Choosing a nursing home can seem like an overwhelming task. If the need for care has become too much for you to continue to safely provide and you find yourself trying to make difficult decisions in an emotional whirlwind, this section will provide you with some invaluable tips if followed.
As with any major decision-making process, finding the right nursing home is a staged (step-by-step) process. But making these emotionally charged decisions can make it awfully hard to understand and navigate through the process.
This is not an exhaustive list, and Aged Care Crisis may update this information on a regular basis, in line with reader feedback and changing industry standards.
Good Choice Indicators:
1: First Impressions
- Do you like the facility's location and outward appearance?
- Is the facility convenient for frequent visits by family and friends?
- Are you welcomed with a warm greeting from the staff?
- What's the home's attitude to regular visitors? (our research shows that in some facilities, constant visitors are regarded as hostile and are regarded with suspicion)
- Does the staff address residents by their names and interact courteously with them during your tour?
- Are the residents socialising with each other and do they appear well cared for?
- Are you able to talk freely with residents about how they like living there and about the staff?
- Are staff members appropriately dressed, friendly and outgoing?
- Do staff members treat each other in a professional manner?
- Are visits with the residents encouraged and welcome at any time?
- What percentage of the rooms/beds is available?
- Is there a waiting list? If so, how long do they estimate it will take to be admitted?
2: Staffing Levels and Experience
Reforms to aged care as exemplified in the Aged Care Act of 1997 have failed to provide for the safe delivery of quality care for aged persons in residential care facilities.
In Victoria, the previous Kennett Government removed nurse-to-patient ratio requirements. The ratios were one registered nurse per 10 patients on day and evening shifts, and a one-to-15 ratio on the night shift. It also required the appointment of a Director Of Nursing (DON) in each nursing home.
It is essential to ask about staff/resident ratios and the facility's staff turnover rate -- eg, a low staff turnover might indicate that the staff are generally happy, and suggests that what is good for staff is ultimately good for resident care. However, the turnover rate is only one indicator - what about the staff absentee rates - especially on weekends.
It is also important to speak to the Director of Nursing her/himself. The Director sets the tone for the facility. Are the values he/she espouses similar to yours?
Some important considerations include:
- Do nursing staff respond in a timely manner to residents requests for assistance such as help getting in and out of bed, dressing and going to the bathroom?
- Which nursing staff members are involved in planning the resident's individual care? Are they the same ones who provide the care to residents?
- How many trained nurses are there, as opposed to Personal Care Assistants/Attendants (PCA's) or Personal Care Workers (PCW's)?
- What is the Director of Nursing like? (the Director wields a lot of influence over the quality of care given)
- Ask questions about staff turnover. Is there frequent turnover among certified nursing assistants (CNAs)? What about turnover for nurses and supervisors, including the Director of Nursing and the Administrator?
- What is the nursing staff to resident ratio?
- How many registered nurses (RNs) are on staff?
- How many per shift? What is their training/education?
- Does this vary at different times, particularly at weekends?
- What is the history of compliance with staffing ratios and staff development and training?
- Is staff on duty qualified to handle the behaviour challenges of some residents?
- How does the nursing home ensure that all staff maintains licensure/certification, receives continuing education, and keeps their knowledge and skills up-to-date?
- How many staff are permanent? (*A high turnover in temporary and/or agency staff means that there could be no-one on duty who is familiar with your loved one and their medical needs)
- Will any special needs of your family member be taken into consideration?
3: Prevalance of Bedsores
Check the resident bedsore rate as a general indicator of staffing problems (Bedsores are a skin condition that if left untreated, can lead to blood poisoning and death. They result when a body’s weight is left for long periods in a single position. The skin area, prevented from receiving proper blood flow, eventually degrades and disintegrates, exposing bone below.)
*Bedsores can sometimes result from other disease conditions, but it is most often a result of staff not turning bedridden residents often enough to avoid the sores. Therefore, good staffing levels are essential.
- Do they specialise in treating bedsores?
- What procedures and specialised equipment (water beds; sheepskins; etc.) do they have in place to limit the prevalence of bedsores?
4: Health, Medication, and Personal Care
- The resident right-of-physician choice has been limited by some parts of the nursing home sector. For example, you may be provided with a list of physician's names from which to choose. If possible, obtain this list before your relative enters the Nursing Home, so that you have an opportunity to research each physician’s background and experience.
- It would be preferable if you actually had your right of physician choice and could choose the quality of care you prefer - you may need to stand your ground on this, although, it may be difficult if your physician is geographically located far away from the Nursing Home too.
- By the Nursing Home controlling the list of physicians, they can also control how medical care is dispensed and the services a resident will receive. To give yourself an edge (and if such a physician is available), choose your own physician.
Why Nursing Home care can be sub-optimal?
Nursing home medical care is not a highly regarded practice area for physicians. Physicians are already unhappy with dropping Medicare and reimbursement rates for services. Therefore, to minimise their time spent with residents, physicians may opt to provide maintenance-only care, sometimes using polypharmia (overmedicating with multiple drugs) to treat residents. Physicians may or may not examine a resident, or may only provide a cursory exam, may even opt to simply record notes in the resident’s medical records, barely seeing the patient. It is the reason why polypharmia is so prevalent in Nursing Homes - the prescribing of medication gives the appearance of care.
Your relative will be depending on you to evaluate the care he/she is receiving - making sure that his/her health stays on a path to wellness, rather than mere maintenance and continued, needless suffering. As you observe your relative’s condition and receive the medical advice given, you will quickly find that your research has prepared you to make the best decisions in preservation of your relative’s health, safety and overall well being.
And finally -- always follow your gut instincts. In a worst case scenario, if the nursing home physician is not cooperating, if your relative is getting worse, if you are confused about what "is," have your relative taken to the nearest hospital for outside medical evaluation under closer care conditions -- today. Don’t second-guess yourself, don’t worry what the Nursing Home will think - take the lead.
Remember, residents have the right to accept or reject healthcare. We employ the medical profession to borrow their expertise, not dictate what we will do. Consequently, if necessary, don’t think twice about rejecting the nursing home physician and proceed to find the emergent care you believe your relative needs.
What type of healthcare and personal care services are available?
- Does the facility have both short and long-term services, such as routine physical and dental/vision examinations as well as skilled nursing?
- How do staff safely administer, monitor, and assist a resident in taking medicine?
- Does the facility's pharmacy provide delivery, consultation and review of medicines?
- Does a staff physician visit the resident regularly for medical checkups or can the resident his/her have own personal physician?
- Can the facility provide a list of available services and are residents and families involved in developing the care plan/service agreement? Who provides these services/what are their qualifications?
- Are physical, occupational, or speech therapy services available onsite? Who coordinates these services and how are they billed? (Medicare, Private cover, etc.)
- Is staff available to provide 24-hour assistance with activities of daily living (ADLs) if needed? Activities of daily living include dressing eating, mobility, hygiene, grooming (bathing, toileting, incontinence)
- Does the residence have Alzheimer's programs, or other dementias and other specialized areas? How does staff safely manage residents who might wander?
- Are staff available to assist residents who experience memory, orientation, of judgment losses?
- How are medical emergencies handled? Does the residence have a clearly stated procedure for responding to medical emergencies? Is there an arrangement with a nearby hospital?
- What's the facility's attitude to medical visits outside? (homes are only required to 'facilitate' these -- sometimes this can amount to no more than dumping your relative in a taxi -- whether they are competent to manage on their own at the other end is something you may need to address)
- Are housekeeping, linen service and personal laundry included in the fees, or extra charges?
- Does the facility provide transportation to doctors' offices, the hairdresser, shopping and other activities desired by residents and can it be arranged on short notice?
- Are pharmacy, barber/beautician and/or physical therapy services offered on-site?
5: Food, Liquids, and Nutrition
- Does the facility provide three nutritionally balanced meals a day, seven days a week, and how does the menu vary from meal to meal?
- Observe meal times:
- Do all residents who need assistance with eating get help?
- Do staff give each resident enough time to chew food thoroughly and complete the meal?
- What about special diets; does a dietitian plan or approve menus? Are resident's weight routinely/regularly monitored?
- Are residents involved in menu planning? Can they request special foods? Are snacks available?
- Does the dining room environment encourage residents to relax, socialize, and enjoy their food
- Are the meals varied and of good quality?
- Are the helpings sufficient for your loved one?
- Are water pitchers/glasses accessible in rooms and does staff assist with drinking as needed?
- Are common dining areas available? Is tray service available when ill and are there staff to assist?
- Can meals be provided at a time a resident would like or are there set times for meals?
- Can residents have guests for meals in the dining room for an additional fee? Is there a private dining room for special events and occasions?
6: Social and Recreational Activities
Social and recreational activities are important for the elderly: Some facilities attitude of 'activities' may simply be limited to placing your loved one in a wheelchair, dumped in a room facing a television, or lined up in a hallway.
You may want to ask the following questions:
- What kinds of group/individual recreational activities are offered and who schedules them?
- Is there a full-time diversional therapist? (These should have a certificate and be trained for the job - cost-cutting measures can lead to untrained recreation officers fulfilling this role)
- Is there an organised activities program with a posted daily schedule of events?
- Do volunteers and family members come into the facility to participate/conduct programs?
- Does the facility schedule trips or go to other events off premises?
- Do residents participate in activities outside of the facility in the neighboring community?
- Are the resident activity (social) areas appropriate and desirable to the prospective resident?
- Are there supplies for social activities/hobbies (games, cards, crafts, computers, gardening)?
- Are religious services held on the premises or arrangements made for nearby services?
- Are there fitness facilities, as well as regularly scheduled exercise classes?
- Does the nusing home create a sense of community by allowing residents to participate in certain activities or perform simple chores for the group as a whole?
- Does the facility have a garden and allow residents who can participate in gardening activities?
- Does the facility have pets? Who is responsible for their care?
- Does the facility encourage "Pet Therapy" visitations?
7: Living Conditions, Safety, and Environment
This section details impacts on the living conditions and environment a resident has whilst in the facility. The facility needs to be open for friends and family to visit. Studies show that the most effective way to prevent elder abuse is to have routine visitors (in some people's experience, constant visitors are regarded as witnesses and some homes don't like them)
- Is the floor plan well designed and easy to follow?
- Are windows easily dislodged for emergency needs?
- Are doorways, hallways and rooms accommodating to wheelchairs and walkers?
- Are elevators available for those unable to use stairways and handrails to aid in walking?
- Are floors of a non-skid material and carpets conducive for safe walking?
- Does the facilty have good lighting, sprinklers and clearly marked exits? (is a sprinkler system and fire extinguishers installed; is there a fire escape?)
- Is the facility clean, free of odors and appropriately heated/cooled? (ie, if your geographical area subjects the Nursing Home to extreme weather conditions, you also want to be sure that proper heating and cooling systems are in use. If your relative’s bed is nearest a window, is the window well insulated, does it keep the area warm?)
- What is the facility's means of security if a resident wanders? (ie, the monitoring of wandering Alzheimer’s residents)
- What safety procedures are followed by the Home (door locking, security checks, etc.)
- Are the common areas in general attractive, comfortable and clean?
- Is there an outside courtyard or patio for residents and visitors, and assistance getting there?
- Does the facility provide ample security and is there an emergency evacuation plan?
- How are residents escorted to safety?
- Are private rooms available and/or double occupancy units for sharing with another person?
- Is there a place where you can talk in private with your loved one?
- Does the residence have furnished/unfurnished rooms? What is provided or what can they bring? (The furniture that is provided should be comfortable)
- Are residents permitted to decorate their own rooms? Is there adequate storage space? (The rooms should have space for personal articles and furniture)
- Is a 24-hour emergency response system accessible from the facility?
- Are bathrooms private with appropriate accommodations for wheelchairs and walkers?
- Do all rooms have a telephone and cable TV and how is billing handled?
8: Patient Choice and Input
The first area to investigate is whether residents are allowed to make choices about their daily routine (for example: some homes make a practice of bedding down residents at an early hour to ensure minimum staff is required for resident care during the night)
Residents should however, still be allowed to make some decisions such as when to go to bed, get up, bathe, or eat (some restrictions concerning the routine can be expected)
If the resident has special needs, it is important to see how the nursing home accommodates such needs
- Is there a resident's committee and/or a family member's group?
- Do they have regular meetings?
- Do residents and their families feel comfortable speaking up at these meetings?
- Can anonymous suggestions be made? (Consumer input is a requirement under the government's standards.)
- Is the home's documentation available in the language you need? (ie, the Agreement you sign on entry to the nursing home; complaint forms; etc.)
- Are you permitted to have your own family physician visit your loved one? (sometimes, nursing homes insist on using their own doctor, as well as their own pharmacy).
- Are the residents and their families encouraged to have input into the quality of care?
9: Accreditation, Sanctions, and Reports
Through process of elimination, you will narrow your Nursing Homes list down to five or six. Next, you must learn more about each facility and evaluate each thoroughly.
After ascertaining which questions to ask and learning about the facility's track record, make sure you visit the facility to get answers to your questions and to see first-hand the appearance and operation of the Nursing Home.
- Is this a high care nursing facility and is a high care bed available?
- Is the facility accepting new patients? Is there a waiting period for admission?
- Is the facility sponsored by a non-profit organisation and managed under contract with a commercial firm? If so, what are the conditions of that contract?
- Is there a Resident Support Group through which resident/family have a means of voicing their views on the management of the nursing home and/or it's delivery of services?
- Each nursing home requires the residence to be "accredited" by the Aged Care Standards and Accreditation Agency. Does the facility have a current license/certification and is it displayed?
- What reputation does the nursing home have in the community? How long has it been in business? Is it in good financial health? Does the nursing home follow generally accepted accounting procedures?
- Check the history of the nursing home, ie, has it corrected any Quality of Care deficiencies in their past or present Accreditation audits or any other reports?
10: Fee based "consultants"
In our opinion the best decisions will be those you have made yourself on the basis of your own assessments after face to face inquiries of the kind mentioned above. However, if you feel the need for an intermediary then we suggest the following questions should be considered and put.
In all cases however, we strongly recommend you make notes about the responses to all the questions you may ask, of the Providers, the staff and the consultant. It may be weeks, months or years – perhaps never, but notes of that kind can be extremely useful if any promises turn out to be false.
An even better alternative is to pose questions and get answers in writing, although this is not always possible.
- Please give me some background details on your experience and qualifications to act as an intermediary for me/ my family member;
- How long have you been doing this work of assisting / advising on the selection of aged care accommodation?
- What are the services you offer?
- Please tell me what fees are payable for your services;
- Can you please assure me that you do not accept commissions or fees or other gratuities / rewards from the Providers which you recommend;
- Can you inform me about the history and some of the important operational and management aspects of the delivery of the care and services by the Provider/s you recommend – like –
a. staff and health services;
b. staff to resident ratios;
c. if an accommodation bond is required, how the bond moneys are invested (i.e., shares, term deposits, cash management funds etc),
d. do you prefer not for profit or commercial Providers?
- Can I be sure that any important complaints issues, breaches of the aged care laws and care requirements and past history of sanctions, Notices of Required Actions (NRA's), or any similar problems which have occurred, are reported to me/ my family member as a prospective resident, with information about whether they have / have not been addressed?
Aged Care Crisis would like to thank Rodney Lewis for his invaluable contributions to Point 10: Fee based "consultants" of this article.