Skilled nursing facilities (often abbreviated as “SNF”) are designed for patients who are not sick enough to warrant continued admission into a normal acute-care hospital, but who are not well enough to be discharged to home.
As a Houston, Texas medical malpractice lawyer, I have found that the care provided in skilled nursing facilities is often deficient and sometimes downright shocking.
As you might expect, Medicare and Medicaid pay a lot of money to skilled nursing facilities and have a strong interest in making sure that the patient care being funded is of a good quality.
The Centers for Medicare and Medicaid Services conducts a significant amount of oversight over all types of facilities, including SNFs. Skilled nursing facilities must submit to Medicare and Medicaid detailed paperwork for each patient, called a Minimum Data Set (“MDS”). This requirement is designed to provide a clinical basis for having individualized care planning and delivery of person-centered care.
In other words, the guidelines aim to prevent skilled nursing facilities from “going through the motions,” rather than looking at each patient as an individual with unique treatment needs. From my experience, this type of reporting oversight is critical to patient safety.
Unfortunately, 2012 findings by the federal Office of Inspector General found that one-third of skilled nursing facility MDS reports did not comply with federal requirements for patient assessments. Nearly half of the SNF MDS reports had incorrect information.
This led the Centers for Medicare and Medicaid’s Services to cooperate with five states to do a short-term study on resident care and nursing homes. The time period of the survey focused on fiscal year 2015, and the results are quite interesting.
The study found that the large majority of skilled nursing home deficiencies posed a potential for more than minimal harm to patients. In terms of how often the specific violations occurred, 56% appear to be isolated instances, but 25% fell within a pattern of violations.
Common skilled nursing facility errors
The Medicare/Medicaid study results included the top-cited deficiencies by SNFs, all of which could potentially compromise patient care.
Facility noncompliance with posting daily nursing staffing information was a frequent deficiency. Medicare guidelines require the skilled nursing facilities to keep daily records of the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for patient care. These daily reports have to be posted in the facility in a prominent place that is readily accessible to residents and visitors.
As a medical malpractice lawyer, when I investigate nursing home or hospital negligence cases, I always look into the number of nurses working each shift, as well as their work schedule. When facilities hire too few nurses to take care of their patients, it can compromise the quality of care. Call buttons may go unanswered. If a patient wets or soils a bad, it may take an extended time to get help. Patients may not be turned frequently enough to avoid bedsore development. In addition, nurses who are expected to work too many hours on a given shift, or even on a weekly basis, can make care mistakes because of fatigue.
Another frequent deficiency cited by the study is the failure to develop comprehensive care plans. Medicare and Medicaid require Comprehensive Care plans to ensure that the facility defines measurable objectives and timetables to meet patient needs. This, of course, prevents patient care needs from falling through the cracks when doctors and nurses do not take the time to think of patients as individuals.
The study also found that skilled nursing facilities were often not free from unnecessary drugs. Medicare and Medicaid guidelines aim to improve approaches of meeting the health, psychosocial, and behavioral health needs of all patients, especially those with dementia. In my practice as a medical malpractice lawyer, I have seen many cases where doctors and nurses tended to overprescribe both pain and psychiatric medications. These drugs can be dangerous because they can sedate or dull the patient’s responsiveness, thereby masking important signs and symptoms of something being wrong. In one case that I handled, a short-term SNF patient actually died from a medication overdose under those circumstances.
I was not surprised to find that the study also concluded that a frequent deficiency of skilled nursing facilities was inadequate treatment and services to prevent and heal pressure ulcers. In a case that I handled several years ago, a hospitalist medical expert told me something that stuck in my mind—the best way to treat pressure ulcers is to prevent them from forming in the first place.
Nursing homes need adequate staffing to ensure that preventative measures are undertaken for patients who have difficulty moving around, including assisting in position changes, and with pillows, padding, and medicated ointments or creams. In addition, I have frequently reviewed cases where hospitalist care was essentially nonexistent in Houston-area nursing homes. This is an important factor, in that hospitalists are physicians who typically manage patient care and give orders to the nursing staff. Although nurses have an independent duty to perform their own assessments and treatments, some nurses often fail to do so without specific physician orders.
Similarly, the study found that SNFs frequently provided deficient care when it came to catheters, urinary tract infections, and bladder care.
The final problem on the top-cited deficiency list for skilled nursing home facilities is the failure to perform comprehensive assessments after a significant change in patient condition. This is a significant issue that compromises patient care. The Texas Board of Nursing requires nurses to follow what is called the “nursing process,” which involves continuously assessing and reassessing patients, and then planning their continued care.
I am currently working on a case where the nursing staff noted significant neurological changes in a patient who had recently undergone back surgery. The nurses dutifully wrote in his medical record that he was growing numb from the waist down and could not urinate. Unfortunately, they waited eight hours before notifying a physician of these findings. The nursing staff to delay is a substantial factor in why this man will never have feeling below his waist, or normal bowel or bladder function, for the rest of his life.
What you can do
Friends and clients frequently asked me for recommendation for a skilled nursing facility in the Houston area. Admittedly, I am not familiar with every single facility, but when I am asked to answer that question, I often think of how it is a choice of least of many evils, so to speak.
An increasing number of experts are recommending that patients think twice before going into a skilled nursing or rehabilitation facility. Some studies have shown that people actually recover more quickly at home, with support from in-home or outpatient therapy.
If you find yourself in a situation where you or a family member does require skilled nursing facility care, there are still some things that you can do to improve your odds for a safe stay.
First, make sure you have a complete and accurate list of all of your home medications. At the beginning of the admission, the nursing staff should do medication reconciliation. This will likely be provided to a hospitalist physician, who likely is unfamiliar with you, but will be ordering medications for your stay. Frequently, the hospital issues medication and other orders before even seeing a nursing home patient for the first time. Providing a comprehensive home medication list can help prevent dangerous drug-drug medication errors.
Second, stay alert. Look for the required daily posting of nursing staffing and hours. If nursing care seems lax or absent, ask to speak to the charge nurse.
Third, if someone cannot stay with you 24/7 during your stay, which is what I always recommend, then do encourage frequent visitors.
Finally, I also recommend that patients and family members keep a journal of illnesses, conditions, and healthcare issues encountered at the facility, as well as orders, test results, and conversations with doctors and nurses.
We are here to help
Painter Law Firm, in Houston, Texas, focuses its practice on medical malpractice cases involving hospitals, skilled nursing facilities, rehabilitation hospitals, physicians, and other healthcare providers. Call us at 281-580-8800, for a free consultation about your potential case.
Robert Painter is an experienced medical malpractice and wrongful death attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator and files lawsuits on behalf of patients and families against hospitals, nursing homes, rehabilitation facilities, and doctors.