As reported by McKnight’s, the city of Tacoma, WA, recently instituted fines for when nursing home or assisted living staffers call 911 for non-emergency lift assistance.
We have a number of concerns about this regulation.
While we agree that emergency resources should not be misused, we are concerned that the threat of fines, escalating from $350, to $500 and then to $850 for each call, may have unintended consequences to the physical health and mental well-being of assisted living residents.
Elderly persons are at great risk of falling wherever they live; in their own private homes and in licensed assisted living. Falls are the leading cause of hospitalizations in our country. Head trauma or hip fractures are common and are often difficult to diagnose by observation alone. To make matters more challenging, elderly residents may not complain of pain or be capable of expressing pain due to dementia or other cognitive impairment.
By law, assisted living communities are forbidden to care for individuals who require the frequent presence and supervision of a licensed nurse. Assisted living communities provide assistance with eating, dressing, brushing teeth, combing hair, shaving, bathing and other activities necessary to manage one’s health and cleanliness. Assisted living communities provide meals and activities of interest to residents so they are engaged and socially active, if desired.
Many assisted living communities will also provide help with medications, reminding residents to take them at the appropriate time and opening containers, if necessary. Licensed registered nurses are not required to be on site but must be available by phone and on a consultation basis. The registered nurse periodically reviews the health and well-being of residents or when caregivers report a change in their level of functioning or participation in usual activities.
When a caregiver comes upon a resident lying on the floor, the caregiver will call a registered nurse, if available, to assess the resident for injury and determine whether 911 must be called for transport and further evaluation and treatment at the hospital. Commonly, however, a registered nurse is not onsite and able to assess a resident fall in assisted living.
In these situations, the caregiver must immediately call 911 to assess and transport if necessary. A caregiver is not trained to assess the resident and determine injury; by law they are prohibited from functioning as a nurse. The scope of practice for caregivers is narrowly defined to include the performance of certain identified tasks and the reporting of observations and resident statements concerning wellness.
Oddly, persons living at home and in adult family homes with caregivers, with the same qualifications and staffing as assisted living, are exempt from these fines. In fact, Tacoma City Councilwoman Lillian Hunter rightly acknowledged the need to exempt adult family homes from this Ordinance because they are not staffed to assess and determine injury.
The recently adopted Tacoma Ordinance is unfair and arbitrary in its application to assisted living communities. The ordinance penalizes the use of emergency services in assisted living but does not impose the same penalty for a similar service use in the home or licensed adult family home. To make matters worse, residents in assisted living may now refuse 911 emergency responder services fearing the financial burden of a hefty fine.
According to the City of Tacoma, the Ordinance is intended to change behavior and curtail a perceived misuse of emergency response services in assisted living and skilled nursing facilities. For example, provided to us by the City Council and its Fire Department: Let’s say emergency responders are called to assisted living to assist an elderly person to the bathroom. We agree this is a misuse of emergency responder services. However, if the Ordinance is intended to prevent this type of misuse, it ought to discourage this misuse regardless of where an individual resides and regardless of their age.
If the call to 911, however, is because an elderly person has fallen and they or their caregiver need assistance to safely lift and return them to a bed or chair, then this assistance should be provided regardless of where the individual lives. The only exception to this should be situations where a physician or licensed registered nurse is immediately available and has a duty to assess and determine need for emergency transport. Otherwise, before attempting to move an elderly person found lying on the floor, the most prudent action is to call 911 so responders can perform a neurological or limb manipulation assessment.
Assessment by an emergency medical technician, with proper training and scope of practice, can then determine whether transport and further evaluation is needed or whether the individual simply needs to be assisted to a chair or bed. To do otherwise places frail seniors at risk.
Injury from a fall may not be readily apparent to an untrained caregiver. Delaying emergency intervention may cause needless suffering or result in more serious, life threatening harm once signs and symptoms become obvious.
The Tacoma Ordinance should be reconsidered and more narrowly crafted to address legitimate misuses of emergency responder services. Availability of 911 services and the imposition of a fine for “misusing” such services shouldn’t be based on where an individual lives. It should be based on whether other credentialed and trained healthcare personnel are on site and able to assess and provide care or request transport.
Deb Murphy, MPA, J.D., is the Chief Executive Officer at LeadingAge Washington.