Last week, I spoke with a friend whose grandmother is in a local assisted living facility. He was frustrated, because although she is fairly independent and doesn’t need consistent medical care, a minor medical issue had quickly turned into a big headache. Her incision from a recent surgery simply needed to be cleaned and re-bandaged, but they were told the onsite nursing care couldn’t do it because it was outside of her realm of duty. Instead, my friend had to make phone call after phone call and wait several days until a home health service was able to come to the facility.
Thankfully the issue wasn’t life-threatening, but that’s what made it so confusing. My friend’s grandmother doesn’t need nursing-home level care, but he was under the impression that choosing an assisted living facility with a “nurse onsite” would mean she would receive minor medical care if needed. According to the U.S. Department of Human Health Services, “a licensed health care professional employed by an [assisted living] facility may administer medications, including injections, oral medications, topical treatments, eye and ear drops, or nitroglycerin patches.” To me, treating an incision would fall under “topical treatments,” but apparently it’s more complicated than that. I have a feeling that other families with loved ones in assisted living come across similar confusing situations, so I wanted to look into it a little further.
There are various levels of nursing care – and different states that allow them
According to a study conducted by the American Geriatric Society on Staffing Services Availability in Assisted Living, the quality of medical care for residents may depend on nurse licensing. Different facilities employ different levels of nursing staff, from licensed practical nurses (LPNs), to licensed vocational nurses (LVNs), to registered nurses (RNs). The study found that communities staffed by only RNs offered significantly fewer services than those who also have LPN and LVNs. While registered nurses usually conduct initial assessments and plan and coordinate care, LPNs and LVNs can check vital signs, insert and monitor IVs, apply bandages and insert catheters. Certified Nurse’s Aids (CNAs) are often the ones who help with activities of daily living such as bathing and dressing. It sounds like a team effort that would ensure residents get the care they need whenever needed, which tells me it’s probably best to look for a facility that has all of these nurses on staff.
But unfortunately, state regulations don’t make it that simple. In some states, a nurse is allowed to act as a direct care provider and perform the care they’re trained to give, but some states only allow intermittent skilled nursing services or a set number of service hours per week. And in some states, nurses can only offer medication administration but no hands-on care. In many states, the job of a nurse is to keep an eye on residents and when they do need medical care, they coordinate with an outside organization such as home health or an offsite physician. Apparently in our state, the onsite nurse isn’t able to help with cleaning and bandaging an incision. It’s all pretty confusing, and it makes me understand my friend’s frustration.
Assisted living licensing levels
To try to gain some clarity, I consulted with Stacey Zerban, Administrator at Friendship Village Senior Living in St. Louis, Missouri. While all assisted living generally include meals, help with personal care, cleaning services, emergency call systems, and organized recreational activities,
Stacey explained that the type of license a facility has determines how much medical care they can give.
“A Level 1 facility may operate with nurse oversight, but outsource all clinical care to home health, while Level 2 may do wound care and some nursing care. It can be hard to understand without discussing it in detail when evaluating the facility,” Stacey stated.
I looked into some specifications on the different licensing levels, and discovered that the facility my friend’s grandmother lives in offers Level 1 care. Here is the difference.
Level 1 residents
- Need minimal support or assistance with activities of daily living (ADLs) such as bathing, grooming, and dressing; may need help with just one of these
- Can manage toileting needs for the most part
- Can feed him/herself
- Has no acute memory loss
- May need help managing medications and testing blood sugar levels
Level 2 residents
- Require hands-on assistance with two or more activities of daily living
- May use a wheelchair or need help walking safely
- May show signs of memory loss, requiring verbal cues to manage ADLs more effectively
- May require medication assistance as well as comprehensive management of chronic issues or medical monitoring
- Facility must employ licensed practical nurses, personal care aides, and certified nursing assistants
- Nursing care can be covered by Medicaid
The call for better medical care in assisted living communities
I still see grey areas between these levels of care, and I know I’m not alone. With most seniors entering assisted living at 85 years old, it’s obvious that they’ll have health conditions requiring some nursing care— even if they don’t need help getting dressed. A study by the Journal of Post Acute and Long Term Medicine (JAMDA) found that 57% of assisted living residents have high blood pressure, 27% have arthritis, 21% have osteoporosis, 11% have cancer, and 11% have suffered from a stroke; yet nearly half (46%) of all assisted living communities don’t even have nurses on staff. There have been calls for more nursing presence and physician care within these facilities, but there’s a lack of clearly defined medical care. Physicians themselves have noted concern about the ability of assisted living staff to assess and monitor medical problems, pointing out that there are often communication issues when trying to return phone calls and set up appointments. And when you add in the time to transport patients to offsite medical offices or arrange for home health to come, it’s just another step in delaying care. How can someone seek a facility where their loved one will get prompt medical care and not get nervous when they leave them there?
The importance of family involvement
My friend’s experience – and my research – have proven that the only way to know what’s best for a loved one is to stay involved at all times. Luckily, since he and his wife check on his grandmother every day, they discovered that she was in need of medical attention and got her the help she needed. They have decided that if assisted living becomes a discussion with their parents in the future, they will use everything they’ve learned to choose the best option – whether that be a level 2 facility or a place across the river – and you’d better believe they’ll visit or call frequently.
There may not be a perfect solution when picking out a forever home, but there are definitely good questions to help make the decision.
“There are no bad questions when it comes to choosing the best place for your family member,” said Zerban. “A good facility will want to be open and honest about their levels of service, because they should care about your loved one’s well-being just as much as you do.”