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10 A Nurse's Perspective

Salvi, Schostok & Pritchard P.C. is fortunate to have Noreen Paulsen as a Legal Nurse Consultant on our team.

Basically, if the home is not the right fit for your loved one’s needs, then your loved one will need to move again or will get care that you feel is inadequate – and that is a big issue.

With more than 30 years of experience in the nursing profession, Noreen’s knowledge and insights play a vital role in our law firm’s investigation and analysis of nursing home abuse and neglect cases. Noreen helps our attorneys to review medical records and to assess whether the standard of care has been met in the treatment of nursing home residents.

Noreen brings a diverse background in nursing to her role, including experience as a general medicine nurse, neurosurgeon nurse specialist and clinical education staff educator. She holds a Bachelor of Science in Nursing degree from Loyola University in Chicago and a Master’s Degree in Health Services Management from Webster University in St. Louis.

In the interview below, Noreen shares her thoughts on what families should consider when choosing a nursing home for an elderly loved one as well as how they can respond to suspected nursing home abuse or neglect.

  1. What are important factors that families should consider when selecting a nursing home, and why are those important factors?

    First, I think you need to look at the reputation of the nursing home. You may need to do some digging. You can go online, for instance, and see recommendations by other people. You can also find information provided by the Centers for Medicare and Medicaid Services. Or you can talk to the nurses at the hospital that your loved one is being transferred from and ask for their opinions. You will find that nurses at the hospital will be glad to share their thoughts if you ask them.

    Second, you need to think about special services your loved one will need and ask whether a nursing home can provide those services. Let’s say your loved one has Alzheimer’s disease. Does the facility have a special Alzheimer’s unit? Are there procedures in place to ensure the safety of Alzheimer’s patients? Is the staff trained to work with those patients?

    Does your loved one need dialysis? If so, will that be done at the home, or will the patient need to be sent out? What is the reputation of the vendor providing those services?

    Basically, if the home is not the right fit for your loved one’s needs, then your loved one will need to move again or will get care that you feel is inadequate – and that is a big issue.

    Third, you need to visit the home. You need to go there in person and talk with everyone on staff – from the janitor to the person at the top. The person at the top may give you the bells and whistles, but the janitor may say, “Don’t come here.” You want to talk with everyone who will have contact with your loved one. You want to know if they are positively invested in this facility. If not, you should keep checking your options.

    At the same time you are doing a visit, you want to notice other things, too. What do you smell? Do people look like they are happy or miserable? Are the staff members interacting positively with the people they are caring for? Do staff members call residents by their names? If they are, then it says that the staff has been there long enough to know the residents and become familiar with them. Also, the home has enough regular staff so that they can get to know the home’s residents.

    Also, the first floor may look really nice, but you want to go up to the level where your loved one will be staying. If your loved one will be in the Medicare unit, you want to see the Medicare unit. Walk into the bedrooms and bathrooms. Do you they look clean and well-kept? Is the paint intact?

  2. What information should a family look for when doing online research into a nursing home, and what do you think are the best online resources?

    As I said, the CMS website is a good place to start. You will be able to find good, objective data. The IDPH [Illinois Department of Public Health] also puts information online about inspections and complaints. You can go to forums, perhaps, or review sites. Yelp has nursing home reviews.

    I also think it’s very important to go to the facility’s website. Does it look updated? If a nursing home isn’t willing to put time into its online site, then it may be the same way with its facility

    I think the key is that you need to take all of these pieces of information and look at them in context. You have to bring those pieces together to get the whole picture. Unfortunately, I know that many families don’t have time to do that.

  3. Why is it important for a family to actually visit and inspect a nursing home before they choose one?

    It’s like buying a house. You wouldn’t buy a home just because someone told you it was a good deal. You would want to look at the home, touch it, smell it and see what’s there. It is the same with a nursing home. You want to have all of those boxes checked.

    Also, what you see in a brochure may not transfer to real life. The brochure may have a picture of a bench next to a beautiful garden. But when you visit, you may see that it’s just a patch of dirt. If your loved one wants a home with a beautiful garden, then that is important.

    It’s important to remember that you really are choosing a new home for your loved one. This is where they will sleep, take their meals, meet loved ones, watch TV, read the newspaper – they should be comfortable. You wouldn’t buy a home without investigating it. You have to follow that same process here.

  4. When a family visits a nursing home, what are items they should be on the lookout for during the visit which may indicate the quality of care and level of safety that residents enjoy at the facility?

    There are really so many things.

    First of all: Cleanliness. Are the windows clean? Are the floors in decent condition? Does it look like the facility is being routinely maintained? Is the carpet clean?

    Then, look at safety issues. When you go up to the Alzheimer’s unit, are the buttons on the elevator covered so a patient can’t get to them and get on an elevator and wander off?

    Does the facility use area carpets, and if so, are they tacked down so the edges won’t come up and cause a resident to trip? Are safety bars installed where they should be?

    You want to check with the facility and ask what happens if a resident wanders away. Are there alarms on the doors? What protocol is in place to ensure safety?

    You really want to focus on small details. If they are paying attention to those small details, then you can extrapolate that they are paying attention to the big details.

  5. Should a family discuss the specific services a nursing home will provide before choosing that facility, and if so, why?

    If the facility is going to offer a special service, it should be well done. I mention Alzheimer’s a lot because those are residents who truly need special services. If a facility says that it will provide a special Alzheimer’s unit, then it must do exactly that – and do it right. The same could be said for residents who need dialysis and wound care. The facility must always provide what it says it will provide.

  6. Should a family discuss a nursing home’s policies and procedures concerning residents’ rights before choosing that facility – if so, why?

    Absolutely, it is something they should discuss. Any of those things that will impact the overall care and treatment rendered to a loved one should be in those policies and procedures.

    For instance, what does the home do if a patient has behavior issues? Does the home follow proper procedures for using restraints? What is the home’s visiting policy? Will the home respect your loved one’s right to privacy with her medical information? You should also make sure that living wills and do-not-resuscitate orders are in place – those are all a part of your loved one’s rights.

  7. After a loved one is moved into a nursing home, why is it important for family members to visit and check on the care that the loved one is receiving?

    The cynical part of me says that you should do that because the squeaky wheel gets the oil. In other words, if the nursing staff sees you are in there all of the time, then they know you will be checking up on them. So, they will make sure your loved one will be ready for you.

    But another part of me – the emotional part – says that you should do that because it is your family member. His or her biggest fear is that they will be forgotten –that you will put them in a home and walk away. You want to make sure they know that they are loved and cared for by you – they are still a part of your family.

    When you visit, it also gives you a chance to see if there is a decline in your loved one’s condition. If you see them every day, you can notice those signs.

    It’s a team effort to take care of your loved one. If you are there all of the time, and you ask the nurse questions, the nurse won’t take it as an affront. It can be a positive engagement.

    However, if you are asking questions, and it’s the first time you have visited in six months, it may set up a confrontational situation.

  8. What are the most telling signs that a nursing home resident is experiencing mistreatment or neglect in the nursing home?

    So many things can go wrong.

    First, broken bones – a broken hip, leg or arm – obviously would be a concern. You have to evaluate whether that is a neglect or mistreatment issue. You have to ask what was going on when it happened – or what wasn’t going on.

    A fracture tells you there could be a possible safety issue – maybe something with the rug, foot ware or lighting. It could be that no one was watching to make sure your loved one was safe in a wheelchair or using a walker. It needs to be fully investigated.

    Pressure sores are also a concern – especially when they were not there at the time of admission and developed later on. If no one tells you about it – that’s a problem. You should intervene at Stage 1. If a pressure sore has advanced beyond that without anybody knowing about it, that is definitely a sign of possible neglect or mistreatment.

    However, I need to qualify that: It could be that your loved one is 90 years old and skin and bones and is not eating well despite everybody’s best efforts. It’s possible that he or she may have a skin issue or a pressure sore, and nobody can do anything about it. So, that’s why it must be investigated.

    Unexplained bruising is another sign. If a patient is not on anti-platelet or blood-thinning medication and develops bruises in the stomach area or on the back, it would make you question if anybody is manhandling the patient. You have to ask how they got the bruise. If the nurses can’t explain it, or if the bruising appears in unusual places, that’s a red flag.

  9. In your experience, what do you believe are the most common types of abuse and neglect that occur in nursing homes?

    The failure to follow a patient’s care plan is a major issue. When a loved one moves into the home, the care plan is initiated based on your loved one’s needs. If the home doesn’t follow the care plan, that’s when things go wrong.

    For instance, when a nursing home deviates from the plan of care, it could lead to dehydration, malnutrition, UTI (urinary tract infection) or a host of other problems.

    Look at pressure sores. That’s an outcome that results from a staff failing to keep a patient mobile or from not repositioning him or her or adjusting cushions so the patient is not sitting in the same position all of the time.

    When a home sets up a plan of care, that’s what the home has promised to do. That’s what the home determined to be the best way to care for a patient and keep him or her safe. The home has to follow it.

    Of course, in any medical facility, medication errors are also a concern. Is the home giving medication at the right time and in the right dosage? If an error occurs, it could be a systemic issue within the home. Also, if psychotropic medication is given, did the home have authority to do so?

  10. If a family suspects a problem with their loved one’s treatment, should the family talk to the nursing home administrators first before taking other action such as filing a complaint, and if so, why?

    In the best situation possible, the family will be there to visit their loved one regularly. They will know the nurses and the CNAs [certified nurse assistants]. So, they will feel free to go up to a nurse and say something like, “I noticed Mom has bruising on her leg. Have you noticed it?”

    When they do that, the nurse’s response should be along the lines of, “Let’s go look.” Or, the nurse should be able to check your loved one’s records and say, “Oh yes, we noticed it this morning. She bumped into a sink in the restroom.”

    When you get that response, it says to you that the nurse or the home is not hiding anything. The nurse reviewed the records and found something documented, and what happened makes sense. So, there would be no need to file a complaint.

    If the nurse says that she doesn’t know how the bruise occurred and will investigate it or keep an eye on it, then make sure the nurse follows up with you.

    If you get no response or a satisfactory response, you can go up the chain of command – the DON [director or nursing], the administrator and so on. If they start trying to backpedal or hide things from you, and it is serious enough such as a bruise or a fall, then you should file a complaint and take legal action. Your loved one should never be exposed to anything abusive or neglectful in their home.

  11. What are the main challenges of moving a loved one out of a nursing home and putting him or her in a new facility – and how can a family overcome those challenges?

    There are many practical challenges.

    You have already moved your loved one from their home, and this facility became their new home. So, if you move your loved one again, there will be some disorientation as he or she acclimates to a new facility. Your loved one will need to learn new faces and get to know caregivers and friends. Also, every facility does things just a little different. If your loved one is starting to shows signs of Alzheimer’s disease or dementia, it may be a true challenge.

    However, there are certainly times where moving a loved one is a necessity. For instance, if your loved one has suffered multiple injuries at a home, or if there is a negative situation between the caregivers and your loved one and your family, it may be time for a clean slate.

    I think you can overcome the challenges you face by being present and available for your loved one. You may have to step up the number of times you visit. If you were going once a week, then go twice a week for a while. The key, always, is to focus on what is best for your loved one.

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A Family Guide to Safety in Illinois Nursing Homes