Archive: What's Your Question About Nursing Homes?
By Kathy Gannoe

Question: How do the people who run nursing homes view the ombudsman?  It seems to me that they wouldn’t like having an outsider observing them. 

Answer: “Outsiders” observe nursing homes all the time–families, community volunteers, various enforcement agencies, local governments.  Ombudsmen are observers who really want to represent the resident’s point of view and who want to encourage the facility to give improved care and services.  Providers who understand the nature of the program consider the ombudsman a valuable consultant who, for no charge, can help improve the care given to residents. Ombudsmen are another set of eyes and ears in the facility, observing a great deal of the day-to-day life. Since they are required by law to submit reports on their activities, classifying and describing the bulk of their cases, any administrator who reviews these reports can easily see potential weaknesses. This can be very helpful as they work to improve their facility. Rather than reacting defensively or being ashamed of these reports, wise care providers ask these no-cost consultants to lead staff  in-services, addressing areas that need to be strengthened.

Question: How can someone who just walks around and talks with patients know what is going on? 

Answer: Ombudsmen are trained and certified before they can go to work. They are taught about the basics of aging, long-term care, various medical conditions residents have, the legal rights of residents, regulations governing nursing homes, and other similar topics. They are also trained in identification, investigative, verification, and resolution strategies. The most important source of information for the ombudsman are the residents.  They are the real experts on what life is like in the nursing home and they know what they like to see changed or improved.

Question: The residents I see in my visits to nursing homes don’t seem to be able to communicate very well.  How can they tell you what is going on? 

Answer: Family, friends, staff, doctors, strangers and residents all bring cases to an ombudsman's attention. We even hear from “anonymous.”  Our services are free and confidential which makes talking to us easier.

Question: What kind of complaints do you get? How do you know it just isn’t someone who is disgruntled trying to get the facility in trouble?

Answer: In 2007 we had 1338 complaints; we verified 1219 of those and resolved (to the satisfaction of the resident) 903.  We only had to refer 117 complaints to enforcement agencies.  Most of the problems we referred were things we weren’t able to investigate (too technical for us) or which the law required us to refer (abuse, for instance.)  So far this year (October to December, 2007) we have received 1360 complaints (!), verified 1216 of these, and resolved 1027.  We had to refer 154 complaints. 

Question: These three months have more complaints than all of last year?  How come?

Answer: We think that it is because more people know about our services.  We don’t think care is worse, just that consumers are more aware of how their ombudsman can help them to solve their problems.  And, please note, 89 percent of all complaints are resolved right in the facility with the ombudsman working with the administration to improve care and services. That indicates that administrators and directors of nursing value the observations the ombudsman makes.

Question: There is a push to mandate staffing ratios. Do your complaint reports support this push? 

Answer: Problems with care comprise 34 percent of our complaints and staffing specific complaints 9 percent. It seems logical to connect staffing problems with care problems, so we can say close to half of all our complaints involve poor care and lack of staff.

Question: I went to visit my husband and he needed help.  There wasn’t a nurse in sight, only those aides.  Aren’t nursing homes supposed to have real nurses?

Answer: Nursing homes are required to have a registered nurse on duty eight consecutive hours each day, seven days a week.  The rest of the time they must have a “professional” nurse on duty. The key requirement is that facilities must have “sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.”  (Those words are from the federal regulations which all nursing facilities must follow.) Look to see if the care needs of the residents are being met and if they residents are being helped to get better and stronger. If lots of residents seem to be in decline, losing weight, losing mobility, depressed, developing bed sores and such, then, very likely the facility doesn’t have enough nursing staff. Many advocates believe that the state should mandate a specific minimum staffing ratio.  This could improve the quality of care for folks if better training and better supervision are in place as well.

Question: This past weekend, there were only two aides on each wing plus a medication aide and a nurse.  Call bells were going off and no one responded.  I asked for help for my mother and no one came for over an hour.  How is that “sufficient nursing staff?”  

Answer: Well, the numbers may have been “sufficient” but apparently the care was not.  You can take your concern to the administrator.  Tell him when you were in the building, what you observed, and the problem with getting help.  It might be that supervision was poor over the weekend or there simply weren’t enough people there to give care.  In any event, report this to the administrator and expect an answer.  Check in next weekend and see if things have improved.  If things aren’t better, contact your facility ombudsman or report the problem to the Office of Inspector General at 502/564-7963.

Question: The aides in the facility I visit seem rushed to death.  They zip in and out of the rooms and never seem to have time to talk with the residents. Does this seem right to you?

Answer: Nursing assistants are task oriented.  They have a list of chores they must do each shift and are responsible to their supervisor for getting these done.  If they don’t, they could get in trouble.  Advocates want to see more staff because it seems like aides are given too many tasks to accomplish in a shift. Residents tell us that they want aides to take time with them and to not rush them. Residents may take a long time to eat or to toilet and being rushed can have adverse effects. Aides who are not hurrying through a task list have time to interact with residents and to develop meaningful relationships with them. They can learn the resident’s preferences and strengths. There is a lot more to quality care than just completing a task list!  It’s sad but true that with inadequate numbers of nursing assistants things like nail and dental care are neglected. So are a resident’s social and psychological needs. Often residents are made to feel guilty for asking a busy aide for assistance.  They are made to feel that their requests put an undue burden on the aides.  That is simply not right. If you hear this or observe care going undone, talk with the administrator or the ombudsman.

Question: This winter my aunt’s room has not been comfortable. What temperature is it supposed to be in the nursing home? When she says she’s cold, they just tell her to cover up with a blanket.

Answer:  Kentucky law requires nursing homes to have temperatures that do not go below 71E in the winter or over 81E in the summer.  This applies to all the occupied areas of the home.  If individual residents need warmer or cooler conditions, the staff must work to develop a plan to accommodate those specific needs. The body thermostat of elders can be out of whack.  It may be comfortable in the room for everyone else but not for your aunt.  This is why it is important to talk with the staff at her care plan meeting about her need for warmth.  It can be really unpleasant to be cold!

Question: What can I give my friend who lives in the nursing home for Christmas? 

 Answer: Think about your friend’s life before she entered a facility. What she has enjoyed all her life is probably what she still enjoys. Is she still able to read or listen to music?  Then books, CDs, and tapes might be nice. You might commit yourself to bringing her books and tapes from the local library rather than buying them. Does she write to friends or enjoy photo albums?  Stamps, note cards, and supplies to assemble albums would be welcome.  Does she snack?  Candy, salty snacks, fruit, homemade goodies, cans of juice and cola are always welcome.  Something to store them in is good, too. Prepaid phone cards, wall clocks, or something to stimulate her senses. What about clothing?  Attractive, easy to care clothes would be nice.  Don’t forget to think about how easy it would be to take on and off.  My mother wants pockets in everything; your friend might be like that, too.  What about “tickets” from you promising to run little errands for her or for outings you will take her on?  My daughter promises her father six lemon pies every Christmas and this is his favorite gift!

Question: I am really grateful to the staff members who take such good care of my mom.  What can I do to show my appreciation during the holidays? 

Answer: It’s always good to thank the folks who do so much to make residents comfortable and happy. Gift certificates are nice; so is cash. If you don’t want to single out any specific person, how about having pizza delivered. (Don’t forget the evening and night shift.) You might want to bake cookies or sweet rolls for staff to eat on their breaks.  Notes of appreciation are nice too, and be sure to let the Director of Nursing or the Administrator know when a staff member has really done a good job.  Just saying “Thanks, I appreciate the work you do” can be the right touch, too.  Remember the people who work in other departments like housekeeping and dietary, too.

Question: I belong to a group that wants to visit a nursing home this season.  Any tips for us? 

Answer: Yes. Plan your visit first with the Social Worker or Activities Director at the facility.  Scheduling with this person will help spread the cheer throughout the season for residents.  When you do visit don’t forget the folks who stay in their rooms and don’t come out for group activities. They often get overlooked.  Engage the residents in any activities you do; don’t just “perform” for them. Draw folks out and stimulate their memories.  Be prepared for sadness and acknowledge that holidays can be hard for residents who’ve had so many losses in their lives.  Check with the social worker about appropriate refreshments and activities.  Take children; use music; small gifts are a nice touch.  Actually talk with the residents; don’t just rush through a program and leave.  A few minutes of your time (try to sit down while you visit) can mean a lot to someone who is lonely. 

Question: Dad would like to come home for our special family party.  Will the nursing home let him come? 

Answer: Your father is not a prisoner. He is allowed to come and go as he is able. Be sure to think through how you will transport him from the facility to your house. If Medicaid is helping to pay for his stay, he is allowed to be gone from the facility overnight for a total of 10 days each year for purely social reasons.  The facility will continue to get paid for his stay and will keep his bed for him. Talk with the nursing staff two to three days in advance of the outing so they can prepare for it. This means packaging medication he will need, bagging up incontinent supplies, writing down special food preparation instructions and anything else you might need to know about his care. Ask the staff to give you instructions in writing.  You can always call back and ask the nurse caring for your dad if you run into trouble. You want your father’s stay at home to be fun for him and for everyone else.  Knowing that he feels better if he naps at 2:00 p.m. might just be what’s needed to make this happen!  If there is a medical emergency while he’s home, call 911 as you would for anyone else and then alert the nursing staff at the facility.  If he just gets too tired and wants to go back to the facility, respect his wishes. Going home will probably be the best gift your dad could have this season.  With a little planning and a lot of love, it should go just great. 

Question: My mom inherited a small sum from her great-aunt. Mom lives in a nursing home and uses Medicaid to pay her way.  What will this little inheritance do to her Medicaid?

Answer: For complete information on this, you should contact your local social insurance office.  But here is some general information. Residents who participate in Medicaid are allowed to have $2,000 in personal funds.  This money may be held at the nursing home in a special account or the family may take care of it for the resident.  If a resident gets a sum of money over and above their regular income they have 30 days to spend it.  It can be spent on anything personal that they want. For example, they can buy clothing, a television, or furniture for their room in the nursing home.  They can give small gifts to friends.  They can pay their family for taking care of them if the family provides the resident with a notarized statement of charges and payments. They can buy new hearing aids or new glasses. They can pay for their funeral and all the associated costs.

Question: Mom got more than $10,000.  I don’t think she can spend it all in 30 days.  What can I do? 

Answer: She can spend all that she wants, right away, and then you can deposit the rest in her personal account.  Any money over the $2000 limit will have to go toward her care in the facility.  In other words, she’ll “go off” Medicaid for a while and then, when her assets reach the $2,000 limit, you will have to reapply to get her back on the Medicaid program.  This sounds like an annoyance but the reality is that the unexpected money is an asset and Kentucky requires that the resident’s own assets be used to take care of them before tax dollars are used.

Question: I went into a facility last week and saw this dear elderly friend of mine having her blood checked in the dining room in front of her dinner companions.  At another table a nurse was putting eye drops in a man’s eyes.  This just didn’t seem right. Am I wrong about that?

Answer: No, you aren’t wrong. The nursing home reform law requires that residents receive treatment and care in private. The dining room is certainly not private.  This is really a dignity issue.  If you see this, or anything else that places a resident in an undignified state, raise the issue with the director of nursing, the charge nurse, or the administrator.  If you need help, call your Ombudsman.

Question: What are some examples of undignified treatment?

Answer: Anything public that should be private is undignified.  For example, it is undignified for residents to lie in bed exposed or to have staff talk about their condition where others can hear.  I think it is undignified to talk “over” a resident and not to her, even if she has dementia.  I think the “golden rule” test can help us determine what is dignified and what isn’t.  If you wouldn’t like being treated in a certain way, chances are the resident wouldn’t be either.

Question: I called your office and told you about some problems with my dad’s care.  You didn’t do anything. Why didn’t you do your job? 

Answer: When we receive a complaint we begin to investigate immediately. We go to the resident first to determine what his/her concerns might be. If the resident is alert and oriented, we ask his/her permission to work on the complaint.  (If they aren’t, we ask their legal representative.) If your dad wants us to stop, we have to stop. But if the complaint is something that affects others, we can investigate without involving your dad. Some complaints are impossible to investigate while the law requires others to be referred to another agency to investigate.  I am very sorry that you had a bad experience with us. Please contact our office to discuss this further.  Ombudsmen want to be as responsive to consumers as possible.

Q. I'm so worried about my mother. She's  in a nursing home and I hear so much about abuse.  How can I protect her?  She has dementia. 

A. I've been an advocate for 23 years.  My experience and the experience of most ombudsmen is that the vast majority of care given in nursing homes is kind, compassionate and competent.  Almost all residents receive good care and experience a decent quality of life.  But, sadly, abuse does happen.  About 6% of the complaints we receive are about abuse. There are several things you can do.  One is to visit as often as possible and to observe carefully what is going on with your mother and with other residents.  Attend your mother's care plan meeting so you know what her condition is and how staff plans to take care of her.  At the care plan meeting let them know about your mother and any preferences or "quirks" she might have.  Get to know the ombudsman who visits in the facility. Listen to your mom. She may not be able to tell you who the president is but she probably can indicate to you if she is afraid of anyone. Ask for a thorough explanation of any injuries to her. Ask what the plan is to make sure she is not injured again. Accidents do happen but when they do, the facility needs to put a plan in place to address the problem.

Q. Are there any red flags I might look for? 

A. General poor care of residents, physical restraints, disregard for residents and their rights, care plans ignored, poor meals--all of these can be red flags for potential abuse.  It also should concern you if staff members ignore or put-down residents and families.  It's a real problem if they seem to be indifferent to your concerns. Conditions are right for abuse to happen when aides are "working short" and are poorly supervised.

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Question: My aunt's facility is apparently in trouble.  I've heard that they can't take any new residents.  Someone else told me the state was going to close them down. How can I find out what's going on? 

Answer: There are several ways to "get the scoop" about your facility.  The first, and most direct, is to ask the administrator.  Even better, ask the administrator to meet with family members at a family council meeting so that all can be informed.  The administrator should be meeting with the resident council, as well.  Information about the facility is required, by law, to be available to the public.  There must be a sign within ten feet of the reception desk stating that inspection reports are available.  The letters on the 8x11 inch sign must be one inch tall and the sign should tell you to ask for reports from the staff.  You can access information about a facility by going to the NHOA website.  Click on Information Sheets, then on Other Sources of Information.  You will go directly to the hot link to the federal reports about nursing homes.  You can also go directly to www.medicare.gov/nhcompare. 

Question: I read one of those reports. Why is the whole facility punished when only two or three residents have a problem?  I know my aunt doesn't have any problems.  And why aren't the residents named? I know most of the residents and would know if there really was a problem with one of them. 

Answer: Rest assured, if the state has imposed enforcement penalties (fines, loss of Medicaid funding) there was something wrong and the facility failed to correct it.  When the state inspects a facility, they choose a random sample of residents to review.  If there are problems with that sample of residents, you can be pretty sure those problems affect others.  The inspectors may broaden their sample if the problems seem to be very serious and widespread.  Once problems are identified, it's up to the facility to tell the state how they plan to fix the problems.  Their plan of correction has to be specific and doable.  They also have to make sure the problems stay corrected.  A lot of facilities mess up at this point. Of course, residents are not named for confidentiality reasons.  And, even if you knew who was mentioned in the report, you still wouldn't have access to all of the information the state inspectors had.

Question: What is the big deal about Medicaid not approving a facility? 

Answer: First, if the federal Medicaid office doesn't approve a facility, no Medicare or Medicaid dollars can be sent to the facility to pay for the care of beneficiaries in that facility.  Second, it is very serious when Medicaid (really CMS, or the Center for Medicare and Medicaid Services) withdraws approval of a facility.  It means that the facility has failed, and probably failed again, to meet the minimum requirements to run a nursing home.  CMS and the state don't really like to impose the penalty of denying funding but if the facility falls far enough below the minimum acceptable standards, they have no choice but to halt funding or even terminate them from the Medicaid program. And, third, if a resident isn't in a certified bed they usually can't get their other Medicaid and Medicare benefits.  Private insurance is often hooked to the facility's compliance with the minimum regulations, so if the facility isn't certified, there is only private pay available to residents and to the facility.

Question: Why does a facility fail to meet the standards? 

Answer: That's something I really can't answer.  They have the regulations, they have professional advisors, they have the complaints from ombudsmen, families, and residents.  They have the incentive to continue to get paid.  Maybe it's a matter of where they put their focus, on giving quality care or on other business objectives.  Facilities which use their resources to focus on giving good care pass inspections.

Question: Will you pass this on to the people who read your column?  We thought this up at my office last year. 

 Answer: Sure! The reader says that she and her co-workers used to exchange Christmas gifts.  They decided instead to do something for others.  So they pooled the money they normally spent on each other and bought gifts for residents at the nursing home across the street from their office. It turned out to be so rewarding to visit with them that they continue to visit at least once a month.  Now that's a gift that keeps on giving!

Question: It's so hard to know what to get for someone in a nursing home.  Do you have any suggestions? 

Answer: My first suggestion is to ask the resident! It may be that they really want something and are reluctant to tell you or forget to tell you, so ask.  Then think about the person.  What have been their lifelong interests?  What are their interests now?  Look around their room.  What can be added or adapted to make their daily life more agreeable?  Ask staff, they usually know the resident and may have some very good suggestions. You can visit our Web site www.ombuddy.org for some more holiday suggestions.  Click on the icon and it will lead you to a list of ideas you can use.

Question: I've heard about a new campaign nursing homes are participating in.  Is this a contest or what? 

Answer: National nursing home organizations have launched a project,  "Advancing Excellence in America's Nursing Homes".  It will last two years. The idea is for facilities to choose one or more goals from among eight on a list and to then work on them. The goals are: reducing restraints; reducing bed sores; reducing pain for long-stay residents; reducing pain for post-acute residents; target setting; measuring consumer satisfaction; reducing workforce turnover; and adopting consistent assignment. 

Question: How does this affect me and my mother who is a resident? 

Answer: Well, I hope that your facility chooses at least one goal and then gets to work. Pressure sores are becoming more prevalent in America's nursing homes.  Unaddressed pain is a significant problem.  And, constant staff changes are very hard on residents.  So if your facility sets to work on one of those goals, you should see an overall improvement in the quality of life for your mom and the other residents. 

Question: How will I know what they choose? 

Answer: Nursing homes are supposed to make their choices and progress known.  This is a good area for family and resident councils involvement. Talk with facility staff about their goals and what steps they will be taking.  Ask them how they plan to measure their progress.  Talk about these subjects at council meetings.  Invite local experts to speak.  Go out on the Web and track how your facility is progressing.  The site is: http://www.nhqualitycampaign.org  Right now, there is only one facility participating in KY.  Talk with your administrator and urge him/her to sign up today.  This is one quality improvement consumers and providers can work on together!

Question: What I'd really like to know is what happened at the last inspection. How can I find that out? 

Answer: There are two ways.  First, a copy of the most recent survey and the past two years of surveys is to be in a notebook near the entrance.  You have the right to see the entire survey which includes the facility's plan on how they will fix problems.  The other way is to go on the web to www.medicare.gov/nhcompare.

Question: The state is in at dad's facility.  What does this mean and why is everyone so hyper about it? 

Answer: This is a good question and deserves a really full answer. Nursing homes are regulated by the Office of Inspector General (OIG). There are four regional OIG offices--Lexington, London, Louisville, and Hopkinsville.  Each has a  Regional Manager and a "complaints coordinator".  Call 502/564-7963 ex. 3292 for your local info.4-7963 ex. 3292 for your local info.

Nursing homes have regulations governing how they care for residents. OIG looks at both the state and federal regulations when they survey a facility. Surveys (inspections) are required by the state to license beds and by the federal government to certify beds for participation in the Medicaid or Medicare programs. Surveys usually happen on a 7-15 month cycle but OIG will survey a facility in response to specific complaints. All surveys are unannounced.

Ombudsmen, families, and residents have important roles in the survey process. They participate in: off-site preparation (Ombudsmen); the Resident Council meeting during the survey; family and resident interviews during the survey; a resident representative and the Ombudsman are to be present at the exit conference; and, finally, anyone can call OIG with information or with a complaint

During the survey, every aspect of life in the nursing home is observed.  Surveyors interview a certain number of residents, observe meals, review charts, conduct a group interview with residents, watch care being given, watch medication passes, etc. etc. etc.  The facility must meet each requirement in the regulations in order to remain certified and licensed.

When nursing homes fail to meet the minimum standards, each failure is called a deficiency.  Each deficiency is rated on its scope and severity.  Penalties for a facility are based on how wide-spread a problem is and how many residents are affected.  These penalties are known as remedies.  The objective is to motivate facilities to remain in compliance with the regulations, not to punish them.  Kentucky has some additional penalties known as Type A and Type B deficiencies.   A facility can appeal penalties and argue with the state about them in an informal dispute resolution process.

Copies of a  facility's current survey and the last three years' surveys must be in a notebook in the lobby of each facility.  They must be available to residents without having to ask a staff person.  The survey report will have both the problems the state found during their last inspection and the facility's plan of correction.  This is interesting reading and a good way for families and residents to see what improvements their facility is planning.

A large number of deficiencies doesn't necessarily mean a poor performing facility and a small number doesn't necessarily mean a better facility.  The type of deficiency and its scope and severity are very important to note.  A full explanation of the scope and severity can be found at www.medicare.gov/nhcompare .  You have to click through several screens, but it's there listed as level of harm/severity of deficiency.  As you read about the survey at the facility, see (on the right hand side of the document) what the administration plans to do to correct the deficient practice.  Sometimes you can observe to see if/when the changes take place.  And, if things slip back to the way they were before.

Question: My mother is very particular.  We've always had to do things just right to keep her happy.  Now she's at the nursing home.  How can I get them to do things the way she likes them done?

Answer: Well, you can and you can't.  Nursing homes are required to "make reasonable accommodations" for a resident's preferences.  However, it is inevitable that when someone moves into a group setting, life changes.  You and your mother should discuss her preferences with the staff when you attend her care plan meeting.  They should work with her to honor her choices and preferences to the extent possible.  But, if she is used to tea at exactly 2:30 each afternoon, it probably won't happen right then. If she likes to sleep until 11:00 and then have coffee and a piece of toast instead of breakfast and lunch, they should be able to make that happen.  For your mother, it may be a matter of choosing which parts of her routine she really wants to keep, and which parts she will have to let go as a result of living with 99 other people. A few nursing homes are really trying to change their "culture".  The kinds of things your mom wants are the kinds of things that make a nursing home more "home".  Perhaps you and other families can work with your administrator to try some of the new "culture change" concepts which really forward thinking providers are doing.

Question: The staff at dad's nursing home keep forgetting to do things for him that he needs–things like putting his foot up on a footstool and keeping his warm sweater on him.  I want to put notes up on the walls to remind them but the social worker always takes them down. What's going on? 

 Answer: This is a dignity issue, from the perspective of the social worker.  The regulations that govern nursing homes stress that each resident is to be treated with dignity and respect.  Putting signs up is viewed as a violation of privacy.  Try this.  Go to the Director of Nursing and discuss your problem.  Tell her that your dad's foot needs to be elevated but that the nursing assistants seem to forget to do this.  Tell her that your dad is cold and that his warm sweater makes a big difference in his comfort.  Give her a few days to get the problem under control.  If things are still not going well, check back in with her.  Usually this will solve a problem.  If it doesn't, you can go to the administrator or the facility ombudsman.  It may be that the problem with your dad's foot is forgetful staff or, it may be that your dad himself doesn't want his foot raised or the sweater on.  Your ombudsman can help you explore the situation.  But, bottom line: the notes will have to go.  It's just too invasive of your dad's privacy.

Question: Well, I think you're wrong!  The staff keeps changing and there isn't enough help on the weekends.  If I don't put notes up I just know my father won't be taken care of.  Don't you agree?

Answer: Yes. Staff changes; weekends can be a real problem;  agency staff doesn't know your dad and his preferences.  This is one of those things where families and advocates just have to keep plugging away. The problem of inadequate, changing, and unskillful staff is a very serious one.  It won't get fixed quickly.  You need to continue to ask the facility to care for your father in the appropriate manner.  Specifically, document when the care is not done or not done right.  Keep track of days, times, staff involved.  Show your notes to the administrator and talk with her about your concerns.  Be specific.  Be polite.  Be firm.  Be persistent.  If you still don't get results, it may be time to take your concerns higher.  Everyone has a supervisor and if you don't get satisfaction at one level, go to the next. You can also report your concerns to the Office of Inspector General at 502/564-7963 x3292.

Question: It's not my job to monitor the staff.  It's theirs! 

Answer: I couldn't agree more but focus on your dad.  Sometimes we just have to work on a problem from whatever direction that can get it fixed. And it's easier to fix a problem that is specifically spelled out and not generalized.

Question: I have been reading about "culture change" in nursing homes. What are they talking about? 

Answer: Culture change is the latest buzzword in long term care.  Another similar phrase is Pioneer Movement.  But, these two phrases aren't just talk, they represent a real shift in how nursing home owners think about giving care.  The movement was started by owners themselves around 10 years ago but is just now beginning to take hold.

Question: Well, what difference does this make to me in my nursing home?

Answer: Culture change focuses on the individual.  The facility organizes itself around the needs and wishes of individual residents as much as possible.  Some of the hallmarks of culture change are: universal workers; neighborhoods, instead of wings or hallways; flexible and age appropriate activities; social services meeting the needs of the whole person; and genuine resident participation in planning and implementation of facility practices and policies.  Another indication that a facility is serious about culture change is the way they treat the direct care workers. Culture change involves these workers in meaningful decision making, offers them career advancement, and respects their contributions to the entire process.

Question: Sounds good but how can I get my facility administrator interested? 

Answer: The nursing home trade associations have been offering training to members on this movement.  There are several facilities in the Bluegrass which are heading in this direction.  The "network" has a website which outlines the entire vision.  It is www.pioneernetwork.net.  Their vision statement says that, "The movement toward a new culture of aging is a vital source of hope for millions of Americans trapped in the old system. The practice of person-directed care offers a relationship-based, values-driven alternative to the out of sight, out of mind institutional model that has plagued the system for decades. The movement is about promoting household living environments – in congregate settings as well as in home and community-based services – where elders and direct care workers are able to express choice in meaningful ways." You might try talking with your administrator, point her to the web sites and let her know that you and others are interested in this better way to provide care. 

Question: My nursing home always says that the state won't let them do anything.  Every time I ask them to do something different. Can this be true? 

 Answer: An honest reading of the nursing home reform law of 1987 clearly supports the notion of culture change.  But, it's taken a long time for the old philosophy to change in both the nursing home community and among the inspectors of nursing homes.  It looks like they are all thinking positively about culture change now and working to support nursing homes which try to move in this direction.  There is even a new initiative called Advancing Excellence in America's Nursing Homes.  However, as of this writing, there are only seven facilities in Kentucky participating.  None are in central Kentucky.

Note: Here is an interesting definition of "elder" from the Pioneer website.  "An Elder is a person who is still growing, still a learner, still with potential, and whose life continues to have within it, promise for and connection to the future. An Elder is still in pursuit of happiness, joy and pleasure, and her or his birthright to these remains intact. Moreover, an Elder is a person who deserves respect and honor and whose work is to synthesize wisdom from long life experience and formulate this into a legacy for future generations."  This is from Barry Barkan, one of the founders of the Pioneer/Culture Change movement.  Pioneer nursing homes seek to honor this in their elders.

This column is presented as a public service of the Nursing Home Ombudsman Agency of the Bluegrass. The author is the agency’s executive director. If you have a question, send it to Kathy Gannoe, Nursing Home Ombudsman Agency of the Bluegrass, Inc., 1530 Nicholasville Rd., Lexington, KY, 40503.