Can We Rate Nursing Homes Like Restaurants?


    The Federal Government has plans to put into place, by the end of the year, a five-star ranking system for nursing homes. At first blush, this seems like a terrific idea. Families could easily find out the ranking of a home and then make a decision based on the number of stars. Five - great! Four - okay. One - no way.


    States and counties already have rating systems for a wide variety of inspections which are done on a regular basis, at least in my area. The results of these inspections are available to the public, so, out of curiosity, I've looked up, on the Web, the ratings of homes I know well. Often, I've been shocked to find that they have "deficiencies."

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    Home A, I know to be excellent. Here, on the rating page, it has a couple of dings because a patient fell. Home B is also very good, from what I've seen, but they took a hit when an inspector found a couple of residents continued to lose weight.


    Then I read the fine print on the inspection site. None of these reports showed neglect or any evidence that the performance of the home caused harm to a resident. None of them showed the home wasn't an excellent facility. Am I glad they are inspected? Absolutely. Do I use these ratings as my only criteria? No way.


    I spent so much time at Rosewood On Broadway (where my parents and mother-in-law were) that I was often there when they had drop-in inspections by the state and/or county. Also, there were planned inspections. The home tried very hard to get a perfect rating, and on occasion did. But they knew that the inspectors would nearly always find something. Why? Because they were in the business of caring for human beings.


    In my mind, there is a difference between an elder falling due to neglect on the part of staff, and an elder falling due to the staff giving an elder as much independence as possible.


    My dad was a good example of this. Restraints are blessedly illegal in my state, and that includes drugs. However, after my dad's brain surgery, he was very unsteady and often forgot he couldn't walk alone. He'd suddenly would get up from his chair and start walking - and then fall.


    The staff and I talked it over and they tried putting a tray on his wheelchair, which was legal. We told him it was like having a desk. But even that small amount of restraint caused horrible emotional pain for him. It literally would drive him crazy. We discussed it and agreed they had to take it off.


    They did use alarms so that when he got up he'd pull a pin and the alarm would shriek. But he hated those too, as every time he'd roll over in bed, or turn too far in his chair, an alarm would go off. I think he felt a bit like a laboratory rat in training (he was a scientist).


    Elders have choices and some of those choices may lead to results such as falls. I'm not saying the care center shouldn't do everything possible to prevent such things, but in the case of my dad, the humane thing to do was give him as much freedom as possible, and risk a fall, as opposed to creating even greater mental agony than he already lived with, from his dementia. The staff and I agreed on this. It was an imperfect option, but life is imperfect.


    My mother offered an example of the weight loss dilemma. She went into the center over-weight and rapidly lost excess fluid when she was put on a healthier diet. This was good for her severe arthritis, which is the main reason she was in the home. She fell at least once a week in her apartment home, so she needed to have care around the clock. Dad was in Rosewood, so she chose to move there, too.


    As mom developed dementia, and cancer spread through her system, she got so she couldn't eat. I discussed with her, and with staff, just how much "encouragement" they should give her to eat. I know first hand what it's like to be to told to eat, when I can't. I was a little kid who couldn't eat a lot at once, living in a world of hearty appetites. I'm still that way. I'm a grazer. Give me a lot of food, and I'll pick at it and soon be full. I can't eat more. But in an hour, I'll be ready to eat again. It's the way I'm put together. So, I understood when Mom said she couldn't eat.

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    We pushed fluids as much as possible and I brought her favorite foods for her including fresh fruit, and shrimp and dipping sauce. But still, she lost weight. This made the home look bad on the surveys. However, it was not neglect. The staff went out of their way to make her toast and other things she wanted if she couldn't eat the full meal. They did all they could.


    As an aside, this home and many others have taken another giant step toward patient-centered care and now offer several meals a day, at the resident's choosing. Mom would have liked that better. However, the staff at Rosewood was so good to her, that they essentially did the same thing, even when it wasn't "procedure." Still, they looked "bad" on the books because of her continual weight loss.


    My point is this. Inspection is necessary. Maybe even a 5 Star ranking system is okay, though it seems like a simplistic bandaid slapped over a multilayered sore. It seems to me that it's more of a political move than a real effort to uncover bad care facilities. Nursing homes are about people. They are about staff. They are about individuals. And the quality of a home is going to go much deeper than a five star rating system.


    Families still need to tour homes. I advise dropping in at a home your are interested in during different times of the day and evening. I also tell people to look at how the lowest level employees at the care center are treated by the upper level employees. That will tell you far more about the quality of a nursing home than how many stars it gets during a once a year inspection.


    The administrator of one local home in my area was once a nurse. He knows every resident by name. He wears street clothes and is out in the hall or in resident's rooms more than he is in his office. And he's not afraid to wipe a runny nose or drippy chin. Where would this kind of care show up on a five star rating system?


    Nursing homes aren't restaurants. They are care centers. They have many more layers to sift through than a mere "5 star" ranking will allow. I'm not saying this system is totally bad - I'm just saying it may lead people to believe that just because a center has five stars, it is the best. There could be one with 4 stars that has a more compassionate, stable staff.


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    I caution families of potential residents to not dismiss a care home because it doesn't have five stars, or accept one because it does. That ranking may be a starting point (a one star ranking may show serious issues), but it should be only a small part of how you will determine which care center is right your loved one. We're not talking about an evening out at a restaurant. We're talking about quality of life for a vulnerable elder.


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Published On: July 23, 2008