Recently I discussed the challenges of acuity-based staffing. But what about memory care in skilled nursing and assisted living?

Consider the following scenario which I frequently use in my elder abuse and neglect classes.

“Let’s say you are comparing two secured memory care units side-by-side. They are the same size, same layout, same number of residents, and the gender, cognition, risk factors, behavior, and ADL dependency is the same,” I tell them. “Now, after I tell you that one group lives in an ALF and the other lives in a skilled nursing facility; do you believe the ALF residents are less deserving of care, close supervision, and protection simply because they live in an ALF?”  

A students who works in an ALF will usually argue that they allow residents to maintain their independence in a homelike environment. My usual response is to ask them if ALF memory care residents are capable of appreciating these quality of life distinctions, if any, or deciding whether aging-in-place trumps quality of care, nursing expertise, and their safety. Most eldercare professionals recognize that acuity is based on resident dependency and risk, and not necessarily by the facility or setting they live in.

The cost-saving practice in skilled nursing facilities of substituting LPN’s for RN’s in management, assessment, clerical, and floor nurse roles severely undermines the depth of clinical expertise, especially for unstable extremely dependent residents who are classified as skilled/subacute. While some defend this practice, a facility saves $5.00 – $12:00 per hour for every shift that an LPN displaces an RN. Unsafe dependence on LPNs is especially apparent on night shifts, weekends, and holidays when resident condition changes are not identified or addressed until they become life-threatening. The practice of substituting medication aides for RN’s or LPNs is even more dangerous if they are assigned to post-acute and high risk residents. Acuity-based staffing is not only defined by the quantity of staff, but the quality.

ADLs are a reliable index of acuity, especially residents receiving Medicare Skilled coverage, those rated as extensive assistance and totally dependent, or those requiring 2 to 3 caregivers for toilet use,  incontinence, turning/repositioning, bed mobility, mechanical lifts, and transfers. Night shifts and weekends are the best staffing windows to measure if ADLs are being met.      

For example, can a night shift aide realistically care for 13 residents, four of which require another aide four to six times per shift per resident to assist with incontinence care and bed repositioning? What if this aide has to travel to another nursing unit/floor every time they need assistance? ADLs are especially at risk in memory care ALFs when only one aide is assigned to a unit/floor, or worse, when they serve as “universal workers” and are required to perform housekeeping, laundry, dietary, and other duties.

Challenging resident behavior can consume more caregiver time than any other endeavor, especially aides. Yet I believe many eldercare professionals do not recognize high risk behavior as a legitimate acuity issue, especially since there is usually no incentive. As a result, I fear many facilities leave resident safety to chance by relying on “passive interventions” (i.e., alarms, equipment, assistive devices, restraints, etc.), rather than “active interventions” (i.e., 1:1, line-of-sight, 15-minute checks, etc.)

This problem is often compounded by when staff talk about about resident behavior. For example, they may use fall back on statements such as, “We can’t prevent all falls,” “We can’t restrain them,” “We can’t provide 1:1,” or “Resident independence trumps safety.” In my opinion, challenging and unsafe resident behavior often requires the same staffing levels as post-acute care. Acuity-based staffing is defined by how a facility manages challenging and unsafe resident behavior.

Some subacute nursing facilities and memory care ALF’s are rapidly outgrowing the regulations that govern the delivery of their care and services. I believe this evolution will eventually result in new provider categories where acuity-based staffing will be a condition of participation. Fortunately, many staffing architects recognize the importance of resident acuity, and it shows.

For every struggling facility that ignores this issue, there is a successful facility that embraces it. The true mission of an eldercare organization is defined by how it manages resident acuity.

Lance Youles, LNHA, has practiced, managed, and consulted in nursing facilities since 1978. His current teaching pursuits include an active website, corporate/public seminars, and workshops. He has served as an elder abuse/neglect expert in 49 states, and has published several articles on this subject.