Built to Fail - How the Nursing Home Business

Model Causes Injuries and Deaths to Residents

Pam: So Barry, from your perspective, why are nursing home abuse and neglect cases important cases to take on?

Barry: The important thing to understand about nursing home abuse and neglect cases is that most often, these aren't accidents that happen in a flash moment in time. What I mean by that is this. Let's assume that you're in a rear-end car accident. You're driving down the road, and you take your eyes off the road to tune the radio, and next thing you know the car ahead of you is stopped and you're unable to stop in time. It's an accident that happens in a flash moment in time, just like that.

Now, with nursing home abuse and neglect cases, what we often find is that things have been going wrong for days or weeks, if not months, before the actual incident takes place that really is the subject of what we're looking at.

Many times when families come in, they're blaming themselves for what happened. They're saying to themselves if I'd taken them out of that nursing home, if I had said something to the staff, if I'd done something differently, this wouldn't have happened.

What we find so often is that things have been going wrong for days or weeks, if not months, before this. The seeds of failure had been planted long in advance of whatever it was that brings the family into my office. So what you're really seeing in these cases are the results of systemic failures. These are things that are really kind of baked right into the nursing home business model.

Why these cases are important to take on is not just for the families themselves, but for the families of people who are still in the nursing home, because the way that the nursing home is doing business tends to actually cause and create the conditions that result in these kinds of accidents and injuries.

Pam: So, I know you have a free report available for download on the resource center of the show's website, fightingforwhatsright.com, which is actually called built to fail. It addresses why you actually have so many accidents and injuries involving nursing home residents. Why do you think that's the case?

Barry: Nursing homes are one of the few sectors in the healthcare industry that are really explicitly for-profit. The administrator for the nursing home is the person who is at least nominally in charge of the nursing home, and most often that's a person who really has a business background. When you're talking about a for-profit business, how you calculate a profit, at bottom, is pretty simple. You take your revenue, you subtract your expenses, and that's your profit.

Now, with nursing homes, the way that they get their revenue on the revenue side is capped, a lot of the times. It's based on how many residents are there in the nursing home, the get paid per patient per day. There are relatively few opportunities for adding revenue on.

The thing that's sort of insidious about the whole process is that the more beds are really occupied by people who are really, truly sick, and have high medical needs, those are the bed that get paid the highest reimbursement rates. So, on the revenue side, they're trying to maximize that by filling as many beds as they can with as many really sick people as they can.

Pam: Okay, so how does all of that get reflected in the kind of care residents receive?

Barry: On the expense side, the biggest item of expense is the staff. To minimize the expense, you're going, then, to want to staff the nursing home with as few people as possible. Now, the state issues a set of regulations through the Illinois department of public health, which sets a formula for how many nurses, how many CNAs you have to have on duty, given the number of patients you have.

The federal regulations has a more flexible standard, but a more demanding one at the same time, and that is you have to have enough staff on hand to meet the needs of the residents on a 24/7 basis. Where that comes back and is reflected in patient care is this. Most nurses and CNAs in a nursing home setting are relatively low paid. Most CNAs are doing the really heavy lifting work, they're changing diapers, they're transporting people, they're feeding them. A lot of CNAs get paid $12 or $13 an hour for doing this really tough, very demanding kind of work.

So you end up with a situation where you have staff that have some fairly extensive demands put on them, they're not very well paid, and you end up with a lot of turnover, and you end up with a lot of work that's not being done. Turnover in particular is something that is really a negative in the nursing home setting, because a lot of the care that gets delivered in nursing homes is a matter of routine. A lot of it is quote/unquote knowing your residents. When you have a lot of staff turnover, that institutional memory of what is this patient's normal is lost when somebody leaves.

So, you have a situation where the staff is stretched to its outer limits, and the nurses who are on staff don't get a chance to give really good, critical thought to the care needs of the residents. You end up with a situation where residents who are in decline, and residents who have different care needs, don't have those needs being met. This is true, especially, in for-profit facilities. There are non for-profit facilities of course, the situation isn't quite as acute there, but all nursing homes are run in relatively the same fashion, and you end up having those problems present in non for-profit facilities, maybe just not quite to the same degree that you see in for-profit facilities.

When things go wrong in a nursing home setting, things have often been going wrong for weeks if not months before that, and the staff has been dodging bullets all along. Relying on good luck isn't a substitute for good care.

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