Good Case Study About Rights Provided To The Residents In Long-Term Care Facilities
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Introduction – case background
Patient safety and patient centered care is the basis of today’s nursing practice. In this present case, a residential patient of dementia at an intermediate level, aging about 80 suffered a fall in her care home with multiple injuries on her face and subdural hematoma and died consequently.
The patient is mentally capable of self-preservation, fully alert with clear speech and has hemiparesis of right side. She was bound to wheelchair but can move her left leg a little and her left arm fully. The patient, considered by the nursing home has much risks of falling.
On that particular day, the patient had taken outside in the sun according to her wish, left on her own by the certified nursing assistant. The nursing assistant was busy smoking and attending her cell phone for a personal call during her duty hours. The wheel chair placed carelessly by her on a side walk with its back to a 3 feet gentle slope followed by a curb and the parking lot. To attend her call she left the patient’s side and move away to another place from where the patient, not visualized. After few minutes, a visitor came to see the old woman and found her fallen head on the concrete of the parking lot, few feet away from the toppled wheel chair, sliding down the three feet slope from where she was kept with facial contusion and without consciousness.
After reporting of the incident a registered nurse came to attend her and taken her to the bed and attended to see her vital conditions where she came to consciousness. She was later sent to the emergency room of the hospital where the patient dies a few days later. The incident, reported to the director of nursing by the visitor, and found that the director already knew about this type of mal practices are regular feature of certified nurse assistants. The incident, narrated on behalf of the nursing home blames that the patient was responsible for the accident. The patient herself has pushed the wheel chair backward and met with the accident.
Residents living in long-term care facilities have certain rights assured to them under Federal and State law. The facility is to provide a resident in exercising his or her basic rights including those persons who faces barriers, like communication problems, hearing problems and cognition limitations in exercising their basic rights . If a resident is incompetent to affirm these rights, he or she must also exercise them according to their degree of capability. Exercising rights ensures the residents to have independence and choice, how they wish to live their daily life and receive care subjected under the rules of the facility and as long as they do not infringe a regulatory requirement. The facility must support or encourage patient participation in meeting goals of care plans. Proper attention to the remarks of both the resident and the staff are essential that stands for purposeful intentions to restrict autonomy or choice of the resident and ensure effective system to prevent negligence and abuse of the residents. In case of a mentally retarded resident, a surrogate or a representative appointed, who has the right in decision-making.
Ensuring a surrogate does not alleviate a facility of its responsibility to protect and uphold the interests of the patient. Information regarding total health status implemented in a language, which is understandable by the resident and enhances further communication with the staff, both written and oral communications is necessary. This also implements if the staff members respond in a respected manner to the resident who have cognitive impairments . They are to ascertain what the residents are trying to express or saying or try to address what the residents are trying to express behind their behavior. The facilities are to create such environments that are respectful, and help the resident to exercise her or his right of autonomy.
In the present scenario, the resident being an elderly and suffering from dementia requires more care and attention from the caregivers. Here the patient is responsive, alert and can communicate clearly makes her more communicable with the staff. Though she has limitations in her movements, she can easily express her desires in her choice of movement. The administrative authority or the nurse director can ensure a surrogate or representative in her care plan or decision-making or in her ambulatory activities since there is limitations in her cognitive capability. This definitely does not ease the duty of the care staffs or nursing assistants that are looking after the patient. Leaving alone a dementia patient is not only risky but is a punishable offence from federal viewpoint.
It is a natural tendency for a dementia patient to exist or escape from a residential care setting to return to his or her home setting or to meet her children as she used to do in her young age. From this viewpoint, the nurse assistant must allow her behavior or her choice of going outside by keeping on her side or supervising her . The facility is responsible in evaluating the specific needs and choices of each resident and accommodates the resident to that extent which does not endanger the health and safety of the resident.
Overall wrong doing observed
According to the researcher, the overall wrong done by the certified nurse assistant, since she has taken the patient outside without giving her company or keeping her under supervision. In this context, the director of nursing is also responsible to some extent, since she has not taken proper disciplinary actions against these certified nurse assistance regarding negligence on their behalf in their duties. Since the patient here is alert and responsive she could use some calling facilities for the resident whenever she needs or could have use some physical restraints that could have restrict the patient from the risks of falling as was used in case of dementia patients who are at high risks.
The staff has to interact with the resident in such manners that takes into account the physical limitations and psychological limitations of the resident. In some cases, the staff can use larger or colorful buttons usually pressed by fists instead of fingers in calling for assistance. In long-term care facilities as in this case, there needs some constant activities in accordance with and depended upon an individual resident’s all-inclusive assessment.
These assessments help in developing wide-ranging care plan and the activities should go with the skills, capabilities, needs and choices and the physical social and cultural environments. In case of patients having cognitive impairment, as in this case, everyday tasks need simplification and segmentation, programs must use retained long-term memory instead of short-term memory, settings that generates previous experiences and duration of activities depending on concentration span.
Quality of care
This ensures that the facility must endow with each of the residents in essential care and services to obtain and sustain the highest possible, physical, mental and psychosomatic well-being in accordance with the all-inclusive evaluation and plan of care. All these needs to assess the facility’s observance with basic requirements of the services recognized in the care plan, based on a wide-ranging and perfect functional evaluation of the resident’s strengths, limitations, risk factors for worsening and potential for development that are recurrently updated by nursing staff and other care providers. The administrative department or the director of nursing has to play an active role in this context. They must observe whether the staffs are implementing the care plan over time and in different shifts and follow up if there is any deviation in the care plan.
All these require interviews with the resident or the representative; to be aware of the current condition, participation in the care plan and how effectual are the interventions and if not whether any other different approaches are given. This also requires interview of the nursing staff in different shifts. Their knowledge about the particular interventions for the residents includes specific guidelines and protocols of the facility. It also includes whether the nursing assistants know when and to whom to report in emergency conditions or if there is any deviation in patient’s condition. The management must also know the nurses are supervising the implementations of care plans and any deviation in conditions and assessing factors whether the staffs are placing the residents in probable risks.
All these ensures in evaluating and monitoring of resident’s response to preventive efforts and treatments . These also implements whether care provided by qualified staffs and are they able to execute the care plans adequately. All these require trained nursing staff in sufficient numbers and services for 24 hours of a day and recognizing whether the nurse aides show competency in the delivery of care.
Wrong committed by staff
In this present case, the administration or the nursing directors have failed in monitoring the quality of care. They are also unaware of the care plans implemented in care. The staffs provided are inefficient, lacks proper training, less in number so that there is absence of registered nurses in caring of high risk patients as that of elderly dementia patients throughout the day. Not only were they unaware but ignorant about practices of quality care to dementia patient. These nurse aides also failed in implementing rules and regulations of the nursing home and the management though aware of these facts fail to take disciplinary actions against these staffs. These nursing aides are not only ignorant but also inhuman in their delivery of care.
The nurse aide did not have the minimum common sense in understanding the consequences of keeping a wheel chair in front of a sloping area. The management was so ignorant that they failed to give a true and proper explanation regarding the cause of death of the elderly dementia patient. Not only were they ignorant but also very careless in handling and assessing their conditions . They were also ignorant about who to refer in case of emergency conditions like the one identified in the present case. They also lack in proper training of attending these high risks patients in case of falls or accidents. The nursing aide had obtained assistance from a visitor of the patient in lifting her to bed.
Violating rules and regulations
In this context, the nursing home has certain rules and regulations. All the staffs are supposed to abide by the rules and regulations laid by the nursing home administration. The rules includes that the employees while doing resident care duties shall carry no cell phones. The employees are to use cell phones only during a formal break. Smoking for employees prohibited; they can smoke on the grounds outside while on break. In this context, the nurse attended totally failed in following the rules of the nursing home. Firstly she smoked though outside but while attending the elderly dementia patient during her duty hours. She also carried a cell phone with her while doing resident care duties. She also attended a personal call while on care duty leaving such a high-risk patient alone and even ignorant about the area where she left her in a wheel chair.
She was totally ignorant or failed to take notice of the sloping ground behind the wheel chair, and what consequences will happen if the wheel if the wheel chair topples on the ground by any chance. She also did not have proper training in caring for an elderly dementia patient who is at high risks. She also did not know the risks of leaving a dementia patient all alone, and what type of behavioral changes may develop in the patient. She did not even care to respect the rules of the nursing home.
Nursing services and relevance
According to the federal law in nursing services, the facility must have adequate nursing staff to offer and related services to achieve and uphold the highest possible physical, psychological, and psychosocial well-being of each resident as recognized by resident evaluations and individual plans of care .
The facility must provide all types of nursing personnel on a 24-hour basis to ensure nursing care. These include licensed nursing staff, registered nurses, certified nurse assistants, licensed practical nurses, nursing home administrators, and nursing directors. The facility can authorize a registered nurse to serve as administrator of nursing on full time basis. The administrator of nursing has to serve up as a charge nurse only if the facility has usual daily habitation of about 60 residents. The essential requirement governs licensed nurses on a 24-hour basis, skilled nursing facility for more than 40- hours a week.
The facility also requires locating areas especially rural and supplying skilled nurses to meet the demands of the residents. There must be proper nurse staffing information provided by the facility; these are facility name, current date, total numbers and actual working hours of licensed and unlicensed nursing staff for resident care shifts. The facility must keep the posted daily nursing staff data at least for 18 months abided by the Federal or State law, and there must be public access to posted nurse staffing data.
In this case, the facility has failed in keeping the Federal and the State law by means of poor staffing, unskilled nursing staff without proper training, devoid of skilled nursing staff on 24-hour basis. They also fail to maintain their own rules and regulations provided by the nursing home. They have even engaged ignorant, unaware, unskilled, negligent nurses who are in habit of mal-practices during their residential care duty hours. There also require rehabilitative services for mentally ill patients, or who are mentally impaired included in the resident’s comprehensive care plan. The facility must provide a safe environment within its premises, so that there cannot be any physical harm or any injury or accident to a resident.
The facility, governed in such manners that make possible to use resources successfully and competently to attain or uphold the highest feasible physical psychological and psychosocial well-being of each occupant. There should be obedience with the Federal, State and local laws, policies and codes with customary professional values and principles that apply to experts giving services in such facilities . In addition to these regulations other governing laws includes nondiscrimination based on social group, race, color, national origin or on basis of handicap or mentally retarded residents. The facility should have a governing body or nominated persons operating as a governing body who is legally accountable for setting up and implementing policies concerning management and functioning of the of the facility. All nursing aides working in the facility must complete the teaching and capability evaluation program accepted by the state. Before allowing, any nurse aide to work the facility looks into registry authentication and the person has met proficiency evaluation requirements and able to display skills and techniques in caring for the needs of the resident. If a hospice care implemented in long-term care facility, it is through an agreement meeting the professional standards. If there are any emergency, clinical complications or death in long-term care, facility reported immediately to hospice, screening or evaluation of all mentally ill patients who apply to or exist in Medicaid certified nursing facilities are necessary irrespective of their source of payment for the nursing services.
The present nursing home fails to provide the necessary standards applicable in administrative services as per the regulations of Federal, State and local laws. They are carrying out their resident care with unskilled or unprofessional persons who fail to meet the required standards. In this context, the administration is primarily responsible for the cause of death of the elderly dementia patient. The governing body is legally accountable for setting up and implementing policies concerning management and functioning of the facility. As per ethics and regulations the nurse director fails to abide by the regulations and unsuccessful against taking any disciplinary actions against the staffs if the rules and regulations are violated. They also do not looks into registry authentication and whether the person has met proficiency evaluation requirements and able to display skills and techniques in caring for the needs of the residents.
Federal Certificate regulatory breached
Any nurse, who is unable to meet the standards of care, runs risks, found negligent involved in mal practice subjects to legal actions against them. Most of the cases against nurses arise from claims by patient that the standard of care breached, and it results in harm to the patient. Negligence on the part of the health care professional is chargeable with legal actions, where nurses are accountable in failing to protect a patient. The nurse is accountable for the quality of care given to the clients. They are to be knowledgeable of safe practice and to meet the standards of care. Here the nurse is a failure in providing a standard care, punishable under federal law .
All the above discussions show that practicing standards of quality care is the basis of today’s nursing practice. An action or mal practice or negligence that leads to potential harm to a patient is always punishable under federal law. These laws have guided all health care professionals in their code of conduct. These are preservation of the rights of the patient, proper assessment, maintaining a care plan, safe nursing practice, proper communication with patient and family, no discrimination in practice, shared decision-making and other practices for the sake of the patient, and improving the quality of care especially in long-term care facilities.
Haugen, D. and Musser, S. Health care. Farmington Hills, MI: Greenhaven Press, 2012.
Hennessy, C. “Model Before Measurement.” CFR 2.1 (2012): 193-215.
Reiss, D. “The Promise and Pitfalls of the Federal Health Care Reform Law for Nonprofit Health Care Organizations and the People They Serve.” Inquiry 47.4 (2010): 278-284.
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