1. Conant, Sandra M. MSN, RN, CAS

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In the years following my time as director of nursing in a nursing home that valued high-quality care for residents, I assumed that all nursing homes placed such a high value on care. I have since become a legal nurse consultant, and after reviewing numerous complaints of neglect and abuse, I now see a different picture. After learning about cases of infected pressure ulcers extending to the bone, a case of leg burns caused by prolonged exposure to a radiator after a resident fell out of bed, and even a death caused by exposure after a patient wandered from a facility, my eyes have been opened to the horrors occurring in some nursing homes and assisted living facilities. How can the nurses employed at these facilities not speak out about what is happening?


According to the National Nursing Home Survey, of roughly 1.5 million full-time staff employed in nursing homes in the United States in 1999, 143,000 were RNs, 200,000 were LPNs, and 618,000 were nursing assistants and orderlies. In that same year, the U.S. Administration on Aging reported that the number of complaints against nursing homes was more than 172,000 nationwide. The most common complaints included the failure to prevent pressure ulcers, malnutrition, dehydration, or infections; inadequate or inaccurate resident assessments; and inadequate plans of care. And in the July 8, 2003, issue of the Boston Globe, Associated Press reporter Laura Meckler wrote that the reason residents of nursing homes are "not receiving needed services" is that there are "not enough staff to provide adequate care" and that the staff who are available are often "without appropriate credentials or training." The problem is that facilities employ too few RNs and LPNs and too many unlicensed personnel, known as certified nursing assistants (CNAs).



FIGURE. Its the duty... - Click to enlarge in new windowFIGURE. It's the duty of nurses to be vigilant about quality control.

The least educated providers constitute the largest proportion of the workforce in long-term care facilities. Although requirements vary, the training for LPNs lasts approximately 10 months; CNA training can be completed in as little as 40 hours. Even though CNAs are the primary caregivers in long-term care facilities, they're not trained in assessment and should not be responsible for delivering the specialized care some residents require. RNs are trained to perform physical assessment, not just functional health assessment, as LPNs are. There is a vast difference between asking someone about his bowel habits and examining him to determine whether there's a blockage.


The position of CNA was created in response to the shortage of nurses, and after reviewing court cases I see that CNAs are often asked to perform tasks outside the scope of their skills and training-tasks that only licensed nurses should be performing. Nursing home workers are asked to do things they're not trained to do and then blamed for their lack of knowledge. A review of medical records shows that while LPNs may document what they've seen, in an overwhelming majority of cases they don't follow up or respond according to treatment plans or contact physicians so that treatment can be delivered in a timely manner. This is what happens when facilities caring for frail residents are understaffed.


Ultimately, it's the dearth of nurses that's overwhelming the nursing home industry. Accurate and timely input from the entire staff regarding a resident's changing health status ensures a prompt response from nurses on each shift. It's the duty of administrators and directors of nursing to determine whether they have enough nurses on staff to assess patients and intervene as problems arise. And it's the duty of nurses to be vigilant about quality control. If residents at risk aren't identified, how can prompt treatment be provided?