Nursing Home Standard of Care Expert Article

In this article, the health care experts discuss nursing home neglect. The purpose of this article is to define neglect and its key components, explain the responsibility for a facility to investigate neglect once it has been reported, and to provide insight on how these investigations are approached from a forensic standpoint.

Investigating Nursing Home Neglect

Neglect is defined as a caregiver’s failure to provide or meet a person’s basic needs such as food, clothing, shelter, proper hygiene, and medical care. Failing to ensure these needs are being met, increases a person’s risk for infections, illness, deterioration, and compromised safety.¹ Neglect is often associated with a care giver, but can also refer to self-neglect. Self-neglect is when a person is unable or unwilling to provide or maintain care for themselves.² Facility based programs have a responsibility to ensure an appropriate level of care is provided to their residents, which includes providing interventions for individuals who can no longer care for themselves. In the broadest terms, it is the responsibility of the facility to provide the care or assistance to ensure that an individual’s basic needs are being met.

Under federal regulations §483.15 Quality of Life, “A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.” ³

A facility has an important role in maintaining the health, well-being, and safety of its residents. This is done through ensuring a person is receiving adequate food to meet their nutritional needs, assisting and providing appropriate clothing, providing a safe environment in which to live, ensuring consistent and reasonable hygiene, and providing or coordinating medical care.

Food

A person may have limited ability to make appropriate decisions related to the types of food required to support their nutritional needs, have difficulty chewing or swallowing, or lack the ability to feed his/her self. When this occurs, they will require assistance from a caregiver and dietician to assure they are getting proper nutrition. Proper nutrition is important in maintaining a person’s physical and mental health.

Long term care facilities are required under federal regulation §483.35 Dietary Services, to “provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident.” The facility is also required to provide residents with assistance in eating, special eating utensils and adaptive equipment in order to best meet their needs. ⁴

Warning signs that a person is not receiving proper food and nutrition may include unusual and unplanned weight loss, dehydration, falls, pressure ulcers, sudden change in mental status, and uncontrolled diabetes.

Clothing

A person residing in a long term care facility may have difficultly moving, stretching, bending and twisting. They may also have difficulty choosing or obtaining their clothing. The person may need to be provided with items such as adaptive clothing. Adaptive clothing can enhance the person’s ability to self-dress and decrease the possibility of injury by making clothing easier to manage.

Under federal regulation 483.15(a) Dignity (interpretative guidelines), the facility should encourage and assist “residents to dress in their own clothes appropriate to the time of day and individual preferences.”⁵ A person residing in a facility should have seasonally and environmentally appropriate clothing. Their clothing should not have labels that are visible externally.

Warning signs that a person is not receiving proper assistance with their clothing may include wearing clothing that is tattered, soiled, ill fitting, or inappropriate for the climate or season. The person should not remain in night clothing or hospital gowns for the convenience of the caregiver.

Shelter

Persons not having or being provided appropriate shelter can lead to serious health risks and increases their risk for harm. Some health risks include infections, acute illness, chronic illness, and death.

Long term care facilities are required under federal regulation §483.70 Physical Environment to maintain an appropriate physical environment for residents. These requirements include meeting Life Safety Codes and providing rooms that are “designed and equipped for adequate nursing care, comfort, and privacy of residents.” They must also “provide a safe, functional, sanitary, and comfortable environment for the residents.” ⁶

Warning signs a facility may not be maintaining a proper environment are resident rooms and common areas being unclean, residents complaining showers are cold, and clutter throughout the facility.

Hygiene

Poor hygiene of a person may be an indicator of a more serious issue. They may have underlying medical issues such as Alzheimer/dementia, physical disability or medical ailments preventing them from maintaining good hygiene. A lack of proper hygiene may not only lead to medical issues but could also decrease a person’s feelings of self-respect, pride, and self-worth.

Under federal regulation §483.20 Resident Assessment, when a person’s care needs change due to either behavioral or medical changes, the facility is required to assess and implement appropriate care interventions to best meet the needs of the resident.⁷ Those persons residing within a facility should receive the necessary care to maintain appropriate grooming and hygiene.

Warning signs that a facility may not be providing proper hygiene assistance includes a person having one of more of the following conditions: foul body odor, greasy or dirty appearance, unkempt hair, dirty and ragged clothing, tooth loss and decay, frequent infections, and pressure ulcers.

Medical Care

Providing the person with appropriate medical care is essential in assisting them to maintain a good quality of life. The most minor of health issues can quickly become serious if left untreated.

Residents of long term care facilities have the right under federal regulation §483.40 Physician Services to have access and be seen by a physician. The regulation states, “The resident must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter and the facility must provide or arrange for the provision of physician services 24 hours a day, in case of an emergency.”⁸ Medical care that may be offered includes physician services, dental care, ophthalmology, mental health, and specialty medical care.

Warning signs that facility is not providing appropriate medical care and follow-up can include issues such as non-age related deterioration of health, frequent hospitalizations, and unexplained and unplanned weight loss, frequent infections, pressure ulcers, and depression.

Internal Investigations of Neglect Allegations

Under federal regulation §483.13 Resident Behavior and Facility Practices, a facility must have evidence that all allegations are thoroughly investigated, and the results of the investigation must be reported to the administrator and to other officials in accordance with State law within five working days of the incident.⁹ A facility may be alerted to a possible problem or suspicion of neglect by a variety of sources; the direct care givers, ancillary staff, family, friends, visitors, or through direct observation of their residents. Once there has been an allegation of neglect, an internal investigation is initiated immediately. An investigation is a process through which the facility gathers facts related to the incident.

Investigations may take different forms depending upon the circumstances of the case but typically, begins with a review of the reported incident. During the fact gathering process, the person(s) conducting the investigation may want to review the staffing records to identify the staff assigned to the resident and ancillary staff in the facility during the time frame. They may want to engage in a process of interviewing and obtaining written statements from any staff that had possible contact with the resident, ancillary staff on duty, the alleged victim, possible witnesses, or the person making the report. A full review of the alleged victim’s medical record should be conducted. Once all facts have been gathered, the data is analyzed and evaluated. At the conclusion of the investigation, the facility will determine if the evidence supports the allegation of neglect.

Forensic Health Care Investigations

The health care experts at Robson Forensic can address the adequacy of care provided in hospitals, nursing homes, and other acute, rehabilitation, long term, outpatient or residential health care facilities. The scope of our investigations will frequently involve an evaluation of administrative policies and procedures, the level of care provided by health care professionals, a review of hiring practices, or the maintenance and custodial practices of care facilities. The forensic investigation will also include determining if there was an internal investigation conducted, if it was timely, appropriate, and thorough.

Submit an inquiry to determine which of our experts is best qualified to assist in your case.