Most of our focus on nursing home care focuses on the care provided by a nursing home to its patients (or residents as the nursing homes call them). It is important to peel back the hierarchy of those who actually provide care and take a look at some of the issues facing these individuals.
Nursing homes, for the most part, are corporate entities, meaning they are owned and operated for the purpose of making a profit. Some nursing homes are locally owned, but more often than not we are seeing nursing homes that are owned by out-of-state entities. More significant, perhaps, there are multiple entities that own or operate different aspects of the nursing homes. For example, there will be a company that owns the building; a separate company that employs the staff at the nursing home; another company that manages the money that comes in; etc.
At the top of this corporate set up, quite often, is a holding company that owns similar companies in various states and by various, but related entity, names. It is not unusual in depositions that a nurse or an administrator will be asked who their technical employer is and oftentimes they do not really know the name of the company that actually employs them. It’s more disconcerting when administrators are asked about related corporate entities and who owns and operates what aspect of the nursing homes, and many claim they do not know.
With this as a background, the top of the hierarchy begins with a corporate body (or bodies) that oversee and manage the actual business. Locally, a regional manager may be responsible for ensuring that a number of nursing homes in a region (or state) are complying with the corporate mandates, which in some instances means cutting costs and maximizing profit.
At the nursing home itself, the top-level manager is referred to as an administrator, who will have varying backgrounds of training. For example, a recent administrator testified that her training and background was as a dietician, and she worked her way up through the ranks to become the head of the nursing home. Most administrators have a nursing and/or a management background.
The administrator oversees the various departments within a nursing home, which would include administration, nursing, therapy, social services, dietary, housekeeping, maintenance, and the like. The administration department is typically a patient or a patient’s family member’s first exposure to a nursing home. The administration department (or business office) has the new patient or his/her family member to sign the admission documents and will assist with obtaining Medicare, Medicaid, and insurance payment benefits.
The nursing department is the one most involved in terms of patient care where issues arise. The nursing department is typically headed up by a Director of Nursing (DON), an Assistant Director of Nursing (ADON), floor or wing registered nurses (RNs), charge nurses, and floor nurses (RNs and LPNs). Also included in this group are Certified Nursing Assistants (CNAs). The RNs and LPNs are required to do the hands-on nursing care, which includes assessments, providing medications, and evaluating the patient on admission and throughout his or her stay. Often a wound care nurse will also provide care for bedsores or ulcers that may develop during a patient’s stay at a nursing home. The CNAs bathe patients, change diapers or bedding, take patients to the bathroom, and help with transferring the patient from the bed to wheelchairs and the like.
Most nursing homes will also have a therapy department. The primary therapists at nursing homes are physical therapists, occupational therapists and speech therapists. Quite often, the therapists are not employees of the nursing home; instead, they operate under a separate corporate structure and perform services pursuant to a contract with the nursing home. Patients and their family members almost never know this significant fact, but it is important in the care process because the therapists are usually not subject to the same rules and policies that apply to the other employees of the nursing home.
The other departments, such as dietary, housekeeping and maintenance are rarely involved in the cases our lawyers investigate and pursue. Occasionally, a dietary issue will arise and on the rarest occasion other issues may arise (such as whether the property was maintained appropriately and/or created hazards), but these incidents are the exception rather than the rule.
Fortunately there are some nursing homes that hire quality individuals who have their patients’ best interests at heart. But unfortunately that is not always the case. Many nursing homes have problems staffing their facilities with quality people at all levels. This could be the result of poor pay, inadequate benefits, or a subpart corporate culture that does not place value on its employees. Of note, OSHA reports that nursing homes workers are among the top to report injuries and illnesses, and the nursing home employees are among the most to have “lost workday injury and illness (LWDII) rates.” The average LWDII is 1.8 for private industry, while this number is as high as 4.9 for nursing homes.
CNAs, who do most of the lifting and moving of patients, were among the highest in the nation to report musculoskeletal disorders (such as back injuries). In 2010, for example, the national average for these types of injuries was 34 per 10,000 workers. Among CNAs (and similar-level employees), this rate was 249 for 10,000 workers, or more than seven times the national average!
What all of the above means is that in nursing homes lots of employees are calling in sick or injured. The natural result is that nursing homes may be understaffed – staff may have to work overtime or extra shifts, and the risk of injury to residents without a doubt increases exponentially.
This corporate structure and the corporate history are important for people to understand when choosing a nursing home. Occasionally, we will hear of rampant issues of abuse or neglect in a particular nursing home. Who owns that nursing home? What other nursing homes do they own? Is the problem a corporate-wide problem or is it isolated to that one home? These are questions we should all ask before we agree to have our loved ones admitted to a nursing home for short-term or long-term care and treatment. If you need more information on nursing home litigation, contact Ben Locklar, a lawyer in our Personal Injury & Products Liability Section, who handles nursing home litigation, at 800-898-2034 or by email at Ben.Locklar@beasleyallen.com.
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