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If your loved one resides in a Skilled Nursing Facility (SNF) or nursing home in Southern California, you should be mindful of the risks of malnutrition and related health problems.

A study was conducted with nursing home residents in Germany, described in the article titled Prevalence of Malnutrition in Orally and Tube-Fed Elderly Nursing Home Residents in Germany and Its Relation to Health Complaints and Dietary Intake, published in the 2011 volume of Gastroenterology Research and Practice. According to this study, malnutrition is widespread among nursing home residents and is related to serious health problems, such as constipation, nausea, and vomiting. Among the residents in the study, 26.7% suffered from malnutrition and 52.9% were at risk of malnutrition. Health problems were more prevalent among malnourished residents. For example, approximately 40% of well-nourished residents and 40% of residents at risk of malnutrition suffered from constipation. However, 55% of malnourished residents had constipation.

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Methicillin-resistant Staphylococcus aureus (MRSA) is a harmless type of staph bacteria that lives on the surface of the skin. It does not become problematic until it enters the body through an open wound, breathing tube, or catheter. Because MRSA is resistant to certain antibiotics that are commonly used to treat and cure staph infections, it can become an extremely serious problem, especially in skilled nursing facilities. MRSA colonized residents are more likely to develop infection than noncolonised ones, and thus have increased risk of death. (For more information, visit the Centers for Disease Control and Prevention.)

A recent study, titled “MRSA: A Challenge to Norwegian Nursing Home Personnel” and published in Interdisciplinary Perspectives on Infectious Diseases, highlights how the spread of MRSA creates challenging tasks for nursing home staff because of the increased workload associated with cleaning, disinfection, and sanitation of the environment and of the MRSA-infected residents. The study also found that problems related to the control of MRSA are associated with “old buildings standards not suitable for modern infection control work with lack of isolates, single rooms and bathrooms, [and] a low rate of professional healthcare staffing and education in infection control work.”

To decrease the risk of transmission of MRSA within nursing homes, nursing home owners and operators need to avoid overcrowding the facility and must provide adequate staff to effectively implement infection control and preventative measures. Without adequate facility space to isolate the infected residents or carriers for treatment and decolonization of MRSA, staff, visitors, and other patients are exposed to the infection and the likelihood of an infection outbreak increases significantly. High quality care by well-educated and well-trained staff, who are capable of following MRSA control guidelines, is absolutely necessary to successfully controlling and treating MRSA infections.

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Nursing homes that get reimbursed from Medicare and Medicaid for residents’ services- approximately 96% of all U.S. nursing homes- must be certified and inspected annually. If a nursing home fails to meet federal requirements, inspectors cite the nursing home for violating specific standards (deficiency citations). Violations cited are first assessed by the scope of their effect on residents and the severity of harm to residents and then placed within categories, such as quality of care, quality of life, or resident rights. Under this methodology, both the scope and severity of deficiencies are evaluated and reported as a total point score, and such deficiency score is a reliable indicator of the nursing home’s quality of care.

Given that deficiencies have significant implications for the quality of care and the quality of life of nursing home residents, many studies have used nursing homes’ deficiency scores in measuring their quality of care. A recent study titled “The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes,” and published by The Gerontologist in May 2011, also used Florida nursing homes’ deficiency scores to find a strongly correlated relationship between the quality of nursing homes and nursing staff levels.

According to this study, higher nursing staff levels are “associated with lower scores on both total deficiencies and deficiencies related specifically to quality of resident care.” Specifically, the findings of this study demonstrate that “with every 6 minute increase (tenth of an hour) in [CNA hours per resident day], there is a 3% reduction in the quality of care deficiency score.” This means that if the nursing homes increase the average nursing hours per patient per day by hiring more CNAs or RNs, they would provide better quality of nursing services in compliance with federal requirements and thus receive lower deficiency scores. The study concludes that higher nursing staff levels would also benefit the nursing home providers because by increasing nurse staffing levels, providers subsequently will receive lower deficiency scores and “thereby improve their quality score and marketability to attract residents.”

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Welfare and Institutions Code section 15610.07 provides that abuse of an elder includes “[p]hysical abuse, neglect, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm or pain or mental suffering” or “[t]he deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering.” (Welf. and Inst. Code §15610.07.) Neglect means “negligent failure of any person having the care or custody of an elder or a dependent adult to exercise that degree of care that a reasonable person in a like position would exercise,” which includes, but not limited to, the failure to assist in personal hygiene; the failure to provide medical care for physical and mental health needs; the failure to protect from health and safety hazards; and the failure to prevent malnutrition or dehydration. (Welf. and Inst. Code § 15610.57.) Physical abuse means, inter alia, assault, battery, prolonged deprivation of food or water, unreasonable physical restraint, or sexual assault. (Welf. and Inst. Code § 15610.63.)

Nurses and care coordinators in community care settings are in a position to easily detect and assess any elder abuse or neglect problems because they are able to observe their client’s home environment and the client’s relationship with the caregiver. However, handling elder abuse or neglect cases is challenging because nurses and care coordinators have to consider the elder client and caregivers’ health and social conditions, their relationship and the possible outcome of their intervention. (Many times, unfortunately, the perpetrator is the victim’s daughter or son and not a spouse or partner.) The intervention is also more effective when they collaborate with managers of their agency and the elder protective services in discussing the cases and identifying available community recourses for intervention.

According to a recent article titled, “Challenges in handling elder abuse in community care. An exploratory study among nurses and care coordinators in Norway and Australia,” and published in the Journal of Clinical Nursing in September 2011, the major problem in handling various types of elder abuse cases was due to the conflict between the nurses’ duty of care and the clients’ right to refuse help. The nurses and care coordinators who participated in this study were mainly concerned about how to secure and support the older victim by individualizing the intervention to alleviate or reduce abuse and their effect, especially when the victim refuses the help.

For their intervention to be effective, it needs to be individualized based on the type and seriousness of the abuse and the victim’s cognitive capacity. (Reduced cognitive capacity was always present in case of elder neglect.) The victim with decision-making capacity has to find his or her own solutions to the problems, and nurses and care coordinators can support the victim by monitoring the situation and by offering suggestions and options to ensure the victim’s basic needs, health and well-being, to reduce the impact of the abuse. If there is no improvement in the situation, nurses and care coordinators need to step out of the caring role and apply for residential care to protect the victim from further abuse. Collaboration with other service providers, such as protective services, would be very important in such case.

The study concludes that community care agencies “need to be aware of the huge impart of the managers’ involvement and the services’ responsibility and capacity to support professionals in the handling of elder abuse.” Individual nurses’ ability and willingness to interact with both victims and abusers are essential, and the community care agencies’ policies and procedures should be in place to promote efficient and appropriate intervention in handling elder abuse or neglect cases.

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If your loved one currently resides in a Skilled Nursing Facility (SNF) or nursing home in Southern California, and has problems receiving adequate nutrition, you may have considered whether your loved one should use a feeding tube.

According to a recent article titled Enteral Nutrition for Older Adults in Nursing Facilities, published in the June 2011 volume of Nutrition in Clinical Practice, older adults (those 85 years of age and older) residing in nursing facilities tend to have multiple health conditions and an increased need of assistance with activities of daily living, such as eating. Approximately fifteen percent of residents of nursing facilities need constant assistance with eating. Thirty-two percent of residents have sensory impairments, including problems with teeth, which hinder eating.

It is the responsibility of the healthcare practitioners at nursing facilities, including physicians, nurses, and dieticians, to ensure that residents receive adequate nutrition. One of the methods used to ensure that residents are receiving adequate nutrition is for those residents to rely on feeding tubes. If a feeding tube is used, the registered dietician (RD) often determines the nutritional requirements of each resident and ensures that each resident’s nutritional needs are met. Failure to monitor the nutritional intake of residents can lead to malnutrition, which in turn can lead to weight loss, pressure ulcers, and other fatal problems. These injuries are often signs of neglect.

According to federal regulations, use of a feeding tube should not automatically be the preferred option for residents not receiving adequate nutrition. Before a feeding tube is placed, the nursing facility must ensure that 1) the use of a feeding tube is unavoidable for those who have been able to eat with or without assistance, and 2) residents receiving nutrition through feeding tubes receive attention and treatment to prevent complications, such as aspiration pneumonia, vomiting, and dehydration, and to restore normal eating abilities, if possible. (42 C.F.R. § 483.25(g).)

The authors of the article state that the resident’s wishes regarding the use of a feeding should be respected. The resident may have expressed his or her preferences when admitted to the nursing facility, in an advanced directive, or a living will. If no preferences can be determined, then a decision has to be made on whether use of a feeding tube is worthwhile. Feeding tubes are appropriate in various situations, including 1) when a return to previous quality of life is expected, 2) when a resident has a permanent problem swallowing or has a damaged esophagus, and 3) for people with head and neck cancer or acute stroke with dysphagia as a possible method to prolong life.

In a nursing facility, the RD is responsible for assessing the nutritional needs of residents, tailoring the formula residents receive through the feeding tube based on those needs, and changing the tube feeding orders as needed. The RD, along with the healthcare team, should continually monitor the effectiveness of the tube feeding, including formula administration, tolerance of the feeding, nutrition status, and overall health and well-being. Proper monitoring will reduce the incidence and severity of complications as a result of tube feeding, including clogging, aspiration pneumonia, and diarrhea.

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Relevant factors that generally lead to placement of elders into nursing homes or long-term care are advanced age, cognitive dysfunctions, and physical disability. The role of acute care hospitalization is little known but also a significant risk factor for long-term institutionalization of elders.

According to a recent study published in the Journal of Gerontology: MEDICAL SCIENCES in August 2011, titled “Risk of Continued Institutionalization after Hospitalization in Older Adults,” three quarters of new nursing home placements were preceded, and presumably precipitated, by a hospitalization with discharge to a skilled nursing facility (SNF). The analysis of national Medicare data from 1995 to 2008 showed that hospitalized patients for acute illness were almost 10 times more likely to reside in a nursing home 6 months later compared to non-hospitalized control patients. The patients who were transferred home were also less likely to be institutionalized in long-term care than those who were transferred to a SNF on hospital discharge.

Based on the results of this study, the article concludes that “an appropriate time to initiate programs to prevent long-term institutionalization is at hospitalization,” and that “[a]nother point for potential intervention is during an SNF stay, which now occurs in almost two thirds of all patients who go into long-term care after hospitalization.” Therefore, efforts for reductions in institutionalization of the elderly in long-term care should focus on elder patients undergoing this transition from hospitalization to subsequent placement into a SNF.

Due to such link between hospitalization and long-term institutionalization, finding the right SNF is particularly important for elder patients’ well-being. Many factors, especially nursing staff levels, can affect the quality of care and the risk of nursing home injuries. Thus patients and family members should carefully compare and choose a SNF that is in compliance with federal and state regulations and laws and provides high quality skilled nursing services.

Of course, a preferable option, if possible, would be home care with the services of a Home Health Agency. This is often a sacrifice for the family who agrees to take in a loved one who needs 24 hour skilled nursing care. The benefit, however, is that the patient is under close family supervision, in a home environment, which can substantially benefit the patient psychologically. This is not to say that all Home Health Agencies are perfect, and you should study their background carefully as well to ensure their compliance history with state and federal. However, given the alarming rate of elder abuse and neglect in California nursing homes, a home health agency is worth looking into.

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In nursing homes, staffing levels of registered nurses (RNs) and the amount of RN direct care time are strongly correlated with avoidable nursing home injuries (“adverse clinical outcomes”), including pressure ulcers/sores, urinary tract infections (UTIs), weight loss, and deterioration in the ability to perform activities of daily living (ADLs). Because RNs influence the quality of nursing homes by providing expertise in direct care and evaluation, nursing homes’ workforce policy should focus on maintaining the recommended staffing level of one RN for every 32 long-stay residents (45 minutes per resident per day) and increasing the proportion of RNs providing “direct resident care” (time spent in hands-on care).

The 2004 Institute of Medicine (IOM) report titled “Keeping Patients Safe: Transforming the Work Environment of Nurses,” recommended that RN time should be 45 minutes per resident per day, including time spent on administrative and managerial tasks and direct resident care. A previous study “RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care,” published in the American Journal of Nursing in November 2005, also found consistent results that support the IOM’s recommendation. This observational study showed that RN staffing of 30 to 40 minutes per resident per day (examined in 10-minute increments) was strongly associated with reduced adverse clinical outcomes in nursing homes, including pressure ulcers, UTIs, hospitalization, deterioration in the ability to perform ADLs, and weight loss
Even after taking the severity of nursing home residents’ underlying illness into account, the study found strong and consistent associations between the average RN direct care time per resident per day and better clinical outcomes, including fewer pressure ulcers and UTIs, less weight loss, reduced deterioration of ADLs, less use of catheters, and greater use of nutritional supplements. On the other hand, more licensed practical nurse (LPN) and certified nursing assistant (CNA) time was associated with fewer pressure ulcers–a clinical outcome that is heavily dependent on nurse interventions–but did not improve other adverse outcomes. (The pressure ulcer incidence rate was 16% among residents who had a CNA time of 2.25 hours or more per day, while such rate doubled to 32% among those who had less than 2 hours of CNA time per day.) The authors of the study noted that this difference “highlights the crucial role RNs play in the quality of care in nursing homes” in providing expertise in assessment and prevention of nursing home injuries.

During the twelve-week period of this study, the nursing home residents’ medical records revealed that “one out of three residents experienced a deterioration in the ability to perform ADLs; more than one-quarter developed a pressure ulcer or experienced weight loss. Between 10% and 20% were hospitalized, developed a UTI, were catheterized, or had some combination of these outcomes; 5% died.” The study concluded that these nursing home injuries were preventable and avoidable if nursing homes had adequate staffing levels of RNs, LPNs, and CNAs, which is also legally required under California Health & Safety Code § 1599.1(a).

You can check a nursing home’s staffing levels at Nursing Home Compare. However, please note that nursing homes often include hours that do not involve direct care of residents, such as director of nursing time, director of staff development’s time, maintenance personnel’s time, and nurse administrators’ time. When assessing the quality of a nursing home, we advise you to inquire its “direct care time” provided by RNs, LPNs, and CNAs per resident per day.

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Under California Health and Safety Code Section 1276.5, skilled nursing facilities are required to provide at least 3.2 nursing hours per patient, per day. The “nursing hours” include only the hours work performed by direct caregivers, which include not only registered nurses and licensed vocational nurses, but also aides, orderlies or certified nursing assistants.

In long-term care settings, especially nursing homes, a high proportion of these certified but non-licensed aides or nursing assistants–non-licensed care providers (NLCPs)–provide the majority of personal care to residents, including transfer, repositioning, and skin care that are necessary for pressure ulcer (pressure sore or bedsore) prevention.

The problem with nursing homes primarily relying on NLCPs for daily personal care is that NLCPs who have the most contacts with the residents lack the knowledge and skills necessary to prevent or identify pressure ulcers. Studies show that long-term care facilities’ training programs and implementation of pressure ulcer prevention protocols primarily involve licensed nurses an not the NLCPs who actually provide a majority of the care, and moreover, many nursing homes even lack established pressure ulcer prevention strategies, guidelines or protocols.

Against this backdrop, the authors of a recently published article titled “A Pressure Ulcer Prevention Programme Specially designed for Nursing Homes: Does It Work?”, published in the August 2011 volume of the Journal of Clinical Nursing conducted an empirical study on a pressure ulcer prevention program specially designed for nursing homes. This program adopted a more structured pressure ulcer risk assessment method and launched the prevention interventions that involved all types of care staff. Notably, it included a separate training course for NLCPs as opposed to licensed nurses and required more involvement from NLCPs in the pressure ulcer prevention protocol.

Twelve weeks after the training and implementation of the protocol, the result showed a statistically significant improvement: both the pressure ulcer prevalence rate and incidence rate decreased from 9% to 2.5% and from 2.5% to 0.8%, respectively. The study results revealed that after the training course, NLCPs were better equipped with the necessary knowledge and skills to prevent pressure sores and were motivated to minimize the risk factors. NLCPs understood that their everyday tasks, such as lifting and transferring residents, were relevant to pressure ulcers and thus they tried to minimize friction and shear force on residents. They were also able to identify and report stage one pressure ulcers–skin redness–to licensed nurses. The Licensed nurses were then able to conduct structured supervision and monitoring of NLCPs, thereby decreasing the risk of developing a pressure ulcer to a higher stage.

The study concludes that a feasible and acceptable pressure ulcer prevention program for nursing homes can be developed, and such a program can motivate NLCPs to improve their performance of pressure ulcer prevention care and increase communication and cooperation amongst all care staff to effectively prevent and treat pressure ulcers. The increased NLCPs’ awareness levels and compliance to pressure ulcer prevention protocols were the main factors that reduced the prevalence and incidence rates of pressure ulcers in the nursing homes studied.

Early detection of stage one pressure ulcers and their appropriate management amongst different types of care staff are crucial for the well-being of nursing home residents. More developed pressure ulcers not only cause more pain but also slow recovery from a morbid condition and require prolonged hospital care. If you have a loved one in a California nursing home, stay involved with the nursing staff and demand that they immediately notify you of any changes in condition. Speak with the nursing staff and make sure not only that they are appropriately trained in pressure sore prevention and detection, but also that they are putting their protocols into practice.

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Pressure ulcers are debilitating chronic wounds that cause torture and suffering to those inflicted, and in severe cases carry the substantial probability of death. Elderly residents of Alameda County and Bay Area nursing homes with physical and or cognitive impairments- especially those with a higher number of medical problems- face the greatest risk of development of pressure sores if they are denied the necessary and appropriate preventative measures. But regardless of any co-morbidities or underlying medical problems, pressure ulcers are by and large preventable.

Because pressure ulcers are preventable, their development is used as a quality indicator for long-term care facilities (nursing homes or “Skilled Nursing Facilities”), hospitals, and effectiveness of physician care. A recent study published in the May 2011 issue of the Clinics in Geriatric Medicine suggests that to effectively prevent pressure ulcers, nursing homes must frequently assess the health condition of a patient. This includes nutrition, mobility, risk for friction and shear, activity level, incontinence, and skin condition. After assessing each patient, an individualized care plan should be developed and implemented for each and every patient in order to effectively prevent pressure ulcers.

The article, titled “Pressure Ulcers in Long-Term Care,” suggests that these strategies for prevention go hand-in-hand with those for treatment of already existing ulcers. For example, it has been shown that frequent repositioning of patients who are bed or wheelchair bound and teaching patients who are prone to inactivity to shift weight and self-reposition are helpful. Other preventive measures include keeping the skin clean and dry, preventing excessive moisture resulting from incontinence, and use of nutritional supplements to maintain good nutrition. For residents who are especially at high risk of developing pressure ulcers, pressure-relieving/reducing cushions or mattresses should be used based on individual needs, comfort, and the cost of the device.

The article emphasizes that the optimal management of pressure ulcers requires understanding of differential diagnosis of chronic wounds and the use of standardized assessment metrics to both recognize and treat pressure ulcers with a systematic approach. It also emphasizes that nursing homes must take precautionary steps toward providing care for conditions that increase a patient’s risk of developing pressure ulcers, including incontinence and malnutrition. The authors conclude that “nothing can replace good personal attendant care with frequent turning, lifting, and transfers that minimize friction and shear.” Therefore, the study once again confirms that adequate staffing of skilled nursing facilities is crucial to carrying out individualized care plans addressing each resident’s specific medical and functional problems.

It has been shown that adequate staffing levels can help reduce the incidence of pressure ulcers in long-term care facilities. In the National Pressure Ulcer Long-Term Care Study more than 0.25 hours per resident per day of registered nurse time and more than 2 hours per resident per day of nurse’s aide time were associated with a lower risk of developing pressure ulcers. The same study showed that a lower than 25% licensed practice nurse turnover in a given facility was associated with better outcomes.

Pressure ulcers are preventable and thus their development is often used as a quality indicator for nursing homes. Residents and families can choose a nursing home by looking at its published incidence and prevalence rates of pressure ulcers at Nursing Home Compare. Statutory standards of care for long-term care facilities under California Health and Safety Code Sections 1276.5 and 1599.1 also make it easier to prove that a nursing home is responsible for allowing a pressure sore to develop.

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Improving the quality of care in California nursing homes is one of the most pressing issues facing our state today. Yes, it’s even more important than our budget problems or who we elect to lead us in the political arena. Regardless of our social backgrounds or political opinions, none of us can escape the fact that as we age, all of us may be faced with the need to seek 24 hour skilled nursing care. This is a difficult reality facing many Californians today, as they grapple with not only selecting an appropriate nursing home for themselves or their loved ones, but also with ensuring that once there, the proper care and supervision is provided.
More, therefore, must be done to ensure significant improvements in the quality of care provided in California nursing homes, and particularly in nursing homes in Torrance, Long Beach and Santa Ana, given the significant rate of deficiencies issued to nursing homes in those areas in the last several years by the California Department of Public Health.
A recent study published in the August 2011 volume of the Journal of the American Medical Directors Association entitled “Randomized Clinical Trial of a Quality Improvement Intervention in Nursing Homes” (available for purchase online,) sheds further light on the various options at the disposal of nursing home owners and operators to improve the quality of care they deliver to our elderly, should they choose to avail themselves of such options. The authors designed a study to determine which of the following two options is more effective in improving clinical practices and resident outcomes: comparative quality performance information and education programs about quality improvement, or a quality improvement intervention that blends expert clinical consultation with existing nursing staff.
The results revealed that although there are no significant differences between the two groups, the outcomes of residents in nursing homes who made use of the clinical consultation showed improvements in Quality Indicators measuring falls, behavioral symptoms, little or no activity, and pressure ulcers.
The results suggest that simply giving comparative quality performance feedback and education are not enough to improve resident outcomes. Instead, nursing homes should seek out active clinical consultation by a gerontological clinical nurse specialist (GCNS) to improve clinical practice and care.
The findings of the study are consistent with California law regulating skilled nursing facilities, which mandates not only sufficient staffing in terms of numbers, but also in terms of the quality of the staff provided. It is insufficient to simply fill the nursing staff with certified nursing assistants (CNA) who do not have the training, education and expertise of licensed and registered nurses. It is clear that nursing homes can actually make an effort in improving clinical practices by putting these essential findings into practice.

Therefore, nursing home owners and operators should dedicate more resources to hiring a GCNS to provide consultation to the regular nursing staff delivering care to residents. A gerontological clinical nurse specialist can help improve the outcomes of pressure ulcer development, incontinence and aggressive behavior. Further, nursing homes should also have a well-developed comparative quality improvement system to improve resident outcomes. Nursing homes must hire more professional staff with leadership skills to implement the quality improvement programs effectively so as to provide better services to residents. With both clinical expertise and a strong quality improvement system in place, residents can receive better care and treatment from the nursing staff.

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