost of caring for dementia patients. This cost reduction should serve as an incentive for understaffed nursing homes to hire and train more qualified caregivers, ensuring a higher quality of care for their residents.

In addition to uncovering the root of a serious issue, this study highlights the extent to which many nursing homes are ill prepared to aid their residents. Without proper and extensive training of their staff, nursing homes will continue their unethical practices of medicating their disruptive patients in order to calm their agitation or aggression. Using psychoactive restraints to sedate patients into a state of compliance is a gross violation of the elderly’s Patient’s Rights. Their cognitive and communicative deficiencies subject them to a torturous silence which must be broken. It is the nursing home’s responsibility to not only care for the patient’s physical well-being, but to ensure their emotional and mental comfort as well.

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According to an article in Bloomberg News, the for-profit private nursing home industry overbills Medicare by 1.5 billion dollars a year by conducting unnecessary procedures and therapy on their patients. This, however, is not the only way that for-profit nursing homes have been using unlawful methods to increase profits. Nursing homes frequently engage in the understaffing of their facilities in an attempt to cut payroll costs and essentially place profits over people. Between the years of 2008 to 2012, federal prosecutors have brought 120 civil and criminal cases against nursing home facilities and other related people that have now been resolved. That is twice the number of cases that were brought in the five years prior to 2008.

One of the most egregious offenders was Skilled Health Care Group Inc., a company that operates 75 nursing homes in the United States. The company was charged with 11 counts of elder abuse at a nursing home in Eureka, California. Prior to the criminal charges being brought forth, Skilled Health Care Group settled six wrongful death civil suits between 2005 and 2012 in California’s Humboldt County. The criminal charges were stemming from incidents occurring at a skilled nursing facility in Eureka, California. This nursing home was one of the 22 company sites that was indentified by the court to be suffering from chronic understaffing and the jury returned a 677 million dollar judgment which was later brought down to 63 million dollars in a settlement. According to documents from the class action suit, patients were left unattended for hours at a time, soiling themselves and not being changed, and being denied meals, which led to suffering and dehydration and malnutrition.

The rise of for-profit institutions in the health care industry, especially with regard to skilled nursing home facilities has led to the cutting of costs that are absolutely necessary to run an efficient and well-maintained nursing facility that provides a high quality of care. At the same time, overbilling and the conducting of unnecessary or even dangerous medical procedures on residents has been on the rise. In the past three years, the U.S. justice department has settled civil fraud complaints against eight hospice companies that enrolled or retained patients that were in improving health and were not dying.

What this means for you and your loved ones is that sometimes, the care and well-being of patients are not being prioritized over low costs and profits. This, in turn, leads to a culture of cutting corners and lack of training, which can result in neglect, elder abuse, and even death. When for-profit nursing homes cut costs by understaffing, they are putting your loved one’s life at risk. Nearly all injuries that occur in skilled nursing facilities can be prevented with proper staff and training. Such injuries include pressure ulcers, malnutrition, dehydration, and those that result from falls.

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The Care Quality Commission recently published a report called “The state of health care and adult social care in England” that reveals problems that are universal to long-term care facilities. The report concluded that three factors can be linked to low quality of care in nursing homes: a culture where substandard care is the norm; care that is task based rather than specially tailored to meet individual resident needs; and high turnover rates or poor deployment of staff.

What these three factors have in common is that they all have to do with the nursing home’s staff. The quality of a nursing home’s staff is central to providing your loved one with the care the he or she needs and deserves. Unfortunately, however, the study found 25% of nursing homes to be understaffed. Although California law requires a minimum of 3.2 nursing hours per patient day, having sufficient numbers of staff cannot be so simply quantified. The study considered inadequate staffing to be any level of staffing that prevented the facility from providing a high quality of care to its patients.

This proposes an alternative approach toward staffing levels that is instead based on patient acuity needs. David Behan, chief executive of the commission, asserts that “Health and care services need to rise to the challenge of responding to the increasingly complex conditions suffered by our ageing population. That means delivering care that is based on the person’s needs, not care that suits the way organisations work.” In fact, it is your loved one’s right under Health and Safety Code 1599.1 (a) to reside in a nursing home that is staffed to meet the needs of all residents at all times. Any breach of this duty on part of the nursing home affects the allocation of staff and resources and negatively impacts the care provided to all residents of the facility.

The study focused on mismanagement of drugs as a result of understaffing, which occurred in 22% of skilled nursing facilities. This can include chemical restraints, polypharmacy, and the use of drugs for off-label purposes, which can all lead to dangerous adverse drug reactions.

Also considered when evaluating the quality of care of a nursing home was dignity and nutrition. Many residents were spoken to condescendingly, did not receive privacy, or could not reach their call lights. In fact, the study found that 15% of nursing homes did not employ staff that treated its patients with respect. Some other common injuries that can be indicative of poor quality of care in nursing homes are pressure sores, dehydration, and infections.

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In every calendar year, roughly 25% of all the patients in a nursing home are transferred to a hospital or emergency room. There have been recent concerns within the healthcare community that transfer rates are higher than what they should be. A recently published study looks at the frequency of hospitalizations in New York nursing homes and what impact education programs can have on preventing transfers.

In the world of long term care, hospitalizations are not generally beneficial to the patient. Such events not only indicate a deterioration in patient health, but the actual act of transferring can put great strain on a person’s body, mind, and health: transportation, change in environment and people, miscommunications about treatment and care plans, etc. Communication between nursing facilities and emergency personnel/hospital staff is an area where much can slip through the cracks, resulting in worse care for the patient. An article that was published last year delves into the issues surrounding the lack of thorough communication involved in hospitalizations. The authors recommended that a more comprehensive documentation system be put into place and that verbal communication, to augment and explain written forms, be mandatory. In the present state of affairs, much information is lost between facilities as people fail to completely fill out transfer forms or are unable to understand the notes of the other facility. In such cases it is the patient’s quality of care that suffers and the already stressful process of transferring from facility to facility is made worse.

Considering the toll hospitalizations can take on the health of those in long-term sub-acute care, it is important for skilled nursing facilities to attempt to reduce any unnecessary or preventable transfers. The recent study of New York nursing homes reported that in using an education and training system, they were able to observably lower the rate of hospitalization. The program used is called INTERACT, “Interventions to Reduce Acute Care Transfers”. The main principles of this system are educating nursing home staff in early detection of problems and how to communicate and handle these issues in a timely fashion, before they become severe enough to need transfer to an emergency facility.

The lynchpin on this program is the education of employees in how to recognize problem symptoms and the correct responses to any such problems. The efficacy of the INTERACT program, which has been through multiple successful trials, speaks to the fact that good training systems for staff are not currently in place. The failure of a nursing home to adequately train staff violates the patient’s right to be cared for by knowledgeable and qualified care-givers, set down in Health and Safety Codes. Factors that can commonly contribute to failure to provide proper training to employees are understaffing and fiscal meanness.

In the situation discussed in the referenced study, untrained staff can lead to increased hospitalizations and miscommunications between facilities, which can have a great negative impact on the patient. And there are many other harms that can be inflicted upon residents in understaffed nursing homes. Conditions such as pressure sores are preventable with enough care and attention, but can become severe and very painful if a patient is not well-looked after or if the proper preventative measures are not carried out. Infection control is also greatly affected by staff numbers and education. Studies have shown that a great number of nursing home staff are not educated in basic infection prevention techniques, such as proper hand washing and sterilization. Lack of training in this area, along with low staffing levels, has been correlated with higher rates of preventable infections, such as scabies and methicillin-resistant Staphylococcus aureus (MRSA).

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Caring for the elderly is no easy task. While some elderly adults require acute care in skilled nursing facilities, others remain at home, often living with their children. Regardless of where they live, caregivers often experience burnout due to the high levels of stress encountered when caring for the elderly. A study recently published in the June 2012 issue of the Journal of American Medical Association compares job burnout in different healthcare settings. The article, titled “Professional Caregivers’ Mental Health Problems and Burnout in Small-Scale and Traditional Long Term Care Settings for Elderly People with Dementia in the Netherlands and Belgium” hypothesizes that caregivers in small-scale facilities experience less burnout than their counterparts in larger facilities.

These small-scale facilities refer to a relatively new type of care facility for dementia patients that treat dementia by allowing residents to maintain their own lifestyles and continue carrying out old habits, hobbies, and activities of daily living for as long as possible. Because these facilities are smaller, tasks are more integrated, meaning that a nurse is required not only to care for patients, but also to perform housekeeping and administrative tasks.

The benefits of a small-scale facility include a greater emphasis upon interaction with individual patients and more individualized care. For example, in larger facilities, all residents are forced to comply with daily routines and schedules, whereas in these small-scale facilities, daily schedules are based on each individual’s need. This highlights the inflexibility of care routines that is often a problem in larger facilities since previous studies have recommended that in order to effectively treat dementia, facilities should be open to modifying care routines to fit the needs of individual patients.

The study obtained its data by questioning workers in five different small-scale facilities and focused on those who care specifically for dementia patients, since the increased level of care required by dementia patients is often correlated with higher rates of job burnout, job dissatisfaction, stress, and mental health problems. “Burnout” was defined as feelings of exhaustion, depersonalization and disconnect from the individual’s job, and a reduced amount of personal accomplishments.

Interestingly enough, the results of the study disproved the hypothesis that caregivers in small-scale facilities experience less burnout than those in larger facilities. Despite the differences in care settings, workers in both types of facilities were observed to experience approximately equal amounts of burnout. However, the study determined that over time, caregivers in all types of care facilities, large or small, experience increased levels of burnout.

In conclusion, the researchers determined that the increased levels of job burnout in care facilities are a result of understaffing.

While these facilities are expected to provide the same quality of care with significantly fewer resources, government agencies are also increasing accountability in nursing homes by conducting inspections and issuing deficiency citations. Some government agencies even offer incentive programs to nursing homes that provide a high quality of care. Others base their funding on quantifiable factors such as number of incidents of preventable fall-related injuries and facility-acquired pressure ulcers. While Medicare’s ‘No-Pay’ rule has proven to effectively improve infection control measures, other programs, unfortunately, have often led nursing homes to withhold care and “downcode” certain injuries in order to avoid liability and continue receiving funds. For this reason, you must be extremely cautious when nursing homes report your loved ones health condition. Even if your loved one is being treated and assessed by nurses and physicians, it is still important for you to personally examine your loved one often since nursing homes often have incentives to conceal certain health conditions.

Many factors such as understaffing and consequently job burnout can prevent a nursing home from providing your loved one with the care that he or she requires. However, regardless of recent budget cuts and sometimes difficult working conditions, skilled nursing facilities continue to carry an obligation to provide your loved one with an adequately staffed facility and a high quality of care. They must learn to adapt and allocate their funding appropriately. For example, despite decreased levels of funding, many nursing homes continue to use their money wastefully by prescribing antipsychotic drugs in order to chemically restrain dementia patients, rather than using this money to increase staffing levels. Your loved one may be a victim of nursing home neglect and elder abuse if his or her nursing home is failing to provide him or her with proper care and an adequately staffed facility.

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A recent article titled “Caring for elders: the role of registered nurses in nursing homes” emphasized the great importance of staffing a sufficient amount of registered nurses (RNs) in nursing homes. The article refers to RNs as the “linchpin” of nursing homes as they are expected to organize innovative activities, exercise clinical judgment, and deal with ethical dilemmas while linking together different departments. The study discussed in the article conducted various interviews with RNs from different nursing homes. The conclusion was that the responsibilities of RNs are absolutely crucial to nursing homes, but many factors such as understaffing and a lack of communication often stand in their way of doing their job properly which in turn leads to a lower quality of care.

While RNs may also do office work and other administrative tasks, these tasks can be delegated to other staff as the skill set of an RN can be better utilized elsewhere. The article stresses that RNs should really be focusing on direct patient care, such as maintaining a good relationship with their residents and exercising clinical judgment. If RNs maintain a good relationship with their residents, they will in a better position to direct other administrative tasks to other staff to ensure that the nursing home is providing the best quality of care.

An RN is becomes tied down with office work usually when the facility is understaffed and do not have enough staff to delegate the proper responsibilities. An RN complained about this understaffing and incorrect delegation of duties saying, “Handling invitations to tender, equipment and resident inventory, billing, and drafting quality control documents could be delegated to others. We actually spend little time building a relationship and communicating (with the resident).” When RNs do not have time to maintain a good relationship with their residents due to understaffing, it becomes nearly impossible to carry out individual care plans for their residents, which is extremely important for ensuring safety of residents and preventing falls.

Previous studies have shown the staffing levels of RNs and the amount of RN direct care time are correlated with avoidable nursing home injuries such as pressure sores, urinary tract infections, and falls. Because of this, it becomes increasingly important that nursing homes both hire enough RNs and allow RNs to carry out their proper responsibilities. Undervaluing the role of an RN could seriously compromise the quality of care. Unfortunately, as this article has shown, many nursing homes do ignore the importance of a proper caregiver-patient relationship, and disregard the importance of staffing nursing homes properly.

When choosing a nursing home, it is important to ensure that the well-being of their residents and the human element of care is one of the most important priorities for the facility. While this may seem obvious, many nursing homes do not have their resident’s health as a first priority. This is both inexcusable and a violation of a patient’s rights.

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In skilled nursing facilities, one of the busiest and most hectic times of the day is mealtime. For dementia patients, mealtime is an extremely significant indicator of quality of life. Recently, a study titled “Factor’s Affecting Independence in Eating among Elderly with Alzheimer’s Disease” was published in the journal of Geriatrics & Gerontology International. Researchers who conducted the study noticed that patients who suffered from dementia often experienced a decline in the ability to eat independently. Because of their need for feeding assistance, it is important to recognize the signs of dementia by monitoring residents during their mealtimes.

The study observed that patients with dementia and other cognitive disorders, such as Alzheimer’s disease often had difficulty beginning their meals by themselves. This could be a result of an inability to recognize the material on their trays as food. Sometimes, even when patients were able to identify their food, they were unable to comprehend how much food to transfer to their mouths, and by what means to do so. For example, patients with dementia often had difficulty using their utensils properly to scoop the proper amount of food, either scooping too little food or too much food all at once.

Often, dementia patients also had difficulty distinguishing between food and non-food items. Even when they were able to identify their food, as a result of visuospatial impairments, these residents sometimes only recognized portions of their meals as food, and left the remainder untouched. Other patients with dementia who suffered from attention disorders or disorientation were unable to stay focused on eating during the entire mealtime. Some were distracted by other activities, while others were unable to remain alert and fell asleep during their mealtime.

Unfortunately, nursing homes are often inadequately staffed and unable to provide their residents with the one-on-one feeding assistance that they often need. Especially in patients with dementia, nursing home neglect during mealtimes has serious consequences. According to the study, one of the most common symptoms of dementia during mealtimes was the inability to begin eating. Consequently, patients often become anorexic or malnourished because facilities are understaffed and nurses are far too overwhelmed during mealtimes.

The study also pointed out that in most skilled nursing facilities today, each individual care provider is permitted to use their own judgment on how to feed patients. While this may be acceptable in nursing homes with qualified and well-trained nurses, such as licensed practical nurses (LVNs) and registered nurses (RNs), many facilities leave meals to the discretion of care aides and certified nursing assistants (CNAs) who often are not thoroughly educated on the dangers of malnutrition and dehydration. Therefore, skilled nursing facilities should have set guidelines or rules that must be followed during mealtimes. Instead, trial-and-error experiments are generally accepted in determining the best foods to feed residents. However, this is extremely dangerous, because just one simple error in feeding that is not in adherence with physician’s orders can have serious consequences, and even lead to death. For this reason, nursing homes should also employ dieticians during mealtimes, to ensure that doctor’s orders are being followed and to maintain the highest practicable nutrition and physical health of patients.

The study suggested altering the texture of meal or adjusting the patient’s posture in order to encourage independent eating. Additionally, certain therapies exist to improve and maintain the swallowing function. However, once dementia reaches more serious stages, it is difficult to perform these rehabilitation exercises. Therefore, nursing staff need to be aware of the symptoms discussed above that patients with dementia often show during mealtimes. It is the responsibility of the nurse to identify the onset of dementia early on in its progression, and to implement the proper therapies and treatments to encourage independent eating.

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While polypharmacy, the use of multiple drugs simultaneously, is known to have dangerous effects on the physical and psychological health of patients, other causes of adverse drug reactions among the elderly population are lesser known. A study, titled “Geriatric Conditions and Adverse Drug Reaction in Elderly Hospitalized Patients,” published in the February 2012 issue of the Journal of American Medical Directors Association, seeks to discover another explanation for the occurrence of adverse drug reactions, focusing on the relationship to geriatric conditions.

After assessing 506 patients, the study concluded that hematologic, neuropsychiatric, and respiratory drugs are the most likely to lead to adverse drug reactions. With respect to geriatric conditions, patients who experienced adverse drug reactions suffered from cardiovascular, dermatologic, gastrointestinal, and psychiatric disorders. They also experienced a loss of independence, including incontinence and an inability to perform other activities of daily living.

Fortunately, incontinence is not a disease, but a symptom, that can be improved with the proper care. One treatment technique is called prompted voiding and involves the coordination of a patient’s bathroom schedule with a schedule of food and liquid intake. Nurses and dieticians also need to manage the nutrition and fluid intake of their residents. According to Patients’ Rights, the nursing staff is obligated to maintain the hygiene and dignity of your loved one if he or she suffers from incontinence. When proper care is not provided and patients who soil themselves are not changed immediately, incontinence can have serious consequences, such as the development of pressure ulcers. Needless to say, adequate staffing is absolutely necessary in order for treatment to be successfully executed and for hygiene and dignity to be preserved.

According to the study, falls, in particular, were strongly linked to the usage of neuropsychiatric drugs. Because falls are so dangerous, as they can lead to injuries, such as hip fractures and head trauma, and sometimes death, caregivers need to be even more careful with patients who are using neuropsychiatric drugs. This requires communication between the patient’s physician and the nursing staff. Unfortunately, the nursing staff does not always have your loved one’s best interest at heart, so it is important for you to ensure that such communications are taking place and that physician’s orders are being followed.

On the contrary, nurses sometimes use drugs as restraints, in an attempt to prevent falls. Often, antipsychotic drugs are used as chemical restraints to sedate patients. The use of chemical restraints is not only a violation of rights, but is also dangerous, as it puts patients at a higher risk for death. You should check that your loved one’s medications are prescribed for medically sound reasons, and also ensure that your loved one is not being physically restrained either.

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In a recent issue of the Canadian Journal on Healing, the Canadian Association on Gerontology conducted “A Survey of Nursing Home Organizational Characteristics Associated with Potentially Avoidable Hospital Transfers and Care Quality in One Large British Columbia Health Region.” The researchers first examined previous studies on avoiding hospitalization in nursing home patients, which have shown that transfers to hospitals often lead to a decline in quality of life for the patient, and that skilled nursing facilities with the proper resources are often better equipped than hospitals to treat certain conditions. However, not all nursing homes are prepared to treat your loved one in the case of an emergency. In this study, the researchers aimed to identify the specific conditions that are required in order for nursing homes to be more effective than hospitals in treating patients. The survey was organized with various questions surrounding some main themes.

The first category of questions analyzed staffing. The study showed that higher levels of staffing were directly linked to lower levels of hospitalizations. Direct care staff members were considered to include registered nurses (RNs), licensed practical nurses (LPNs), and care aides. The results of the study also emphasized communication between staff, particularly care aides. Despite the fact that they usually engaged in the most contact with patients directly, care aides were often excluded from everyday decision-making processes concerning patients.

While most facilities employed all three types of direct care staff, the presence of non-nursing staff, such as dieticians and rehabilitation and activities directors, varied. However non-nursing staff are also very necessary to provide your loved one with the quality of care that he or she needs. For example, a dietician should be present during mealtimes, to ensure that your loved one is receiving the proper nutrients to support his or her health, and to prevent the possibility of malnutrition.

The study also took note of each facility’s nursing hours per patient per day, which shows the importance of adequate staffing. On average, nursing hours per patient per day was calculated to be 3.17. However, according to California state law Health & Safety Code §1276.5-1276.65, the minimum staffing level is 3.2 nursing hours per patient per day. It is important not only to ensure that your loved one’s rights are not being violated and that the care facility is fulfilling staffing level requirements, but also that they are receiving high-quality care from well-trained professionals.

The second theme of survey questions focused on physician care. The results of the survey showed that continuity of care contributed to lowering the amount of hospitalizations. When a patient is continually examined by the same doctor, the physician establishes a familiarity with the patient’s medical history and is better able to treat the patient effectively, thus avoiding unnecessary hospitalizations. However, we must warn you to be cautious with who and what you believe because nursing homes have an incentive to manipulate their patients’ diagnoses. While upcoding is advantageous because it involves reporting more serious health conditions to receive more funding from the government, downcoding, which involves intentionally underestimating the seriousness of a condition, is also beneficial for the nursing home because it reduces the facility’s liability. Therefore, if you sense that something is wrong, it is important for you to get another doctor’s second opinion.

The third type of questions analyzed palliative care. All too often, nursing homes neglect patients whom they perceive are dying and leave them to suffer in the last days of their lives. In other cases, the facility often instigates a transfer of the patient to a hospital, so that he or she can die there. However, nursing homes can usually provide better, more comfortable end-of-life care than hospitals, and those with palliative care standards, which are pre-signed orders from a certified physician, usually involving the prescription of narcotics to ensure a death void of as much suffering and pain as possible. Although most of the facilities had updated palliative care orders, a significant 22% of nursing homes did not have any form of palliative care at all. Therefore, you should take the precautions to ensure that palliative care orders exist for your loved one in the necessary cases.

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