The Nursing Home Crisis

CHAPTER 1

THE GOOD, THE BAD,

AND THE TERRIBLE

Whether you realize it or not, our society has shifted in demographics within the last few years, and continues to shift toward an aging population. The baby boomers are reaching their 60s, 70s and 80s, and as a result, elderly care has become not only a crisis but big business. The statistics are quite staggering. As of the 2000 census, nearly 19 million people were between the ages of 65 to 74 years of age in the United States; and over 11 million were between the ages of 75 to 84 years of age. Together this group made up 11 percent of the American population, and this percentage has continued to increase.

There are now over 17,000 nursing homes in this country, and more than 1.8 million nursing home beds available. Considering there are more than 30 million elderly in the country, (and likely more than 5% require skilled care), there remains a shortage of nursing home beds available. However, despite this, there is currently less than an 85% occupancy rate of the nursing homes. This means many elderly are receiving care at home through private care agencies or from family means of support, sometimes due to certain cultural beliefs that keep them at home. There may also be limitations in financial resources to afford nursing home placement from families and/or the elderly patient. Some families may feel the level of care in a nursing home facility is substandard.

Of the nursing homes in the United States, about two-thirds are for-profit, and the remaining are either non-profit or government-based. More than half are part of business chains, and about 13% are hospital based facilities. And a final note is that the majority of the care provided by nursing home staff comes directly from nursing aides and assistants. Registered nurses make up only five percent of the care, and LPNs (Licensed Practical Nurses) make up only about ten percent. As the elderly population has grown, and healthcare dollars have become scarcer, there has been a shift in the level of care provided. Both experience and education skills for the average nursing home worker have declined during this time, yet the demands of their jobs have consistently increased in the level of care required. Overall this is a bad recipe.

As pressures on our society have increased in both the healthcare sector as well as on the ability to provide services for our geriatric population, resources in general have been limited to accommodate these well. In order for many nursing homes to stay in operation, staff salaries have had to be cut to keep a positive bottom line. This has meant less skilled workers at lower wages. Nursing homes also serve a large number of individuals with Medicare and Medicaid simply due to the age and disability of their residents. Reimbursements for the nursing homes for their services are notoriously low from these government health care insurances. Staff to resident ratios have been decreasing in order to stay ahead of the game. Programs that might be advantageous for elderly care have been cut due to lack of funds. The crunch is being felt nationally in these facilities and is getting worse as the elderly segment expands.

So exactly what defines our current nursing home crisis? Is it the lack of available beds and services? Is it the lack of financial resources? These certainly are stimulating the problems that we as a country face regarding elder care; but the nursing home crisis is far worse than this. The crisis that we now face has to do not only with the decline in care and services to our elderly family members, but the rise in elder abuse and neglect that has developed simultaneously. While abuse and neglect of elderly individuals is not a new problem, the increasing number of cases reflects two things: the rise in elderly population numbers and the increasing burden placed on facilities and caregivers in providing care. Neither of these two items is a cause. But they do represent a stress to the system that encourages pathologies to surface. Individuals who abuse and neglect elderly residents have poor coping skills to stress, which are seen when situations become pressured. This is the current nursing home crisis that we face, and there are many potential victims at risk.

The Good

Nothing sounds very positive so far, does it? Overwhelming numbers, declining staff, declining skills, rising abuse. What on earth is good and positive about that? Well, nothing specifically about those things directly. However, with an awareness of these things has come a host of changes geared at protecting and serving the elderly. Federal laws have required many state and county services to now be in place for our elderly citizens and their families. These include legal advice and representation services, protection services, financial resources, case workers, ombudsmen, state health agencies for the elderly, and others. The new information on reports has resulted in greater requirements for nursing home licensure and certification have developed to enforce higher quality care. Community groups have organized to provide oversight of local facilities and to help elderly individuals and their families cope with various problems. And a growing population of attorneys that have expertise in nursing home care and elder abuse now exist.

Basically, as these problems have surfaced, we as a nation have begun to respond with better safeguards and services for our elder citizens. But this is far from adequate, and this book aims to help you and your loved one make good choices if a nursing home is considered. Nothing replaces being informed and staying abreast of current developments in the nursing home’s care of your family member. This book is a resource to assist you with that task. The good has been our response to the crisis, and the increasing attention that our elderly have received as a result. There remain many obstacles still to overcome, but at least our attention and focus are in the right place.

The Bad

While you may suspect the bad is the increase in abuse and neglect, that is actually reserved for the terrible. The bad is how we have addressed the ongoing problem of caring for our elderly family members in terms of resource allocation. While it is easy to simply point a finger at nursing homes and state the care is poor, it does nothing to provide clear resolution to the problems. By increasing requirements for licensure and certification, while providing little help in achieving these demands, our nursing homes are in a tough position. They find they have to meet high standards of care with less financial means to do so. While this has increased creative thinking and solutions, it can only go so far.

It is our responsibility to allocate resources as we see the need for the benefit of everyone. This is not a new debate, but actually one that has been going on about health care since the 1970s. To what level of care do we deem standard for our elderly? Ask an attorney and you get one answer, a politician another, a doctor another, and the daughter of an abuse victim another. The perspective changes and the answers are vastly different. It has made the stance very gray, and in the end, health insurance companies and nursing home laws have decided what is determined to be adequate. No one has collectively looked at the big picture. If they would, it would be obvious that supply and demand are not meeting half-way. Unless we re-look at providing our nursing homes with better tools and resources to provide better care, the bad (and the terrible) are likely to be continuous problems.

The Terrible

Though more details will be covered in chapters to follow, elder abuse and neglect is on the rise and has been for several years. Statistics show as many as 30% of nursing homes have reported incidents of abuse or neglect of their elderly residents, yet less than 20% of these incidents actually get reported. Applying these figures to the nursing home resident numbers enumerated previously, you get an idea about the scope of this crisis. Abuse and neglect range from mild to severe. It can be an isolated occurrence or it can be repetitive and chronic. And elder abuse is not simply limited to nursing homes. Private caregivers and family members in a private setting have also contributed to the rising abuse statistics.

We are not suggesting that all nursing facilities engage in neglectful practices, but it is important to be aware and vigilant. When you decide with your loved one to relocate to a nursing home, you may never have thought such a disaster could ever happen. Hopefully, this book finds you before a terrible incident has occurred. There are many tools available to you to help protect your family member and to choose a good nursing home facility. It simply is a matter of being thorough and patient. Persistence and good follow-through is a must. Steps to identify a quality nursing home are available in this book that will give you the best chance of a good outcome.

If you suspect any degree of abuse or neglect, it is important never to delay an inquiry. Even if minor in scope, make your concerns known and ask for assistance in assessing the problem until it is satisfactorily addressed. It should be in everyone’s best interest to solve this problem if one exists, so don’t be hesitant. It could save tremendous emotional and physical trauma in the end simply because you acted upon a small concern. By the time the obvious happens, an elder may have already suffered greatly. A key to the complex answer for this crisis is staying involved and keeping a high level of alertness. It takes your involvement to ensure good care and a safe environment, and this pertains to both a nursing home and to your own home.

In this book, guidance will be given to help you through the struggles of having to determine if abuse or neglect is present, and then how to proceed if it does indeed exist. Also relocation of your family member (if needed) and how to choose a quality care environment will be described as well. Many resources are available and these will be mentioned at the end in a resource list. Information provided throughout this book has been obtained through reference sources of statistics, guidance, advice, and factual information. Likewise, a list of these references will be included at the end if further research or verification of information is desired.

It is my intent to provide you with the best knowledge and resources available to make this complex decision process easier and safer. It is worth every effort to protect someone from abuse or neglect, especially when there is a degree of disability and vulnerability. And this is even more important when it is a family member. As we proceed through this section, the worst case scenarios will be discussed along with the milder cases. Elder abuse is a serious matter, and by putting this information at the forefront, it emphasizes its importance. Tackle these issues first and then reassess. The first step is to define the abuse and identify it when it is occurring. Once this is done, safeguards can be put into place while investigations and resolutions are made. It is crucial to prioritize your focus in this fashion for both your loved one’s safety and your peace of mind.

Now you know the good, the bad and the terrible. There is still work to be done on an individual level and a societal level, but progress has been and is being made to protect our aging citizens. Become knowledgeable and stay involved. Become an advocate for the elderly as you will be one yourself one day. Through these measures, stable solutions can make substantial changes that endure.

CHAPTER 2

COMMON TYPES OF

ABUSE IN

NURSING HOMES

While it may seem like an obvious thing to know how abuse is defined, there are actually many forms of abuse. As a result, some are not quite as apparent as others. By definition, the term abuse implies a mistreatment in some aspect. Specifically, nursing home abuse implies elderly abuse, or the mistreatment of elderly residents. Not all abuse occurs is in nursing homes. Also assumed in the definition in the term is that there is an intentional component. In other words, whether premeditated or not, the abuse is knowingly directed at someone. It has an active connotation, meaning there is an action performed that renders abuse to another.

In contrast, negligence is considered a form of abuse that is a little different. Negligence is more of a passive form of abuse rather than an active form. It defines a mistreatment through the lack or failure to provide an expected or reasonable service for someone. Like abuse described above, it can lead to significant harm. Now, please don’t misunderstand. Just because negligence is passive does not indicate that it is any less abusive. Both active abuse and negligence have serious consequences. Unfortunately, this has become increasingly evident in the nursing home environment.

Exactly What Constitutes Nursing Home Abuse?

In nursing homes around the country, there has been a progressive increase in elder abuse. In general, elderly abuse comes in four broad categories even though the boundaries are a little gray between some. In addition, some abuses can be clearly incorporated into more than one category. Regardless, for purposes of clarification these four categories include:

(1) physical abuse (which includes sexual abuse),

(2) emotional/verbal abuse,

(3) financial abuse, and

(4) neglect.

By understanding each of these classes, it may be easier to recognize elderly abuse and in turn prevent it.

Physical abuse describes any action that results in physical harm to a patient or nursing home resident. In general, physical abuse can lead to emotional abuse as well, but the main action is physical rather than psychological. For instance, a staff member becomes progressively irritated with an elderly woman who is suffering from dementia. In frustration, the poor resident is slapped, and out of fear, she cowers. Now the red mark on her skin and subsequent bruise defines the physical abuse, but emotionally she has suffered as well. In describing this abuse, however, it would be primarily labeled as physical rather than emotional.

There could be an argument that sexual abuse should have its own category, and for good reason. It represents a specific type of physical abuse that has serious emotional aspects as well, presumably more than other types of physical abuse. However, for the purposes of organizing this information, it will be included in the physical realm of abusive activity.

Abuse that is primarily verbal and targeted at emotional suffering is the second category. In this situation, a person suffers various actions that are directed at their self-esteem. Through activities that degrade, isolate, embarrass, or humiliate them, emotional abuse seeks to control the person through psychological means. As a result, behaviors change to show various reactions including depression, fear, isolation, and lack of communication. This form of abuse can be just as powerful as physical abuse in terms of affecting one’s health.

Clearly under-appreciated, financial abuse of the elderly is quite common both in the nursing home setting and in the community. By definition, it includes a mis-use of a resident’s financial assets or properties. This may include a direct action where money, property or personal belongings are stolen for the unauthorized benefit of someone else. Or it may be an indirect action such as changing a will and testament or failing to pay bills for the resident when required. Either way, the elderly individual’s financial interests are not served, and in essence abused.

Lastly, neglect may be the most common form of abuse. This results in failing to fulfill a duty or obligation for a person. Because these individuals require a great deal of attention and care, the failure to provide these responsibilities can have horrible consequences. Failure to provide the basic needs of care can result in dehydration, malnutrition, and health complications. Failing to provide personal hygiene and basic mobility needs can lead to bed sores and other infections. Although this form of abuse is more passive, it is just as detrimental.

In distinguishing what constitutes