Who Cares for Nursing Home Patients?
A Comparison of Nursing Care at Two Nursing Homes
Written by George Ricci
A daughter had to find a nursing home for her father who was being
discharged from the hospital after being treated for injuries caused by a
fall. Her father had Alzheimer’s Disease and was getting very confused and
injury prone. The hospital social worker told her that there were two
nursing homes with openings in the area.
The daughter interviewed administrators of the nursing homes to make a
comparison of the nurse staffing policies at each home. The questions and answers
at the first nursing home are as follows:
Q.
Exactly who will be taking care of my father’s immediate day-to-day needs of
getting in and out of bed, dressing, bathing, going to the toilet, grooming,
hygiene, eating meals, hydration, medications, exercise, and therapy
treatments?
A.
We have an excellent staff of nurses who will see that he gets medications
and therapies prescribed by his doctor and help him with all his activities
of daily living.
Q.
Who are the nurses that will be responsible for his care?
A.
I can’t give you the names of the actual nursing staff who will care for
him.
Q.
Why?
A.
Because it is impossible for me to find out who is scheduled to take care of
your father at any given time or day.
Q.
Don’t you have a schedule of staff who are supposed to care for my father at
any given time or day?
A.
We have a staff schedule that we prepare every two weeks, but we have to
make a lot of changes for our fluctuating census and for the nursing staff
who may or may not show up to work.
Q.
Can I at least see the prepared schedule?
A.
We don’t like families to see that schedule, and it doesn’t show who will
take care of your father at any given time or day.
Q.
Then how do I find out who is taking care of my father at any given time or
day?
A.
When you come to visit, you can ask the charge nurse.
Q.
Will the charge nurse always know who will be taking care of my father at
any given time or day?
A.
No, because there are too many changes that must be made every day that are
beyond the control of the charge nurses who may not know where they or their
nursing assistants may be working at any given time or day.
Q.
With all these changes, how do you, or anyone else, know that my father is
getting all the needed nursing care everyday?
A.
We use a state-mandated nurse staffing level formula that tells us if your
father will have sufficient nursing care everyday.
Q.
How does that state-mandated formula work?
A.
Everyday we are required to total the number of hours worked by every nurse
or assistant that shows up on that day, and divide that number by the total
number of patients in our nursing home at 12 noon on that day.
Q.
How does that calculation prove that my father is getting good care?
A.
Because the state agency that inspects and licenses our home has determined
that if we are at or above the minimum mandated level of nurse hours to
patient days, we have met the nurse staffing standard which means that your
father is getting good care.
Q.
What level or ratio of nursing care will my father get?
A.
At this facility he will always get a minimum of 2.75 hours of nursing care
per day.
Q.
How will I know if my father actually received 2.75 hours of nursing care per
day, if you don’t know exactly who will take care of him or when on any
given day?
A.
It’s not that we have no idea of who is caring for him and when on any given
day, but it would take too many nursing hours to explain it in detail. We
are already forced to spend many of those nursing hours figuring out how to
meet state standards. We just expect you to accept the fact that we are
meeting state standards.
Q.
Are you saying that if you meet the state standards that my father is
guaranteed of getting at least 2.75 hours of needed care everyday?
A.
No, because the state standards do not guarantee that your father will get
at least 2.75 hours of nursing care. It is just an average and it includes
all the time we must spend to stay at the average. We are not allowed to go
under the average and we cannot afford to go too far above it. Therefore, we
expend a lot of time and expense to meet that state standard to assure you
that we provide a sufficient level of nursing care.
Q.
Are you saying that because the 2.75 hours of care is only an average and
that many nursing hours are used to arrive at that average, my father may
not get anywhere near the so-called minimum of 2.75 hours?
A.
Yes, but I am sure he will get all his needed care.
Q.
What makes you so sure?
A.
As long as we do what the state agencies tell us to do about staffing, we are
in compliance with the law and that means we provide good nursing care.
Q.
If they change their staffing standard and eliminate the state-mandated
staffing level ratios, what would you do then?
A.
I am not sure. I suggest that you ask the other nursing home on your
list. They
believe that the mandated staffing level concept should be eliminated from
the regulations.
Q.
Are their staffing methods different from yours?
A.
Yes, their methods are very different.
Q.
What do they do that is so different?
A.
We haven’t had the time to find out.
The daughter went to that nursing home and asked a lot of the same
questions. Those questions and answers are as follows:
Q.
Exactly who will be taking care of my father’s immediate day-to-day needs of
getting in and out of bed, dressing, bathing, going to the toilet, grooming,
hygiene, eating meals, hydration, medications, exercise, and therapy
treatments?
A.
He will be assigned to a certain section with a certain group of nursing staff
organized into teams, and the team members will be responsible for your
father’s care.
Q.
Who are the nurses that will be responsible for his care?
A.
Here are the names and schedule of the team of nurses who will be assigned to
care for your father. As you can see from the schedule there are exactly six
charge nurses and nine nursing assistants who are responsible for your
father’s care 24 hours a day, seven days a week. You can keep a copy of the
schedule and it will tell you the names of all the nurses who will be caring
for your father at any given time or day.
Q.
Do you know why the other nursing home could not give me this information?
A.
Yes, because they just don’t use good staffing and scheduling methods, like
we do, that allows them to give you that kind of information.
Q.
Can you tell me why your staffing and scheduling methods are so much better
than other nursing homes?
A.
Unlike the other nursing homes, we only use a full-time nursing staff to
care for our patients. We are then able to organize the nursing staff into
high performance teams that have a carefully planned mix of personalities,
education, skills/abilities, and experience. We group the nursing staff into
special team partnerships of three nurses and three nursing assistants for
every eight-hour shift to care for certain patients. As you can see from the
schedule I gave to you, every day there are two team members working and one
team member off. Furthermore, the schedule is designed for all three team
members to have the exact same schedule whereby each team member works the
same amount of days (Mondays, Tuesdays, weekends, etc.) so that no team
member has any better or worse schedule than their team partners. The
schedule may be adjusted now and then when there is a team member who can’t
work on that scheduled day but the replacement is usually the other team
member who is off. The only time we use a different replacement team member
is during vacation times. Basically, however, the team partnership functions
like a close nit group and team members will usually try to cover for their
partners when necessary. Another important thing that we are able to do,
unlike the other nursing homes, is to design a schedule so that no team
member is ever scheduled to work more than forty hours a week, or more than
four consecutive days or less than two consecutive days. Every team member
has at least two full weekends off and three consecutive days off every six
weeks. The schedule is designed to keep the team members from being
overworked and tired which will enable them to avoid the medical errors and
mistakes that are very common in most other nursing homes. We believe that
our high performance teams will eliminate most medical mistakes and errors
that are usually caused by the way the other nursing homes hire, organize
and schedule a nursing staff. We believe that taking care of nursing home
patients is a very difficult job with a lot of responsibility, particularly
for nursing assistants, and that burden should not be put on one individual
at any given time or day. It is the team that is responsible and
accountable, and each partner will help the other one when necessary (such
as in lifting, bathing, exercises, etc.). We believe our staffing and
scheduling methods are designed to provide the highest degree of quality and
efficiency for the patient and will prevent the kind abuse and neglect that
is caused by the chaotic nurse staffing and scheduling methods used by the
other nursing homes.
Q.
Why don’t all the other nursing homes use your methods?
A.
Mostly because the other nursing homes are overly dependent on the government regulators
to tell them what to do to meet nurse staffing standards and those standards
make no mention of using good staffing and scheduling methods. Their nurse
staffing standards are primarily concerned with numbers of nursing hours per
patient day.
Q.
Is this why other nursing homes believe that the state-mandated nurse
staffing level ratio determines if there is sufficient or adequate nursing
care?
A.
Yes, most nursing homes spend so much time thinking about meeting this ratio and
satisfying the government regulators that they do not have any time to think
about using good staffing and scheduling methods, especially when the
government regulators don’t think it is important for good nursing care. As
a consequence, the consistency, continuity, and cohesiveness in nursing care
is not important and the nursing homes are forced to ignore the problems
caused by poor staffing and scheduling methods. Those problems are the
nursing errors and mistakes that in turn causes abuse and neglect.
Q.
Why can’t the government regulators see all the problems they are causing?
A.
There is no short answer to that question. I would have to explain the
history on how government regulations developed to keep pace with the growth
of the nursing home industry, the Medicare and Medicaid funding mechanisms,
and the labor contracts negotiated for the nursing staff.
Q.
How do the current regulations on nurse staffing standards prevent nursing
homes from improving the quality of patient care?
A.
Nursing homes are forced to use the nursing staff more to meet the staffing
level ratio requirements and less to meet the specific needs of their
patients. The patients have to suffer from the nursing staff tripping over
each because of their chaotic staffing and scheduling methods created to
meet these ratio requirements. Nursing home providers panic if they cannot
meet these requirements. They are often forced to use overworked nurses and
too many temporary and part time nurses to fill in the hours necessary to
meet these state-mandated staffing level ratios. Turnover and perceived
staff shortages are another result of the chaos caused by these regulations.
The most profound result, however, is the patient abuse and neglect that is
created by the chaos.
Q.
How does the government react and address the nursing home staffing problems
that result in this abuse and neglect of the patients?
A.
In 1990, the Congress mandated that the Department of Health and Human
Services do a report about this problem. It took
over 12 years to complete one phase of the report, and they still
cannot see the real solutions to the problems.
The main conclusion of their report is very interesting. It stated that
quality nursing care could not be provided in most nursing homes due to
their inadequate staffing. We agree with that conclusion, but we disagree as
to their particular meaning of the term “inadequate staffing.” They define
inadequate staffing to mean that the minimum staffing level ratios are too
low. Our meaning of inadequate staffing, however, has little to do with
ratios and more to do with how the staff is hired, organized, and scheduled
to care for patients.
We believe that it is better for patients to be taken care of by a few well
organized and scheduled nursing teams that use our methods, rather than by
large numbers (higher staffing level ratios) of disorganized individual
nursing staff members made up of overworked and burnout full timers, part
timers, temporaries, and weekenders.
Q.
Do you meet the government standard regarding the minimum nurse staffing
levels?
A.
Yes, but that is not our standard. Our standard is to organize and schedule
our nursing staff to provide the best possible care and services to our
patients and their families.
Q. Can I admit my
father to your nursing home?
A.
Yes, and we hope that you spend a lot of time with the individual nursing
team members assigned to care for your father. Unlike many other nursing
homes, we encourage family members to actively participate with the nursing
team members who are responsible and accountable for taking care of the
patients. In order to do that, we make sure that the families know exactly
who is taking care of the patients.
Note: For the Australian Version of this Article see Staffing Issues in Australia Nursing Homes