Recently one of my patients transferred her 83-year-old mother from a hospital to a nursing home for physical therapy and recuperation after an illness. Upon discharge, her mother went to the nursing home by ambulance. My patient followed shortly after by car. Imagine her surprise when she learned that in the brief interval between her mother’s arrival and hers, a visiting dentist had performed an admission dental exam and—without explanation to or consent from the daughter, who held power of attorney for her mother’s health care—extracted a tooth. Her mother, who was in the early stages of Alzheimer’s disease, was confused and frightened. My patient was enraged.
The rights of nursing-home residents are protected under the federal Nursing Home Reform Act. Passed in 1987, it applies to every nursing home certified to accept Medicare or Medicaid patients. Among the law’s provisions are the right to freedom of choice over medical care, the right to refuse treatment, and the right to advance notice of changes to the resident’s care or treatment plan.
But some nursing homes disregard the law, and often they get away with it. One reason is that residents or their families might be reluctant to make a formal complaint because they fear the staff will retaliate. Some also worry, wrongly, that refusing an unwanted treatment will lead to eviction. (That is illegal.) As a result, a culture of acquiescence develops, and egregious behavior continues.
In addition to unneeded dental work, several other practices may be overused or misused in nursing homes, even though the law restricts their use except for very specific reasons:
Physical restraints. The use of vests or belts that tie residents to wheelchairs or beds has declined, but some nursing homes still use them, and they can be physically and emotionally harmful. (They might be justified in situations where a patient has the capability to do bodily harm.) It’s illegal for staff to use restraints for convenience, such as to prevent wandering or address behavioral challenges. Electronic monitors, increased staffing, and behavioral interventions to discourage boredom are better options.
Antipsychotic drugs. These and related drugs are supposed to be used only for patients with diagnosed psychiatric conditions such as schizophrenia and not for disciplinary reasons such as quelling agitation in patients with Alzheimer's. In a large 2010 study, almost 30 percent of nursing-home residents had received an antipsychotic drug; of them, almost one-third had no identified indication for use. The drugs don’t help dementia and have been linked to other risks, including less functional improvement, longer nursing-home stays, and a greater chance of dying. A review published in March by the Cochrane Collaboration concluded that most older adults with dementia can successfully be taken off antipsychotic drugs.
Feeding tubes. They deliver nutrition via a tube inserted into the stomach and are sometimes necessary for people who can’t swallow or otherwise eat safely. But nursing homes sometimes use them to save time and labor with residents who eat very slowly or need encouragement to eat. That is never a legitimate reason for inserting a feeding tube, which denies a patient the pleasure of tasting food and can diminish quality of life.
Residents and their families should be on the lookout for those practices and ready to speak up if they’re used or pushed unnecessarily. My patient ultimately did just that: She filed a complaint about her mother’s hasty and unpermitted dental procedure with the state board. It led to the firing of the dentist and a state investigation of the facility.
National Long-Term Care Ombudsman Resource Center: Find contact information for your state’s free ombudsman program, which provides advocacy for nursing-home residents.
National Senior Citizens Law Center: Download a booklet on common nursing-home problems and how to resolve them.
ProPublica Nursing Home Inspect: This program of the investigative journalism group ProPublica lists inspection reports for more than 60,000 nursing homes.