Social Media Abuse In Long-Term Care: Sensitivity Needed

I am saddened by recent reports about social media abuse in nursing homes.  It is hard to fathom that people can be so insensitive.  How have we failed?

As leaders, have we instilled in the staff the importance of their work?  Have we made an effort to touch the hearts of those we hire?  We must do so, not just for the care and respect of the residents we serve but to assure those we lead that we are responsible for caring for another human being.  This is a person – a father, brother, mother, friend – just like those people in their own lives.

We must teach them to think with their hearts and to understand how this would feel if such abuses happened to someone they love.  And if we are lucky to live a long life, to consider how it would feel if they were the victim when they need care.

It is a wake- up call for all leaders in long-term care and serves as an opportunity to change the perspective of some of those we lead.

There are multiple processes for consideration to determine what outcomes you will have in your facility:

  • Do you hire anyone who walks in the door?   Do you ask why they want to work in your facility and do you determine their intent?   Do you get a sense that they care about older adults?   Are they willing to do whatever it takes to be a team member, and to work and respect others?
  • Are there expectations for performance that are clearly stated?  Do you have a discussion about the specific expectations for your facility?  Do you, in fact, hold them to those standards?  Do you hold yourself to those standards?
  • Is there an ongoing discussion about roles and responsibilities?  Do you meet with the staff on a routine basis?  Is there a means of planned, routine, communication and support for staff?
  • Is there a thorough orientation and education program?  Does your organization support continuous learning and growth for all staff?   Have you provided opportunities for ongoing education internally and externally?
  • What are you doing to care for your staff, as individuals?  Do they know and see that you care as well?  Actions speak louder than words, so do they see you supporting and caring for each resident as you expect them to do?
  • Do staff feel valued and are they being cared for and nurtured as well? Does staff have ways that they, too, can relieve stress and do you allow/teach them how to do so?
  • Do you emphasize the very important role staff play in another person’s life?

Yes, there is much for a leader and administrator to do on a daily basis which is overwhelming many days.  Yet one day it may be one of us in the hands of a staff person who has not been guided by a leader who values every person under their care as they would their own mother.   If we do not instill the importance of respect and dignity in those we lead, then we have done them and ourselves a disservice.


Pre-Admission Assessments Help To Help Eliminate Resident Discharge/Evictions

Resident discharge or “evictions,” is a complex issue, no doubt.  I write this without blaming any party – the point is to determine what we can do in the long-term care industry to decrease the occurrence.  I am encouraged by the many comments on my initial post as it means others care as well, no matter their perspective.  The report illustrating the increasing eviction events of residents in long-term care should raise concern and alarm, within and outside of the industry.

Though in my first post I addressed the importance of initial and ongoing staff training and support, another opportunity to decrease discharges is for the facility to assess potential admissions in advance, and determine their ability to provide the necessary care.   It requires taking the time to conduct a thorough in-person assessment prior to admission to the facility.  This is especially significant when the individual has memory loss.

While as the initial report and article states that the practice to evict or remove residents “allows a facility to admit more profitable residents who are less problematic and time-consuming,” we all know that census is a constant struggle and facilities feel a continuous pressure to “fill the beds.”

Facilities also face pressure from hospitals to “accept” residents quickly and feel that they have no control over who and when someone is admitted.  However, for many facilities that is not the case.     Many long-term care facilities choose to take the time to determine their ability to provide the necessary care and “manage” admissions.

Managing admissions is a choice and especially important for individuals with memory loss.   Gathering information i.e. “knowing the person” is significant for planning and providing care.   Facility admitting personnel need to secure all information from records, family and caregivers.   This individualized, person-centered information regarding the potential admission should be discussed with nursing and appropriate colleagues in advance to know whether or not the facility is able to provide the type and level of care that is required.  It is understandable that when a facility accepts residents blindly, uncertain that they can manage the care, that evictions will occur.

An in-person, pre-admission and personal assessment is invaluable.  It enables the facility and staff to prepare for the admission and create a plan for success.  It is an opportunity to determine important factors that impact outcomes.  Is the individual stable and ready for discharge?  What initiated the hospitalization and is it resolved?   How will you manage the transition?  What are the specific care needs?  Who are the best staff/people to work with that particular individual?  What will the initial strategy be for providing care – person before task?   What will the family need to do and what will they need to know upon admission and in the days to follow?

Following the visit the personal, medical, social history and caregiving information gathered must be communicated to staff – prior to admission or as soon as possible.  This critical information on the desk of the admissions department will not serve anyone – not the staff, resident or family.  Unless there is a system and consistent practice of communicating information about the resident to the direct care providers, collecting health information, personal history and care strategies is fruitless.  And if you expect staff have time to dig through an electronic health/medical record to find it, think again.

An in-person assessment of a potential resident does not have to take a great deal of time or need to be the responsibility of a single person, but simply a commitment on the part of the facility.  A personal assessment visit enhances the relationship with the family and resident.  Even hospitals, though pressuring to discharge as soon as possible, respect the decision to move carefully in order to decrease the possibility of a hospital readmission and as a means of enhancing resident and family care and satisfaction.

Can it be done?  Yes it can.  Despite the outside pressures, you control admissions, discharges, evictions and your reputation.  Determine internally what level of care you can manage at any given time.  While it will require a little additional time or in some cases saying no to some resident admissions, in the long run it will be better for the resident and family, your staff, liability, reputation, census, and financials.

Fourth of July and Other Holidays: A Celebration or Burden for Long-Term Care Leadership?

A long Fourth of July weekend is coming, a time for national celebrations, picnics, cookouts, and fun with family and friends.  As a long-term care leader, are you exited for the celebration, or are you overwhelmed with anxiety bracing for staff call-offs on another holiday?

Two recent scenarios lead me to believe that your attitude, actions and culture determine your ability to enjoy or dread holidays in long-term care.

The first scenario involved attending a leadership team meeting, where the leaders and managers were complaining about the number of staff who would probably call off for the holiday weekend.  Dreading the weekend, they were already mad at some of the staff with a history of such behavior – even though it was two weeks week before the holiday with no call-offs yet!

Members of the leadership team were discussing their own family plans and trying to sort out who on among them would be responsible for covering for employees who called off, and preparing a schedule of coverage for the entire long weekend.  It was not a particularly happy experience.

The second scenario was a leadership team who were planning a variety of fun events for the upcoming long holiday weekend.   Managers were volunteering to be responsible for various activities and food as well as times that they would be at the facility for the holiday – simply for fun – not as a requirement for staffing.   They showed no concern that the staff would call off.  The leadership and management team believed that the staff would be at work as scheduled to care for the residents, because they were dedicated to their colleagues and facility.  This team was laughing, happy and honestly trying to outdo one another in offering ideas of events to create the most fun events for both staff and residents.

Holidays can be enjoyable occasions for the residents and staff.  Plan a party, a cookout, get all staff engaged in decorating and determining what special foods should be prepared and offered.  Facility leadership, as well as managers need to be present at some point on holidays to encourage a “we are all in this together” attitude.  Lead by example.  Consider – as a staff member – if the leader and all of the management staff are always off on a holiday, what would be your level of commitment?  Why should the staff be the only ones to work holidays and why should it always be a burden to only the direct service staff?

Working some part of a holiday weekend is an opportunity for facility leadership – to be with residents and families in a festive environment, and as a chance to further relationships with residents, families and staff in a relaxed, fun atmosphere.   It demonstrates that the organization exists as one whole – equally supportive and responsible.  Believe me, employees will notice, and they will be grateful, for gestures such as this promote staff satisfaction and retention.

Happy Fourth of July to the leaders and to all staff in long-term care, no matter where you are.

The Sad Truth on Evictions in Long-Term Care

A report was released a few weeks ago regarding evictions in long-term care, and frankly I have been surprised by the lack of attention or comments on this issue.  The report sheds light on the increasing practice of resident discharge, or “eviction” of residents in nursing homes.  Increasingly, residents are being discharged to hospitals and then denied readmission to the facility from which they came.

While the articles mentions “nursing homes” in the title, discharge is, in fact an issue in all long-term care environments including assisted living.  Given that the rise of occurrence parallels the increase of assisted living facilities, it would be valuable to know the environments in which it occurs most frequently in an effort to decrease the numbers of such a traumatic event that affects the lives of many people.

This is a very complex issue, and can’t simply be described as a good or bad practice employed by good or bad organizations.  There are multiple factors involved, and too little information has been supplied by either side to determine solutions.  However, I am devastated by this increasing practice and believe there are ways we can all contribute to eliminating some of these unfortunate discharges.

Individuals with memory loss have specific needs and it can be anticipated that many will take more staff time.  We also know that their needs will change over time and even if their care is manageable initially their needs will change as the disease progresses and should be anticipated.

I would bet that most, if not all of the evictions are of residents with memory loss.

Two major factors influence the ability of a facility staff to provide quality care to persons with memory loss.

Individuals with memory loss have specific needs and it can be anticipated that many of these needs will take more staff time.  We also know that their needs will change over time, and even if their care is able to be managed initially, those needs will change as the disease progress and should be anticipated.

First, in my experience, turnover in most long-term care environments is high.  What defines high turnover?  Though a turnover rate of 40% is deemed “acceptable” for long-term care, even that rate is much too high in my opinion.  Quality memory care is impossible when there is high staff turnover.  Critical to person-centered memory care is consistent caregivers who come to know the resident, their history and what makes them tick.  It fosters the establishment of relationships with the resident and family, which is invaluable to providing care and satisfaction.

Staff in assisted living and skilled facilities are often not trained in the disease process and management of needs, frequently leaving them to fend for themselves.  Initial and ongoing staff training and support is critical, especially for memory care.  Training should include all staff, all departments and all shifts.  They will not learn everything they need to know in one training, lecture or computer training program.  There will always be new residents, and staff who have questions and need additional information, sharing of strategies and support of facility leadership.

For families, the decision to place a loved one in a facility – to turn over the care of someone they love – is one of the most difficult decisions they have ever made.  Families do not take this lightly.  Homes are dismantled, houses sold, personal items dispersed.  What are they to do after trusting you to care for their loved one and you can’t?

While this will not address all of the evictions, it may very well eliminate many sad and unfortunate discharges.

Wanted: Young, Passionate and Energetic Long Term Care Administrators

A highlight of the recent ACHCA 50th Annual Convention was the students in university programs and internships preparing to become long-term care administrators.

This industry will benefit from fresh, passionate, and energetic young people with new ideas, an optimistic perspective and the desire to make a difference in the lives of residents in long-term care.

Some of the students presented their research in poster sessions.  They were excited to discuss their work and talk about a future in long-term care.   As participants in educational offerings, they were eager to learn and had many questions.  Their enthusiasm was contagious!

One young lady I spoke with said that she has known that she wanted to be an administrator since she was a child.  What kind of passion and enthusiasm do you think she will bring to the industry?  I can’t wait to see what she creates.

Another young man had already secured a job as a nursing assistant/orderly so that he could understand the internal workings of an organization from all perspectives.  His willingness to experience what the staff do, what they think, and how they manage their work on a daily basis will be invaluable to him when, as an administrator, he has to make decisions as the leader.

Health administration programs need to promote the benefits of becoming a long-term care administrator.  Yes, there are many challenges but the desire to positively influence the lives of older adults is a blessing.  More programs are needed as well as faculty who encourage entrance in the field, communicate the benefits of becoming a long-term care administrator and engage students in clinical experiences that are positive and rewarding.

Nearly every one of us will need such services currently about 70% of all adults spend at least some time in long term care.   If someday I need to be admitted to a long-term care environment, may I be lucky enough to be in a facility that is led by one of these great young people.

First Antipsychotics, Now Antianxiety and Hypnotics: Can your Staff Manage Without?

Nursing facilities have been successful in reducing the number of antipsychotics in the past few years, even exceeding the CMS goal. The monitoring of antianxiety and hypnotic medications, while once a discussion, is now a reality, as CMS announced last week that they will now be monitoring antianxiety and hypnotics. While there is not a specific goal for reduction, CMS has added the utilization of these drugs to the list as the 5th new, quality measure for the consumer-based Nursing Home Compare.

Now one has to wonder, why? Does CMS believe that these medications are substitutes for the decrease in antipsychotics? Are they?

All of these medications have a place in long-term care when properly used, monitored and discontinued, and they are not meant to be used for the remainder of a person’s life.

However, the use of these medications for some can be life changing and truly impact a resident’s quality of life. When someone is anxious and confused with no recognizable source to relieve their discomfort, using medication seems more humane.

The concern is that these medications are used on too many residents, particularly those with dementia when their confusion and behaviors become unruly or disruptive. A dementia diagnosis does not justify use in all residents. In many settings, both nursing facilities and assisted living, I have seen these medications used repeatedly for the convenience of staff who lack education and knowledge about the disease, or who simply don’t want to deal with a resident’s behavior. Unfortunately medication use versus education in many environments has been an acceptable practice. Never a good solution.

When consulting with facilities to create or enhance person-centered memory care programs we find that staff want to understand the disease, want to improve their ability to manage care, and desire systems and processes that give them the personal information and strategies necessary to provide effective care.

The choice: medications and regulatory penalties, or education and an organizational strategy for memory care. It’s up to you.


How To Fail at Everything in Life

While I recently wrote about choosing to be a “complainer” in your work or choosing to be proactive, I simply have to share with you some wisdom passed along to me from an 18 year old man.  Why an 18 year old would pay attention to something like this is beyond me, but I guess it shows what an exceptional young man he is.

It was an inspiration to me and hopefully to others.  I regret that I do not know the author, but I believe sharing it with others in this day and age just seems to be necessary.

3 Ways to Fail at Everything in Life:

  1. Blame all of your problems on others
  2. Complain about everything
  3. Not be grateful

I have now posted this in my office so that I can see it every day when working at my desk, along with some other reminders that life is short and special – and that we always have a choice.



Your Choice: Complain or be Proactive

Healthcare, and especially long-term care, can be a rather difficult place to work these days.  Leaders have been inundated with multiple changes and new regulations, including requirements for additional electronic connectivity and software, while at the same time dealing with declining reimbursement.  In addition, goals and mandates exist for new transitional care and “partnerships” with hospitals, ACO’s and managed care – organizations not considered their “best friends” in the past.

Recently, I have attended conferences and forums that have been rather depressing.  Honestly, at one point I did not think I could stand one more person complaining about things that I and they could not change.   So I sought out other people who may not be happy with the changes but were not going “to the dark side.”  They were consciously accepting reality and seeking information, education, assistance from consultants and experts, and trying to figure out the best way to deal with the changes and still provide quality care.

There is no doubt it is stressful industry these days and there is work to do.  But every leader has a choice.  They can continue to sit around, bury their heads in the sand and complain about things they cannot change, or they can choose to be proactive.  Learn, listen, seek out experts to help and pursue solutions.  I choose the latter.

Millennials in the Workforce: Designing Programs to Meet the Needs of all Employees

Millennials currently make up about one third of the workforce.  While the perceptions about this group are not always positive – referred to as the “me” generation, “entitled” and “noncommittal,” – their real needs and desires in the workplace are not all that out of line with other generations of healthcare workers.  In essence, providing what millennials want in their work is simply to me “best practice” to provide for all employees by any leader or organization.

Lindsey Pollack delivered a fascinating talk at the Independent Owners Leadership Conference where she presented facts and historical events of each of five generations that impacted their subsequent beliefs and behaviors in the workplace.  According to Pollack, millennials essentially care about three things in the workplace.  They desire personal development in jobs, like a variety of work, and want to make an impact by finding work that matters where they “give” to others.   But is that unlike any other generation who seek a positive work environment?

While in my own personal leadership experience, it was anticipated that millennials would pose a certain challenge and that it might be necessary to establish specific programs to meet the needs of millennials – we found we never needed to do so.  Seemingly, much of what we had already planned and created for all staff happened to be what the millennials desired as well.  We created programs to address all staff needs, from 18 to 65.  However, for the purpose of this blog, I’ll outline some of those that were particularly beneficial for millennials.

Three major points were emphasized for millennials in the workplace:  Personal development, variety and making an impact.


  • Personal development and the “experience” of work
    • We cared about them as individuals
    • They were prepared for their role – provided a thorough orientation
    • Created a  “learning environment” and provided ongoing educational programs
    • Welcomed every new employee – an expectation of all staff
    • Provided recognition for their growth – peer-to-peer and management
    • Created an open door policy
    • Expected management to teach and coach –  “education before discipline”
    • Offered training, career building opportunities, tuition


  • Variety
    • We were open to new ways of doing things – listened
    • Encouraged and enabled managers with opportunities to try new things
    • Made staff part of the decision-making team – encouraged input – asked them
    • Allowed for involvement in organizations/events outside of the facility


  • Impact – Give Meaning and A Calling
    • Routinely discussed the importance and impact of their work
    • Used stories to demonstrate the impact of their work on the lives of those they touched – residents, families, visitors, community
    • Created a vision – a shared vision – that emphasized “being the best” – and we were

It turns out that millennials want what many people want in their work, regardless of the generation in which they grew up.  Decades of staff satisfaction research indicates the same.  Provide it and not only will the millennials be more satisfied and stay, so will all other staff.



CEO of AHCA/NCAL Advises Employee Satisfaction Critical to Survival

The Honorable Mark Parkinson, President and CEO of AHCA/NCAL knows the importance of staff satisfaction and retention.  During a recent address at the Independent Owner Leadership Conference in San Diego, Parkinson emphasized the importance of enhancing staff satisfaction and retention as a means of staying in business.  He urged owners to focus on an organizational plan to improve staff satisfaction and rid their facilities of any agency utilization.  With the ongoing and pending changes in long-term care regulation and reimbursement, staff stability will be critical to survival.

Parkinson and his team made staff satisfaction in his own organization a priority, focusing on creating a mission based program, and were able to decrease their turnover to less than 20% and increase employee satisfaction to over 90%.  This data echoes the outcomes I shared in my session, “Customer Satisfaction – It is Hurting or Helping Your Business?”  Creating a customer satisfaction program is dependent on staff satisfaction and engagement.  Essential for customer satisfaction is staff providing the “product,” a level of “service” that customer’s desire and long-term care is expected to provide.

High turnover in a facility makes it nearly impossible to create a culture of caring, and thus establish the customer relationships desired.  Turnover destroys the staff ownership and loyalty necessary to satisfy customers or anyone associated with the organization.  In addition, high turnover makes achieving positive results with AHCA/NCAL quality goals or Five Star hopeless, and destroys the possibility of being considered a viable partner in the ever-evolving ACO and managed care world.  As one geriatrician once told me, “The first and most important question I ask in evaluating a long-term care partner is: “What is your staff turnover?”

Programs, processes and systems designed to improve staff satisfaction and engagement must be in place and include a service orientation, shared vision, respect and appreciation, preparation for the work and ongoing education, communication, inclusion and recognition/celebration with even small accomplishments.  Organizational models do exist and can be implemented in any long-term care environment; once implemented it must be monitored and evaluated for their effect/success.

Sustainability is key.  Staff is sick and tired of single initiatives or “programs” that die whenever someone is too busy, the state comes in, is seen to be financially unpopular, or the novelty wears off.   Our research shows that when initiatives come and go staff is more dissatisfied, skeptical and mistrusting than they were before such programs were initiated.

Can you change staff turnover?  Yes, we know you can – we have done it and so has an industry leader and one of your own – Mark Parkinson.  Evaluate your status, build it and stay with it.  Monitor/assess progress regularly and improve as appropriate.  The staff will come, and the staff will then stay.