A Description of Board and Care Facilities, Operators, and Residents. 3.7 Quality of Care


3.7.1 Facility Measures

The environmental surroundings of long-term care residents enhances or detracts considerably from the quality of care and life for residents. We defined several quality measures to characterize different aspects of the facility’s physical surroundings. These measures included scores that summarized the prevalence of safety features, assistive and supportive devices, social and recreational aids, and physical amenities. To create the structural measures, we combined varying numbers of elements (ranging from 4 to 21) and then calculated a percentage score for the number of factors present. A description of these results follows.

Facilities scored the lowest on components contributing to facility safety. The average facility safety score was 58 percent, indictating that about one-third of the safety features measured were absent from the average facility. Facilities scored higher on the prevalence of assistive and supportive devices and social and recreational aids, with average scores of 65 and 69 percent, respectively (Exhibit 3-16). Average scores of 72 and 74 percent on measures of physical attractiveness and evnvironmental diversity indicated that most facilities were clean, pleasant, and at least somewhat diverse.

It is important to note that the safety measure used in these analyses does not represent a gold standard for what constitutes a “safe” facility. It presents a summary measure of the 10 characteristics that contribute to a safe environment: smoke detector, fire extinguishers, fire sprinkler, call buttons in bathrooms and bedrooms, nonskid stair surfaces, adequate lighting, presence of obstructions in the halls or on the stairs, and an outside area that is visible to the front desk (Moos and Lemke, 1978). A closer look at the components of the measure indicate that the three most frequently missing safety characteristics of the facilities in this study were fire sprinklers (only 29 percent of the facilities had working systems) and call buttons in the bathrooms and bedrooms.

Board and care homes, though perceived as substantially less institutional than nursing homes, actually varied quite a bit in terms of environmental features or practices that many observers regard as “homelike.” Board and care homes varied from places in which three or four residents shared a room to places in which residents lived in private apartments. Most had common areas, which included community rooms or living rooms and outside sitting areas, although only about half of all homes allowed residents access to a kitchen to fix a snack, a cup of coffee, or a soft drink. Homes also differed in the degree to which the environment was “homelike” or more institutional and whether residents were allowed to bring their own furniture or only a few private possessions, such as quilts, photographs, and other small mementos.

Since the role of regulation also is to prevent the occurrence of “snake pits,” we also looked at facilities to determine which had very low scores on these measures. Only 6 percent of the facilities had the lowest possible scores in one or more of these areas. Another 27 percent had inadequate or barely adequate lighting. (A total of 32 percent of the homes had such lighting, but 5 percent had other environmental problems as well.) We defined lighting as problematic if it was absent, clearly inadequate, or barely adequate (e.g., low or glaring).

EXHIBIT 3-16. Summary Quality Indicators
  Total Population
  Percent     SE  
Facility Indicators
Average prevalence
   Safety features 58 0.9
   Supportive devices 65 2.2
   Social/recreational aids 69 1.8
   Physical amenities 80 0.6
Average facility cleanliness/attractiveness 72 0.6
Average environmental diversity 74 1.0
Working fire sprinkler system 29 3.9
Staff Indicators
Staff knowledge of (total score = 100%
   Normal aging 14 1.5
   Basic care/monitoring 66 2.5
   Ombudsman program 65 2.9
Use of physical restraints and/or psychotropics 15 3.3
Prevalence of physical and/or verbal abuse or punishment 15 2.5
Resident Indicators
Resident can eat whenever she wants 64 3.0
Visiting hours are anytime 69 2.9
Visiting hours area every day 98 1.0

3.7.2 Staff Measures

Well-trained and knowledgeable staff are essential to provide high-quality care. The average staff knowledge scores ranged from 14 to 66 percent on three different measures. Staff scored lowest on questions about the normal processes of aging and highest on questions about basic care and medications monitoring.

We asked staff members which of the following were normal processes of aging: becoming incontinent, becoming forgetful or confused, becoming quarrelsome, or being sad and depressed. Almost three-fourths of all staff members reported that it is normal to become forgetful or confused with aging; over half of the staff members said that becoming incontinent and being sad or depressed were expected with aging.

To determine staff knowledge about basic care and medications monitoring, we presented four scenarios describing changes in a resident’s condition or a resident’s reaction to medication. We then asked staff to select an appropriate course of action. We also asked staff about monitoring residents on specific medications and what side-effects to watch for. Based on answers to these seven questions the average staff score was 66 percent.

3.7.3 Use of Physical Restraints

We found that the prevalence of physical restraints, although serious, was not widespread. Fifteen percent of the staff reported use of physical restraints, an intervention that is widely viewed as inappropriate for behavior control and ill-advised as a means of addressing the possibility of falls. A similar number of staff reported witnessing other staff engage in verbal abuse, threats, or similar forms of punishment (e.g., withholding food, isolation) to address difficult behaviors among residents.

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