They’ll want to show you their renovated patient rooms and their glitzy calendars. They will want you to see the art room and hear about the visiting music therapist. They’ll make sure you notice the flower-bedecked reception area and see the nicely-appointed dining room. They might even cite the training their aides receive. And these are all positives. But administrators of long-term care homes may not encourage you to examine the nuts and bolts. To spend the time it takes to make a true assessment of the standard of care and the residents’ ‘joy’ levels. (Yes, that’s what I said, JOY.) You need a more evidence-based way of assessing the quality of care your loved one will get in the long-term care home that may cost $4000 to $12,000 a month. What do you look for to judge the quality of the home?
When you visit a long-term-care home your tour guide might want to direct your attention to superficialities or to things no longer relevant for your family member, especially one declining physically or cognitively. (Smart TVs, anyone?) Here are some features that are essential for your family member’s well-being. Look for them. These are the minimum No-Frills tests your prospective long-term care home should be able to pass.
1. The Wheelchair Test, suggested by ‘May,’ a former CNA Edge contributor. When you visit a home take a good look at wheelchair footrests and frames. Are they clean? If not, other unseen areas may be neglected. Are footrests attached to the wheelchair? Sometimes a resident benefits from ‘paddling’ along with her own feet; this can strengthen ankle or leg muscles. But if you see residents being wheeled uncomfortably without footrests, this may signal minimal attention from aides and inadequate monitoring by nursing supervisors.
2. The Bathroom Linen Test: Are there clean facecloths and towels in bathrooms? Shortage of towels is a perennial problem in care homes. If management is asked they will tell you that the residents hide towels, and this is sometimes the problem. But sometimes the problem is that there simply aren’t enough towels, or not enough laundry workers to ensure that clean towels are always available. How can we maintain hygiene standards if there aren’t clean bathroom linens? Ask to visit a few resident rooms. If the tour guide discourages you from seeing occupied rooms (“Privacy Rights.”), befriend a resident and ask if you can see his/her room. This will nearly always gain you access.
3. The Warm Water Test. All medical authorities tell us that hand-washing with warm water is the best way to prevent the spread of infection. CNAs are expected to wash their hands with soap and warm water frequently. When you visit a room, check out the sink. Do warm-water faucets in residents’ bathrooms and hall toilets actually run warm? How long does it take to get hot water? If you aren’t able to enter a resident’s room, try sinks in the visitor’s toilets, in the kitchen area, wherever you can find a sink that should have hot running water. The water may warm up after two or three minutes. But when an aide might have only five or ten minutes to get a resident washed and dressed in the morning, she might not have that two minutes to wait. Your family member might get a cold face cloth first thing in the morning. Is this what you want? Do you want the most basic infection-control measure, warm water, to be MIA?
4. The Bath Room Temperature Test. Visit the bath or shower room. Is it warm enough? Older residents usually want warmer rooms for bathing. When they leave the bath or shower, they shouldn’t shiver and shudder.
5. The Call-Bell Test. Do you hear annoying call bells that go unanswered? How long does it take an aide to attend to the person calling for assistance? If these annoy you, imagine how they affect a resident who feels anxious and confused.
6. The Chair-Alarm Test. Notice the residents’ bed and seats (both wheelchairs and other seating) to see if there is a chair alarm on the seat. Virtually every group with an interest in improving the lives of residents in long-term care homes, including CMS, recommend eliminating the use of chair alarms. “But these keep residents safe,” supervisors will say. Evidence suggests that they don’t keep people safe and indeed lead to more falls. (Google it!)
7. The Noise Level Test. It’s not only alarms that can distress residents. If aides routinely shout down the hall to each other, this can be upsetting.
8. The Dining Room Test. How is the noise level? Is hot food served deliciously warm? Are residents offered condiments (salt, pepper, sugar, mustard, ketchup) they would have used at home? Are the aides attentive to residents or do they converse mostly with each other during mealtime, as if this were an extra break time? For those who can no longer use a knife, is the food served in bite-sized portions that the person can comfortably chew? Are residents offered refills of drinks?
9. The Calendar Test. Every long-term care home has its monthly calendar of activities posted prominently. Pay attention to the type of activities offered, how often the calendar matches what is happening in real time, and whether residents seem engaged when they are at the activity session.
10. The Family Council Test. In elder care homes a Family Council is one of the strongest ways we have of monitoring care and advocating for high-quality care for residents. Many homes do have resident councils, but frail elderly residents, especially those with dementia, either don’t know their rights or just can’t express their needs and preferences and criticisms. They rely on us, their family and friends, to be their eyes and ears and their mouths. Once they needed you as a caregiver, and you did that lovingly. Now they need you to be their advocates. So ask whether the home has a Family Council.
11. The Staff-to-Resident Ratio Test. You want your family member to get the attention and care she/he needs. You ask the supervisor about staffing levels and are told, “We meet all the state’s requirement for the number of staff.” And they probably do. The problem isn’t that the home isn’t staffed according to standards. It’s that the standards don’t meet today’s needs. Our expectations for care are higher today. Residents’ needs are also greater; many have cognitive as well as physical disabilities. In some homes there is one aide assigned for eight or ten (sometimes more) residents. And if an aide calls out sick or has a family emergency at the last minute, the ratio is worse. Care quality is worse. Though you may not find an ideal staff-to-resident ratio anywhere, at least ask about this. Ask whether census or resident acuity determines the staffing level. Ask how the home assesses resident acuity, and whether dementia symptoms are factored into acuity.
12. The Supervisor Test. Who is responsible for monitoring care standards of the unit your family member will live in? Where is that person’s office located: within the unit or in some distant section of the home? Ask to see that person’s job description. (After all, you’re paying the salary!)
13. Last but not least: The Aide-Engagement Test. Do aides smile and make eye contact when they engage with residents? Do they seem to know and respect the residents’ needs and preferences? When a resident calls out for something—a snack, an answer to a question, a response of some kind, how do the aides respond? This may be the most important thing to look for on a visit: how aides interact with residents. To get a truer picture of aide engagement you’ll need to visit several times, including weekends and at different times of day or evening. Midmorning. Mealtimes. After supper. Try to visit during a change of shift. Are aides still available to pay attention to residents during shift changes?
When you’re evaluating long-term care homes, don’t be overly swayed by the charm initiatives of the marketing staff. Instead, use this checklist to observe those conditions your family member will live with day in and day out. There is more involved in achieving excellence of care. But these concrete items can be clues to less visible elements of quality care. If those in charge aren’t getting even these basics right, are they really committed to the loftier goals they claim to have?