We often think that issues of quality are unique to each distinct portion of the long term care industry. Menio and Keller's article addressing abuse prevention in nursing homes strikes many themes that are common to OMR providers and therefore reminds us that "cross training" can be a very valuable activity.

The article begins by identifying the Coalition of Advocates for the Rights of the Infirm Elderly (CARIE), which since 1978 has sought to address the quality of services that those elderly adults who are particularly frail receive. As one would expect, the issues about which CARIE would be most concerned are most often related to nursing home care.

Early in the article the authors attempt to describe the nature of the problems arising in long term care settings. Citing HCFA data from 1997, they list the most common problems that agency discovered in its surveys. Many are familiar in MR settings: assessment, care planning, pressure sores, restraints, housekeeping, dignity, and accident prevention. The authors also discuss the issue of abuse. They rely on research that CARIE itself had sponsored. Interestingly the research measured the incidence of abuse by asking nursing assistants questions about the frequency in which they personally had engaged in abusive behaviors. According to the article,

Fifty-one percent reported that they had yelled at a resident in anger; 23 percent had insulted or sworn at a resident; 17 percent had excessively restrained a resident; and 10 percent had pushed, grabbed, or shoved
a resident.

Perhaps most disturbing is that the figures represent the staff's conduct over just a one month period!

I should not, however, suggest the article merely lists problems. The authors spend the majority of their time identifying ways in which organizations can remedy deficiencies in care. One such approach is to rely on the offices of an ombudsman to help solve problems which might not otherwise be soluble through the investigative process. The authors write that,

In a recent case of verbal abuse reported by the ombudsman to the regulatory agency, the complaint was not substantiated because of a lack of documentation....(But) the ombudsman did not close the case. The ombudsman met with the administrator and the director of nursing on behalf of the resident. After several meetings, the offending staff person was identified and transferred to another unit.

Another interesting portion of the article addresses the training of staff to avoid abuse in the first place. One of the points the authors make is the need to not just provide training, but to develop measures that will help determine whether individual behaviors actually changed as a consequence. The ultimate measure of success is, of course, whether the behavior change actually results in a more caring and hospitable environment in which individuals receive services.

Although most OMR providers are not providing services in services comparable to nursing homes -- many individuals live everyday lives, residing often in homes and receiving services in one or more locations outside the home -- this article's perspective is sufficiently broad to help stimulate thought about how we might improve our own systems.