Nursing Assistants

Nursing assistants, meanwhile, become budgeted expenses that homes try to keep to an absolute minimum. This is not hard to do because federal standards require far less staff than is necessary to provide adequate care. Yet almost no homes meet even those low standards. As a result, nurs- ing home residents are unnecessarily placed at risk for numerous health problems. For example, residents can experience malnutrition when there are not enough assistants to cut up their food, help them eat, and encourage them to take more than a few bites. Similarly, residents may be drugged, strapped to chairs, kept on a strictly regimented schedule, or left in a single central room during the day so they can be supervised by only a few assistants. One study found that 71% of new residents received psychiatric drugs even though most had neither been diagnosed with a psychiatric problem nor received such drugs before admission.

Although all these problems also can occur in nonprofit nursing homes, a re- view of federal data from all U.S. nursing homes found that both quality of life and quality of care were significantly worse in for-profit homes. One reason for this is that within the profit-driven system, managers constantly stress to staff that providing care is less important than documenting care. As a sign proclaimed in one nursing home where Diamond worked, “If it’s not charted, it didn’t happen.” For example, state regulations where Diamond worked required homes to serve residents certain “units of nutrition” each day. Consequently, each day nursing assistants collected cards placed on residents’ food trays that named the foods and their nutritional content. Every few months, state regulators would inspect the cards and certify that the homes met state nutritional requirements. Yet these cards bore little relationship to reality because the appetizing-sounding names given to the foods rarely matched the actual appearance or taste of the food. Nor did the cards note if a resident refused to eat a food because it was cold, tasteless, or too hastily served. Similarly, sanitation regulations required homes to shower residents regularly but did not require that the showers be warm. Nor did they require the homes to hire enough nursing assistants so that residents who used diapers could be cleaned as soon as needed or so that residents could get the help they needed in using the toilet and thus avoid the indignity and discomfort of diapers. Unfortunately, more recent research suggests that low reimbursement rates by Medicare—and especially Medicaid—now encourage nonprofit nursing homes to make similar choices.