Model Standards for Skilled Nursing Homes

By Benjamin E. Ruark

Introduction

Nursing homes are not unique when it comes to bandying the word quality around in their self-promotion literature. More likely than not, they’ll be found sorely wanting in how to epitomize such a claim. The model presented herein admittedly constitutes a “respectable draft” only, since I’m no longer a training and management consultant; regardless, it sets out standards that push toward service excellence and focusing on the best interests of customers: the residents who’ve chosen a nursing facility to be their 24/7 care-based home for their remaining time in this world.

The model does not include specific standards referring to administrative offices, dining hall service, grievance handling, parking lots and facility grounds, physical therapy operation, resident care plans, and scheduled activities for resident entertainment and exercise. Nonetheless, it puts forth 15 distinct categories, listed alphabetically.

1. Expectations for new hires & temporary contract personnel

o Cover the following points in a frank and sober discussion before any new/temporary staff person begins work:

• Professional conduct
• Major roles performed
• A statement of what constitutes unacceptable conduct
• A statement describing how misconduct will be handled
• The requirement to seek guidance from their supervisor on any incident posing uncertainty
• Their top priority, which is to think and act in each resident’s best interests—preferably as residents explicitly express them
• The need to resist the temptation to perform routine actions reflexively—not to view the facility as human warehousing and their job as a daily grind, but to retain their full attention to detail and optimize actions taken according to each resident’s needs

2. Expectations for visiting student nurses

o Visiting student nurses should be assigned assistance tasks, as needed, and take direction from permanent staff in whichever units are visited.

o They should interact with residents on a work-related basis only.

o They should avoid huddling, conversing socially, and making a distraction around residents in public areas such as commons and dayrooms.

o Prepare beforehand to give every student nurse both learning and service opportunities, rather than allowing them to stand idly by.

3. Facility safety, security, and maintenance

o Institute, at minimum, instructions for:

• Handling resident threats made about other residents
• Setting/resetting exit alarms
• Respectfully handling resident attempts to leave premises
• Unvarying hours on facility lockup and opening for business
• Handling troublesome situations instigated by visitors (include identified examples for practice drills)

o Adopt a comprehensive inspection and planned maintenance schedule of:

• Operability of heaters, overhead lights, and toilets (and water pressure)—facilitywide (rather than waiting for malfunctions to occur)
• Hot water volume in restrooms and shower rooms
• Operability of public-area lighting and TVs
• Cleanliness, function, and appearance of furniture
• Various body-lifting/transporting equipment—cleaned, lubricated as needed, and tested for functionality
• Operability of devices in residents’ rooms: remote controls, TVs, table lamps, and HVAC units (and thermostats)

4. Housekeeping

o Resident rooms: Avoid any cleaning that conflicts with a resident’s need for private time or aggravates their health condition. When otherwise deemed appropriate, sweep, mop, and empty wastebaskets daily, cleaning any dried spills and other floor stains. Periodically clean the inside windows.

o Public/resident restrooms: Thoroughly sweep and mop, along with emptying wastebaskets and replacing linings. Clean and disinfect outside toilet, toilet bowl, washbasin and counter, and mirror. Replenish room deodorizer and toilet paper on wall units, with a surplus roll set on toilet tanks. (In resident restrooms, especially, perform closer inspection of floor to ensure all “matter” has been scraped and swept away, then mop with bleach or other regulation-adherent additive to fight infection. Perform this same practice from floor to head level on interior walls and doors. Rather than strict utilitarianism and hospital drab, resident restrooms should have a home-like appearance.)

o Public areas: Periodically, lightly shampoo and/or disinfect chairs, sofas, picture frames, mirrors, windows, foot stools, benches, tables, TVs, computer stations, and bookcases.

o Shower rooms: Preferably, each shower room should be gone over by a night crew who perform floor-to-ceiling cleaning with a disinfectant soaping and rinsing. When this is done, the sinks, floor, and fixtures should be sparkling clean, giving an impressively orderly appearance for the start of the next day.

5. Individual resident vulnerability monitoring

o A resident’s BBPP proneness monitoring plan should be posted next to their care plan in clear, concise language. BBPP stands for biological, behavioral, physical, or psychological tendencies or vulnerabilities. Just as elderly people are susceptible to injurious falls, and still others are susceptible if certain foods are included in their diet, nursing home residents can be susceptible to gastrointestinal issues, headaches, nervous tics, etc. caused by factors such as stress.

o Thus, each resident’s specific vulnerabilities need to be identified, recorded, and memorized, then monitored daily for early onset as well as prevention through preemptive actions. For example, if a resident has severe back problems, staff should lift any of the resident’s items that exceed 5 pounds, make their bed, and retrieve items from floor level to prevent the resident from stooping low and minimize the risk of back injury.

6. Medication dispensing & administration

o Nurses and med techs will dispense all medications in accordance with the physician, PA, or nurse practitioner’s prescriptions.

o Nurse and med techs will double-check that they have the correct medication name and the correct dose for the time period stipulated.

o Nurses and med techs will repeat the name of each medication being administered and its dose to all cognitively functioning residents, and inquire whether the resident agrees on the medication names/doses and/or the number of items being handed over. This approach allows residents to disagree in the event they receive some medications that are only taken “as needed.” It’s doubly important that such distinctions are also made clear at resident intake. (Note: If oral medication requires a glass of water, use either tap or cool water—not ice-chilled, which can induce throat constriction.)

o Follow protocol for IV administrations and needle injections.

o All resident requests to increase, or terminate use of, a medication will be thoroughly explored and referred to higher authority. Resident requests to decrease a medication will also be explored before being granted. If the reason(s) given are not sound, the matter will be referred to the charge nurse or possibly also a facility social worker.

7. Overall facility appearance & setting

o All commons and dayrooms: Maintain casual, comfortable décor with stain-free carpeting, pleasant fragrances, color-coordinated settings, adequate activity tables and coffee/end tables, and nicely appointed wall hangings. Selected furniture should rest high and firm enough for elderly to rise without risk of falling. Rooms should be spacious enough to accommodate parked walkers and for wheelchair-bound persons to move about freely. TV/radio volumes should be low enough for residents and visitors to converse and socialize.

o Dining halls: Apply a standard spacing arrangement for wheelchair-bound diners and chairs for those entering by foot, with space to park walkers. The décor should be cafeteria style and spotless, and the space should be brightly but not excessively lit. Wall sanitizers should be mounted at all resident entry/exit points. Soft music should be playing; this music should be unobtrusive, not played to entertain service personnel.

o Equipment: Store large pieces of equipment in less-traveled hallways, at least 18 inches away from doorways for resident safety.

o Hallways: Air fresheners should routinely deodorize resident hallways with a semi-tropical scent (most widely accepted) whose chemicals are non-allergenic. (The customary condition of offensive odors emanating along hallways—often taken as an inescapable fact—is no longer acceptable, just as it would not be in residents’ former homes.) This can be done through piping, exterior nozzles and timing, or remotely triggered wall mounts (appearing as sconce-like ornaments). PA system announcements should be short, reserved for business purposes, and discontinued after 8 p.m. Staff should make it standard practice to talk in low tones in hallways—not competing with noise within residents’ rooms. Every room should be furnished with noise-canceling wireless earphones. With many rooms’ doors left partway open for peek-in monitoring by passing staff, residents whose hearing is still intact will no longer be subjected to loud noise emanating from adjacent rooms in the event that residents (e.g., those suffering from dementia) resist use of earphones.

o Shower rooms: Use high-quality (non-leaking) hoses and spray nozzles. The heating and cooling apparatus installed should have plenty of capacity to perform given the size of the room itself. An overhead warming light outside the shower stall is recommended. Washable bench seats should be sturdy, weight-bearing, and roomy enough to hold a person and toiletries. Wall hooks should be well placed for hanging clothes, gowns, towels, etc. Adequate-size shelves should be located at the sink, along with outlets for personal appliances and grooming devices. Ceiling-hung curtains should skirt both the toilet and the shower stall. Non-skid footpads should be fastened inside the shower stall for added safety.

8. Resident call-light requests

o Aides will learn the personal preferences of all residents with regard to lids with spouts positioned on water bottles for drinking, and on condiments, medical containers, etc., to alleviate residents with arthritic and weak hands from readjusting them based on handedness.

o For all other requests, aides will ask residents’ preferences for optimizing any task with an intent to provide a best way of performing it, such that its configuration or outcome is optimal for each resident (requiring listening skills and analytical thinking skills).

o For incoherent residents, aides will have been tutored to interpret residents’ likely requirements for most optimally performed tasks and then follow through with such actions, witnessing anticipated results as positive confirmation.

o Aides will respond to call lights within 12 minutes from their signal 85% of the time (allowing for coded assistance interruptions, etc.). All promised actions made to residents—including implied follow-up actions—will be handled within one-half to one full business day.

9. Resident information handovers at shift change

o Staff will adhere to the SBAR or I-PASS method of conveying individual pertinent resident information to their counterparts at shift change. This handoff will include any resident requests that are set to take place during the next shift.

10. Resident in-room meal service

o All staff involved in meal tray delivery will work out an efficient system that moves trays to resident rooms at the fastest pace feasible. (This minimizes lukewarm resident meals and protracted hunger; contract food services, for example, may supply a skeletal staff who deliver food carts consecutively on one unit/ward at a time.)

o Tray servers will quickly inspect trays to ensure a complete silverware and napkin set is present, adequate condiments are provided, and the items on the tray match the preferred drink(s)/meal for each resident (on food ticket).

o Tray servers will tactfully explain to any residents wishing to chat, etc. that meal delivery fills an urgent need and that other requests will be handled after meal delivery is completed.

11. Residents’ quarterly satisfaction survey

o The satisfaction survey’s purpose is to routinely assess for levels of effectiveness across key facets of healthcare services, not to gather glowing ratings. It should identify specific weaknesses, omissions/neglects, and possible indications of where performance is slipping from its former level. Data gleaned from the quarterly assessment is then used to install organizational improvement interventions such as refresher training, peer coaching, supervisory spot checks, or job aids. As many as 18 to 24 categories of assessed service might be useful.

12. Residents requiring morning wake-up assistance

o Residents not requiring assistance are offered the option of being woken up at a pre-specified time.

o Residents requiring assistance will be courteously coaxed to start their day, given physical assistance as needed, and assisted with cleaning up and getting dressed. Incoherent residents are scheduled for earlier wake-up based on their likely need for extended assistance.

13. Residents requiring special handling—location & monitoring

o Cognitively “animated” residents suffering dementia (and emitting various loud, incoherent vocalizations, etc.) are to be contiguously sequestered in nooks/alcoves ideally located adjacent to nurses’ medication carts. Residents with special needs are thus prudently clustered together for closer monitoring; in addition, since these needs tend to correlate with louder noise levels, sequestering the residents helps avoid stress within the general population due to excess noise.

14. Residents requiring toileting assistance—daytime & overnight

o Aides are to modulate voice level based on each resident’s hearing capability. An air vent will be turned on as well to minimize the chance of toileting conversations being heard by third parties who share the same restroom.

o Late evening/overnight toileting assistance should be held to whispers, or at least done with a restroom vent turned on. Avoid waking sleeping residents within close proximity.

o After assisting with toileting and returning an assisted resident to their quarters, the restroom is made relatively sterile—not just given an appearance of cleanliness. All affected surfaces are thoroughly cleaned with approved cleaners.

15. Staff demeanor around & communication with residents

o All frontline staff will comport themselves as caring, compassionate, and empathetic professionals; supervisors will coach staff a minimum of one or two times per week (depending on individual staff skill levels) on exemplary demonstration of actual service examples indicative of one, two, or all three of these attributes.

o Presumptive of residents’ dignity and integrity, every resident will be shown respect, without exception—regardless of their current behavior. Staff will not adopt a surly attitude or use patronizing or condescending language like “dearie,” “honey,” “sweetie,” “sugar,” etc. (as is apparently still prevalent in rural locales).

o Residents will be given advance notice of planned procedures and other actions they’re targeted to receive, to be in effect in 95% of occasions. A staff person about to perform some task/procedure will explain to the resident why it is needed, in language the resident is able to comprehend. With cognitively impaired residents, staff will offer simpler explanations and resort to approved, tactful methods to achieve the task at hand.

Final words

Many of the italicized phrases found herein denote quality standards; a few of them denote quantity and timeliness standards. Performing all of them with consistency is indicative of another service standard: reliability. Staff competence is another critical area of focus—their requisite knowledge, technical ability, and soft skills (such as communication, listening, and interpersonal skills) need to be of the highest caliber. It is recommended that skilled nursing homes budget for training workshops on soft skills, which generally are the most lacking. Supervision and top management both need to set impressive standards for being accessible (by phone and in person) and responsive. This translates into satisfying resident requests of all kinds and taking follow-up action in a manner that matches the customer service standard of other industries.

Benjamin E. Ruark is a former learning and development and continuous quality improvement professional. He now devotes his time to writing on important subjects for various industries, healthcare included.