The health and safety of your loved one in a nursing home or assisted living facility cannot be delegated to others
When loved ones are no longer able to care for themselves, it is the hope that they receive the best help possible. These individuals often require assistance with many of the activities or needs of daily living, such as eating, using the bathroom, dressing, and even turning or repositioning in bed. Relatives who cannot provide the adequate time or medical skills necessary to meet these challenges often depend on nursing homes to provide the care and attention these individuals deserve.
You may not want to hear this but if, as you read these words, you currently have a loved one in a nursing home, that resident’s safety and ultimate health outcome is very much up to you. Make sure you understand this point. If you are relying on the attending physician at the nursing home to protect your loved one you are setting yourself up for a major tragedy. You may or may not be aware that that physician probably has over a hundred patients in the facility your loved one is in and probably another few hundred in at least one other facility. You should also know that under current Federal Law the attending physician in a long-term care setting is only required to examine your loved one once a month! Do the math. While the attending physician is an integral part of the overall quality of the care your loved one receives, leaving the responsibility for your loved one’s safety to this individual is a major mistake and it could be a deadly one.
Similarly, if you are thinking to yourself that “well, this is a medical facility of trained individuals, that’s why I placed my loved one there in the first place” you are disillusioned and your loved one is in danger. I don’t say this to hurt you, frustrate you, frighten you or overwhelm you. I tell you this because for the past 24 years I have seen literally hundreds of families who came to me to sue a nursing home after their loved one was literally killed by the “care” of the facility.
The overwhelming majority of these well-intentioned families shared a very similar set of characteristics.
If you take nothing else from these pages, take this: The health and safety of your loved one in a nursing home or assisted living facility cannot be delegated to others.
I know of too many instances to count of bedsores, rapes, fractures, abuse, malnutrition, and death that were the direct result of “leaving it to the professionals”. As an empowered advocate, DO NOT leave the health and wellbeing of your loved one to other people, regardless of their level of training or education.
Despite what a nursing home’s marketing might tell you the truth is: It is not the goal of the nursing home to provide the very best care possible for your loved one. It is the goal of the nursing home to provide the minimum level of care possible to avoid a lawsuit while maintaining their own profitability as a business.
Ultimately the mindset you must adopt to be an empowered advocate is this: You are the only one who can protect your loved one and make sure they are being cared for properly.
You should not leave the health and safety of your loved one to the nursing home, state agencies, lawyers, attending physicians or ombudsmen. While all of those entities have a role in the process of adequately protecting the health and rights of a frail vulnerable nursing home resident it is the family of the resident that must lead the process.
As a nursing home abuse attorney, I represent the families of residents who have been abused and/or neglected. I sue the facility; the facility defends the claim and ultimately, we settle or try the case before a jury for money damages. But day in and day out the families come to me. It is the same story with different faces. They say things like:
This program was born out of frustration. I am still collecting millions of dollars for the families of these residents, but the families just keep on coming through my door. Punishing nursing homes for abuse is an important thing I do but I must come up with a way to prevent these abuses rather than just suing them for money after it happens. By utilizing the information in this program, I want you to know exactly what to do to protect your elderly or frail or disabled loved one in a nursing home or assisted living facility.
You may be asking yourself whether I believe that nurses and aides are sadists? Do I believe they go through all that training and education to help others only to purposely abuse and mistreat them? Absolutely not! Being an aide or a nurse is one of the greatest jobs in the world when it comes to what it does for others. It is truly a noble calling to care for a frail and vulnerable class of human beings. Nurses by and large are caring, intelligent, compassionate, and talented healers. The same can be said for people who choose to do the thankless and poorly compensated job of nurse aide. These individuals are the frontline caregivers who clean urine and feces, change diapers, reposition residents, feed and bath residents and do so for the same pay as the person who works the register at your local fast-food joint.
They have an emotionally and physically grueling job and they do it almost always because they genuinely care about residents. But here are two truths that you must acquaint yourself with if you are going to be an effective advocate for your loved one:
I want you to remember this and remember it well: “A nursing home is a business.” While many nursing homes are not for profit or so-called charitable organizations, the large majority of them are a business like any other. And just like every other business they have one main goal; to make money. If you asked me, what McDonald’s business is I would not tell you making hamburgers. I would tell you making money. They just use hamburgers to make their money. American Airlines doesn’t fly planes. They fly planes and operate airports to make money. And nursing homes don’t take care of the elderly, they take care of the elderly to make money. But there is a unique element to the nursing home business. Namely, how much they can charge for their “product”. If McDonald’s wants to make more money, they raise the price of hamburgers. They could also try to make hamburgers more inexpensively. If they both raised the price of hamburgers and made their hamburgers more inexpensively, they could really create a much higher return for their business.
A nursing home is a business like any other. It has customers, prospects, marketing, overhead, staff payroll, budgetary constraints, and profit goals. One of the unique characteristics of the nursing home business, however, is that over 80% of its revenue comes from government insurance programs such as Medicare and Medicaid. In fact, three-fifths of the nation’s 1.3 million nursing home residents’ fees are paid by Medicaid, the federal-state insurance program for low-income Americans. The average payment made by Medicare is $215 per resident per day. Medicare which is the federal insurance program for Americans over 65 pays more than double that amount. Even at an average per day per resident spend of $535 this amount of money must cover all the care, meals, supplies and staff required for that resident each day. While 30% of nursing homes in America are non-profit or charitable institutions, 70% are “for-profit” businesses which means the ultimate goal of the facility is to spend less per resident per day than what Medicare and Medicaid is paying for the care of those residents.
The cheaper they can provide the care the more profit they make and unlike other businesses they have severe restrictions on their ability to raise their prices. So, other than cutting costs, the nursing home has very little ability to increase its profits. Not surprisingly, a number of research studies have found that for-profit nursing homes generally have significantly lower staffing levels and quality of care than nonprofit facilities. The single greatest expense of a nursing home is the salaries of the staff. In 2019, for the first time in 34 years, the median operating margin for America’s nursing homes was negative. This means that about 50% of the nation’s nursing homes are not operating profitably. In the middle of the Covid-19 Pandemic, some estimate that 90% of American nursing homes were losing money. The pressure on for-profit nursing homes to cut costs is overwhelming as the literal existence of the facility is at stake if profitability cannot be obtained. If profitability must be obtained and revenues cannot be reasonably increased, the only answer many facilities will find is to further cut staff to dangerous levels.
It is absolutely beyond debate that the quantity and quality of the nursing home staff is the single greatest predictor of quality-of-care outcomes in a nursing home. This isn’t unique to the nursing home business by the way. The best restaurants have adequate staff that are very well trained. The very best department stores. The very best hotels. The very best convenience stores. The quality of any service industry is largely a function of the quantity and quality of the people they hire as well as the investment and development of those people. The difference is an understaffed or undertrained restaurant might result in a cold meal or a long wait for a table while an understaffed and/or undertrained nursing staff can mean the difference between dignity and shame, comfort and pain and in some circumstances – life and death. The result of these staffing cuts is simple. SOME RESIDENTS WILL GET NEGLECTED. The nursing homeowners fully understand that some services won’t be able to be provided with staff cuts. They hope that nobody will get hurt or killed to the point that they get sued over it. That is the reality of what over 50% of America’s nursing home residents and their families are facing. Can you see why you cannot delegate the responsibility for your loved one’s care to these “professionals”?
So why am I sharing all of this with you? Why is it so important for you as an advocate for your loved one to understand the nature of the nursing home business model? The answer is in the fundamentals of persuasion summarized as follows by Cicero centuries ago:
If you wish to persuade me, you must think my thoughts, feel my feelings, and speak my words. – Cicero
You must understand that in the great majority of circumstances the facility will be staffed at a level where it literally cannot provide adequate care to everyone in the facility. This means that each and every day that facility and its limited nursing staff will have to make a decision as to who they will provide adequate care to and who they won’t. While it is cold and morbid to say, effective advocacy for your loved one is really about making sure your loved one is one of the residents that gets the limited resources. Effective advocacy therefore begins with understanding how the nursing home will ultimately make its decisions as to who gets the limited resources and who doesn’t.
The short answer is this- The nursing home resident that will get the best care is the one whose advocates make the nursing home staff believe it is in their business/occupational interest to care for their loved one.
I don’t know what you do for a living. I am a nursing home abuse attorney. My wife is a medical receptionist. My brother is a football coach. My sister runs a non-profit. While I don’t know what you do for a living, I do know this – you have some days where you are exceptional at your job and some days you aren’t. We all have bad days at work. We all have days when we just don’t “feel it” and give less than 100%. For some, they have gotten used to giving less than 100% on the job. . . a lot less. We all know people who don’t take their job seriously. We know people who do just enough not to get fired and are generally paid just enough not to quit.
The same way you need to understand that a nursing home is a business to come up with an effective advocacy strategy for your loved one you also have to embrace the reality that for the nursing staff (RNs, LPNs and CNAs) this is their job. It’s just a job. That doesn’t mean they don’t care about what they do or think it’s important. It doesn’t mean they want to hurt anyone. I can count on one hand over 24 years the true monsters who were nurses or aides. 99% are decent hardworking and caring people who got into this line of work and went to school and studied hard and somehow survived anatomy and their first catheter placement. My daughter in law is a nurse and I watched the tremendous sacrifice she made to become an RN. She truly did it to make a difference in the world, not to torture people. BUT it’s a job. If I honestly polled everyone in this room, studies tell me the following:
Do you really think that a nurse aide who cleans dirty diapers, gets spit on by dementia residents once a week, gets yelled at weekly by superiors, family members and residents, works terrible hours, and makes about $9 per hour loves every day at their job?
Let me ask you something about your job. Ever had a bad day? Ever coasted? Surfed the net instead of focusing on your work? Spent more time on Facebook than your projects? Felt unappreciated? At your job have you ever been tired? Have you ever been lazy? Have you ever cut corners?
Please tell me you don’t think nursing staff at a nursing home don’t have these days and probably more often than you do.
You can read all the glossy marketing material you want, but if you believe that anyone who is being paid to care for a complete stranger is going to treat that person like their own family, shame on you. NOBODY WILL CARE FOR YOUR LOVED ONE LIKE YOU WOULD. It’s a job.
Why do I tell you that? Again, to remove from you this naivety that says these staff members are somehow different than you and me. That they do not have the right to have a bad day at work or that somehow because they are taking care of your mom or dad, that means they wake up every day and are on top of their game. That they understand that every single thing they do every single minute of every single shift has an actual impact on a helpless individual.
Use this, for the staff it’s a job mentality, to your advantage. So, what motivates them to give great effort to one resident over another on a day (or many days) when they don’t feel like giving their all? Well, what motivates you to work harder for one customer than another? For a moment put yourself in the shoes of a nurse or aide at a nursing home. In a world of limited resources where they may be forced to only give full and complete care to one resident and not the other which one would you choose between the two below?
| Resident #1 | Resident #2 |
|---|---|
| Family rarely visits and always visits and the same time and day of the week when they do | Multiple family members visit practically daily. They show up at different times of the day completely unannounced. |
| Family does not participate in care plan conferences when they are scheduled. | Family is always participating fully in care plan conferences. |
| Family doesn’t care to know the names of individual caregivers or what they do for their loved one. | Family insists on knowing the name of anyone who cares for their loved one and has a complete understanding of their job duties. |
| Has no idea who is “in charge” because “everyone looks the same” in scrubs. | Knows exactly who is in charge from the charge nurse all the way to the administrator (and beyond) and is more than willing to take their complaint “up the chain” if their concerns are not addressed at lower levels. |
| Doesn’t know who enforces the regulations in a nursing home. | Knows all of the federal and state agencies that investigate regulatory infractions and enforce quality of care laws as well as how to initiate such an investigation. |
| Doesn’t have representative capacity in the form of power of attorney/guardianship over the resident. | Has legally binding POA or Guardianship with plenty of copies to hand out to anyone questioning their authority. |
| Never asks questions and knows very little about their loved one’s medical conditions, physicians and medications/treatments. | Knows everything about their loved one’s medical conditions and treating physicians. They know what medications have been prescribed, when they were prescribed, by whom they were prescribed, the dosages and the underlying condition the medication is treating. |
I could go on forever, but you get the point I am making. It’s just human nature to protect your own butt as an employee. Customers that know what they are supposed to be getting for their money are more respected and generally treated more favorably than those that don’t. Customers who know how to bring a problem to the attention of your boss quickly are simply less likely to face a problem. Employees know who can get them in trouble and who has no clue what’s going on. Employees understand which customers cannot be sweet talked and which ones can. They know who might complain and who won’t. They know who is paying attention and who isn’t. You do. I do. And the nursing home employees do.
Are you interested in learning more about the Empowered Advocate? We are offering the Empowered Advocate Journal, Empowered Advocate Seminars and other materials to help guide you through the nursing home journey with your loved one. Request more information here:
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