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6 Nursing Home Environment and Resident Safety
Pages 303-356

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From page 303...
... . Omissions of care, also referred to as missed care, are a key patient safety issue in nursing homes (Ball and 303
From page 304...
... . This chapter discusses some of the more common safety-related areas of focus in nursing homes including improving medication safety, resident falls, preventing elder abuse, improving communication during transitions of care, enhancing infection control, and strengthening emergency planning, preparedness and response.
From page 305...
... Efforts to improve medication safety involve regular, formal pharmacist reviews of medications combined with an enhanced integration of the pharmacist with the interdisciplinary care team. One review found that the introduction of pharmacists into nursing homes contributed positively to reducing the number of drugs taken by nursing home residents (Lee et al., 2019)
From page 306...
... . Antipsychotic Medications A serious patient safety and quality issue in nursing homes is the use of antipsychotic medications.
From page 307...
... system (discussed in Chapter 9) that is highly integrated with medication prescribing and administration processes, for example, could enable nursing homes to run automated comparisons of MDS survey data and pharmacy data (part of Medicare Part D claims)
From page 308...
... . Falls are very common occurrences in nursing homes due to the high prevalence of gait, balance, and muscle strength problems among residents (Chang et al., 2010)
From page 309...
... . Preventing Elder Abuse in the Nursing Home Setting Despite these protections enshrined in federal legislation, elder abuse in nursing homes continues to represent a serious threat to residents' safety and quality of life.
From page 310...
... . Physical restraints, the use of which had previously been common in nursing homes, were allowed only under very narrow circumstances, and strict requirements were established limiting the amount of time that residents could be restrained.11 OBRA 87 also expanded the rights of nursing home residents to communicate with regulators and specified that residents have access to a state long-term care ombudsman.12 As emphasized throughout this report, many nursing home residents have physical or mental impairments, and their dependency on others for care amplifies their vulnerability to abuse (Braaten and Malmedal, 2017; Lindbloom et al., 2007)
From page 311...
... . Scope of Abuse in Nursing Homes Abuse in the nursing home setting could take a variety of forms, including physical neglect and depriving residents of their dignity (e.g., not changing their dirty clothes)
From page 312...
... Now this CNA is not allowed on my unit at all." -- 78-year-old nursing home resident, MA This quote was collected from the committee's online call for resident, family, and nursing home staff perspectives. Staff are not the only perpetrators of abuse in nursing homes.
From page 313...
... . Oversight of Elder Abuse in Nursing Homes Federal, state, and local agencies as well as individual nursing homes all have a role to play in oversight and investigation of elder abuse in nursing homes.
From page 314...
... Non-immediate jeopardy low requires investigation during the next survey. Federal law requires nursing CMS policy requires state survey agencies to notify law homes to establish policies for enforcement of substantiated findings of elder abuse ensuring that law enforcement that occur in nursing homes.
From page 315...
... . OIG's analysis revealed significant failures within each step of the process, showing that nursing homes had failed to report many instances of abuse or neglect to the state survey agencies and that several survey agencies had failed to report abuse to local law enforcement.
From page 316...
... , includes an alert icon to help potential residents and their families gain a better understanding of the quality of care provided by specific nursing homes, including citations for resident abuse.16 Preventing Elder Abuse Elder abuse in general, and particularly in the nursing home setting, is not well understood or recognized. Research on elder abuse in nursing homes is still in its early stages, particularly compared with other forms of interpersonal violence (Lindbloom et al., 2007; Myhre et al., 2020; Yon et al., 2019)
From page 317...
... have been proposed as effective approaches to reduce elder abuse in nursing homes. Characterized by the core elements of staff empowerment, consistent staff assignment, resident-directed care and activities, decentralized decision making, and the creation of home-like living environments, culture change is viewed as an effective approach for promoting the safety of residents (Berridge et al., 2019)
From page 318...
... These range from high-quality research to identify the most effective prevention strategies to staff training and education about effective clinical interventions, the implementation of the culture change model for nursing homes, and creating public awareness of the problem of elder abuse more broadly. Care Transitions Many nursing home residents have multiple, complex medical conditions and require transitions between the nursing home and the hospital.
From page 319...
... Infection Control A major patient safety concern in nursing homes is infections, with nearly 2 million infections occurring in nursing homes each year (Mody et al., 2015; Montoya et al., 2016; Strausbaugh and Joseph, 2000)
From page 320...
... Nursing homes have increasingly been identified as high-risk settings for the transmission of infectious diseases, and this was confirmed by the devastating impact of the pandemic. The extremely high mortality levels among nursing home residents and staff during the early phases of the public health emergency underscored the extent to which the lack of robust infection prevention and control programs rendered nursing homes extremely vulnerable in the face of a highly transmissible novel pathogen (Andersen et al., 2021)
From page 321...
... . 20 Federal strike teams deployed nationally to assist nursing homes with significant COVID-19 outbreaks consisted of infection prevention specialists, epidemiologists, Public Health Service officers from CDC, CMS, and the Office of the Assistant Secretary of Health, while local and state public health officials joined when available.
From page 322...
... . Another study also found more than one in five nursing homes reported severe PPE shortages of less than a 1-week supply in July 2020 (McGarry et al., 2020)
From page 323...
... . Lockdown of Facilities as Infection Control Response In an effort to protect residents and staff, in March 2020, CMS directed nursing homes to severely limit or not allow any visitation from family members and loved ones, with a significant impact on residents in the form of social isolation and loneliness (discussed in Chapters 2 and 8)
From page 324...
... require long-term care facilities to maintain a comprehensive emergency preparedness program, based on a thorough risk assessment, with written policies and procedures in place specific to their population.24 Additionally, regulations expanded emergency plan requirements to consider items such as sewage disposal, supplies, emergency lighting, and evacuation procedures with a resident/staff tracking system, and more.25 Beyond having such written plans in place, nursing home staff need to review and audit the plans on a regular basis to ensure that the plans are robust, that nursing home staff can locate supplies, and that there is accurate documentation of participation in emergency management planning discussions and exercises. Frequent life-threatening events ranging from the COVID-19 pandemic to weather-related disasters such as hurricanes, tornadoes, floods, and wildfires clearly underscore the urgent need for nursing homes to plan and prepare for a broad range of public health emergencies.
From page 325...
... . Including Nursing Homes in Federal Emergency Preparedness and Response The Federal Emergency Management Agency (FEMA)
From page 326...
... . ESF 8 includes specific considerations related to public health and medical services in the context of federal emergency support, and it provides a mechanism for the coordination of federal assistance to support state, tribal, and local officials in response to a disaster, emergency, or incident that may lead to a public health, medical, behavioral, or human service emergency (FEMA, 2016a)
From page 327...
... and the importance of providing PFA to nursing home residents in the aftermath of an emergency, as discussed above. The devastating impact of COVID-19 on nursing home staff and residents described above demonstrates the urgent need to explicitly ensure that long-term care settings such as nursing homes are included in the broad range of emergency planning, preparedness, and response activities for health care settings similar to what is done for acute-care settings.
From page 328...
... Nursing home planning and preparedness efforts therefore need to be closely coordinated with those of public health departments, health and social care organizations, and other health care facilities and emergency services. In this way, an integrated network of care among hospitals, nursing homes, and local and state community services can be established to ensure that nursing home residents' health care needs can be met during emergencies (Harnett et al., 2020)
From page 329...
... Therefore, support for positive sensory perception and minimization of unpleasant sensory experiences are critical elements of quality nursing home environments, as summarized in Table 6-2 below. Building Layout Many nursing homes were developed using design features adapted from hospitals constructed in the 1960s and 1970s (Eijkelenboom et al., 2017; Schwarz, 1997)
From page 330...
... Sound Most nursing home residents have some degree of hearing loss, including aging-related changes that impair speech discrimination and increase sensitivity to background noise. Noise is common in many nursing homes, due to environmental factors such as poor sound absorbency of surfaces; loud sounds generated by staff communication, meal service, housekeeping, and maintenance; resident vocalization; electronic systems such as televisions, radios, and computers; and alarms.
From page 331...
... Moreover, there is a greater interest in filtration systems that can capture and eliminate aerosolized viral particles from circulation. The need to care for residents with active, airborne/droplet infections such as COVID-19 in the nursing home setting has raised the possibility of mandating that nursing homes have some negative pressure rooms, with separate systems to ventilate air outdoors to the facility roof.
From page 332...
... For nursing homes located in areas where the weather presents a barrier to outdoor activities, interior designs should include windows, not only to ensure a sufficient amount of natural light, but also to enable residents to experience the outdoors visually. Given the important association between access to the outdoors and residents' health, the thoughtful design of outdoor space is an important element of nursing home planning, construction, and use (van den Berg et al., 2019)
From page 333...
... . Private Rooms and Bathrooms Having one's own private bedroom and bathroom is important for addressing nursing home residents' needs such as privacy, dignity, relationship considerations (e.g., family visitation)
From page 334...
... . On the other hand, a limited number of nursing home residents will prefer to share a bedroom, for example, with a spouse, partner, or close friend.
From page 335...
... . Innovative Physical Design of Nursing Homes This chapter has discussed key safety and environmental aspects that influence nursing home quality of care and which have a direct impact on residents' quality of life.
From page 336...
... • Establish a national forum to share best practices on how to best use physical space • Establish a commission to identify long-term priorities and funding to re design nursing homes (separate wings for cohorting, separate entrances and exits, separate bathrooms and break areas, etc.)
From page 337...
... Interest in reconfiguring large, institution-like traditional nursing homes as smaller, more home-like settings is not new; innovative approaches such as the Eden Alternative31 and the Green House Project32 have been around for more than 25 years in this country. As discussed in Chapter 4, creating a more home-like atmosphere is a key element of the culture change movement in nursing homes.
From page 338...
... They applied the Eden Alterna tive philosophy, had many design features that made for a home-like atmosphere." -- Daughter and caregiver of two parents with dementia who needed nursing home care This quote was collected from the committee's online call for resident, family, and nursing home staff perspectives. Another example of an alternate approach to traditional nursing home care that has been in place for nearly 20 years is TigerPlace.
From page 339...
... . Despite the positive impact they have on a range of resident health outcome measures and the enhanced quality of life they provide, Green Houses represent less than 2 percent of all nursing homes and provide care to less than 1 percent of all nursing home residents.
From page 340...
... The median mortality rate in Green Houses was 24 for every 100 COVID-19 cases, as compared with 80 per 100 cases in small traditional homes and 53 per 100 cases in large traditional nursing homes. The lower rates of COVID-19 cases and mortality among Green House residents were likely due to residents having private rooms and to the fact that fewer people live and work in Green Houses than in traditional nursing homes (Zimmerman et al., 2021)
From page 341...
... Because of the dual role of nursing homes as care settings as well as places to live, nursing homes must balance resident safety with resident autonomy and quality of life. • Even before the pandemic, infection control issues were the most common reason for citation deficiencies by nursing home surveyors.
From page 342...
... nursing homes with COVID-19 cases. Journal of the American Geriatrics Society 68(8)
From page 343...
... 2018. Does Nursing Home Compare reflect patient safety in nursing homes?
From page 344...
... 2018. The physical environment of nursing homes for people with dementia: Tradi tional nursing homes, small-scale living facilities, and green care farms.
From page 345...
... 2011. Medication errors during patient transitions into nursing homes: Characteristics and association with patient harm.
From page 346...
... 2019b. Elder abuse: Federal requirements for oversight in nursing homes and assisted living facilities differ.
From page 347...
... 2015. Sexual abuse of older residents in nursing homes: A focus group interview of nursing home staff.
From page 348...
... 2007. Resident outcomes in small-house nursing homes: A longitudinal evaluation of the initial Green House pro gram.
From page 349...
... 2008. Effects of Green House nursing homes on residents' families.
From page 350...
... 2021. Effectiveness of a multicomponent intervention to reduce multidrug-resistant organisms in nursing homes: A cluster randomized clinical trial.
From page 351...
... 2021. CMS could improve the data it uses to monitor antipsychotic drugs in nursing homes.
From page 352...
... 2006. Radical redesign of nursing homes: Applying the Green House concept in Tupelo, Mississippi.
From page 353...
... 2002. The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH)
From page 354...
... 2007b. Effect of specialized bathing systems on resident cleanliness and water quality in nursing homes: A randomized controlled trial.
From page 355...
... 2015. Characteristics and effectiveness of fall prevention programs in nursing homes: A systematic review and meta-analysis of randomized controlled trials.
From page 356...
... 2020. Family satisfaction: Differences between nursing homes and residential care facilities.


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