Nursing Home Ombudsman Speaks Up for Residents' Rights
Sondra Everhart used to be a surveyor -- inspecting nursing homes and investigating complaints -- for the New Mexico Department of Health. In 2006, she moved on to become the state's long-term care ombudsman.
New Mexico has about 12,000 residents living in assisted-living and long-term care facilities, including 72 nursing homes. The ombudsman program comprises an 11-member staff and 100-plus certified volunteers who visit facilities on a regular basis to ensure advocacy services are available to residents and families. Everhart visits many of the nursing homes personally, crisscrossing through this frontier state to meet with residents, family members, administrators and workers. On a leadership level, she meets with government officials and deals with concerns such as new policies that may violate resident rights.
Everhart talked with U.S. News about her work and why she changed roles. Here are edited excerpts from the conversation:
What's the difference between an inspector and ombudsman?
Surveyors have to be certified by the Centers for Medicare and Medicaid Services. They are looking at whether a facility is in compliance with federal regulations. For example, does the smoke alarm system work? Has the medication not reached its expiration date?
Every state has an ombudsman, as part of the Older Americans Act, which is now being reauthorized in Congress. Ombudsmen work for the residents. Our job is to resolve your issues, your complaints.
Inspectors want to know if the call-light system works. Family and ombudsmen want to know if somebody answers the call light when the resident pushes it. They're both designed to make residents safe. But they look at it just a little bit differently.
A nursing home inspector would go in and make sure the food was stored properly, had the appropriate date on it and wasn't expired. The ombudsman and family want to know: Are there food choices? If they're from Pennsylvania Dutch country, do they get Dutch and German food?
What are a few things you look at regarding staff?
Facilities have to have in-service staff so many hours a year on a series of topics, like preventing dehydration. The inspectors will make sure the records show that staff has been in-serviced. Are the staff members wearing name tags? Are they speaking in a language that you understand? If you're in a nursing home, and everybody that works there speaks Vietnamese, you're not going to be able to communicate.
Out here in the Southwest, we have a number of residents that are Native American -- they're Navajo. Some of them can't communicate comfortably in English. And in the nursing home, we need to provide a Navajo translator and somebody that can speak to their native cultural needs and wishes.
What safety issues do you check in the kitchen?
The CMS surveyors will check the equipment to make sure it's clean. They check water temperature to make sure it's hot enough. The freezer to make sure it's cold enough. They will check that the food is warm and served appropriately. Individuals with certain clinical conditions have a high risk of choking when swallowing certain kinds of food products, and the doctor will order mechanically soft or puréed diets. And the inspectors will make sure that they're getting the food served the way they need to eat it.
Is resident abuse a problem?
In nursing homes, abuse is not as much a problem as neglect. For example, if I give you a pitcher of ice-cold water, but I put it across the room so you can't reach it, that is neglect. If you push your call light because you have to go to the bathroom, and I say, 'Oh, just go in your diaper; I'll get you in an hour,' that's neglectful behavior. The biggest fear in nursing homes is retaliation. That's a real phenomenon. If you rely on me to feed you, shower you, dress you and take you to the bathroom -- and you make me angry -- your pain pill might just be an hour late.
There are many very good staff members who care a lot about the safety and comfort of residents. But every once in a while, you get one with a chip on their shoulder.
The regulators will ask people, "Do you feel comfortable?" "Do you feel safe?" "Are you being treated roughly?" They have a series of questions they ask to make sure people feel safe in their own home.
What about staffing ratios?
Under the current regulations, you have to have enough -- "enough" is the important word -- enough staff to provide quality care. If you're a surveyor, you go in and look if there has been what they call a "negative outcome," [such as] "I've fallen" or "I have a pressure ulcer" or "My shoulder's dislocated." If I go to the hospital because I'm dehydrated, that's a negative outcome. All those are preventable. So inspectors look at the negative outcome and backtrack to [determining that] "not enough staff" was the cause.
Do you go through patients' medical records?
As a surveyor, yes. You look to make sure the doctors' orders are being followed; whether that means to start a medication or stop it. You want to make sure therapies that are ordered -- physical, speech, et cetera -- are happening on a regular basis.
Are you looking at people being chemically restrained?
In some situations, antipsychotic medications are used to blunt or control resident behaviors. Antipsychotic medication is designed for use with a diagnosis of psychosis, not as a means to dull a resident's consciousness to reduce behaviors that staff members think is inappropriate or bothersome. Following research and data collection, CMS initiated a national movement to reduce the unnecessary use of antipsychotic medication.
There is a document in the [resident] medical record which lists each medication, the amount, when you take it and why you take it. If you're constipated and you take medication, the reason you're taking it will list "constipation." By the same token, if I'm taking an antipsychotic, the diagnosis should be "psychosis."
What are you looking at in rooms?
This is their home. We're looking to see that there are not full bed rails. If they want rails for security, repositioning or mobility, they can use half or quarter rails. If the resident has a history of falling out of bed, we would look to make sure they have a bed low to the floor and a mat on the floor to prevent falling-out-of-bed injuries.
We make sure the privacy curtain between the beds is working to benefit both residents. Make sure the bathroom is clean and accessible. And if residents have clean clothes. It's amazing how many pieces of clothing can get lost in a nursing home in a day.
What was the most telling thing you learned about nursing homes, as a surveyor?
I learned I wanted to be an ombudsman.
As a surveyor, you're looking at how they're out of compliance. As an ombudsman, I can help them fix it. I can give opinions. I can say, "Here's what the resident wants." As a surveyor, you can't do that. They have very strict [boundaries] of communication. As an ombudsman, I can go in and fix something before somebody gets hurt. The surveyors will tell you after something has happened.
What are some of the big complaints you deal with?
The biggest one we're dealing with during this economy is discharge. We get phone calls: "They're telling me they're discharging my mother tomorrow." Well, they can't discharge your mother tomorrow. There are some very specific guidelines about discharge from a nursing home.
The ombudsman might hear so many complaints: "I'm thirsty all the time; I can't reach my water." We can fix that in about 30 seconds. We go to the staff and say, "Excuse me. Mr. Garcia is very thirsty, and it appears he can't reach his water. Would you go in and fix that right now, please?"
Residents have you on their side.
You might or might not be surprised at the number of times a discharge meeting is planned, and guess who's not there? The resident. Well, how would you like it if six people and your sister and brother got together to talk about the rest of your life, and you weren't involved?
So we will say, "Excuse me, where is Mrs. Smith?" "Oh well, we don't want to bother her." "Bother her? This is her life. I think maybe we'll ask her."
Do they usually say yes?
Of course. Some do say, "No, I'm too tired; let my daughter handle it." That's fine. But that's giving the resident the respect to make the decision. Just because people are old and have wrinkles doesn't mean they can't think or speak. You just need to ask them.
Lisa Esposito is a Patient Advice reporter at U.S. News. You can follow her on Twitter, connect with her on LinkedIn or email her at lesposito@usnews.com.
