Infection control in nursing homes

Infectious diseases are a major concern for our nation’s nursing home residents. In fact, Infectious diseases account for one third of all deaths in people over the age of 65. As such, infection protocols in nursing homes must be implemented as a matter of Federal law and as a line of protection. On this week’s episode, nursing home abuse attorney Rob Schenk welcomes Richard Mollot @LTCconsumer  of the Long Term Care Community Coalition to discuss the importance of infection control protocol in nursing homes.

Schenk: Hello out there and welcome back to the Nursing Home Abuse Podcast. My name is Rob Schenk and I will be your host for this episode. We’re going to be dealing with infections and the problems of infections and how infections are controlled in nursing homes. And we are not going to be doing that alone. We will have long-time friend of the podcast Richard Mollot on.

Just to recap – I want to recap this because this is his sixth time, his sixth time being on the program. First we had him on in April of 2018 for back to back episodes, 63 to 64. We talked in both those episodes – you should go back and check those out – we talked a lot about the Centers for Medicare and Medicaid Services, how they regulate the nursing home industry and how nursing homes are guided by the regulations and are sometimes fined and cited by them.

Then we had him a little later on, August of 2018, Episode 83 – we talked about the Nursing Home Compare website, so CMS has a website, which you can go and see what the scores are that are provided by CMS on the nursing homes, so one out of five stars based on different criteria, and he talked about how that can be a useful resource but not your only resource in finding the website. That was a great episode. That was Episode 83.

Then we had him on in September of 2018, Episode 84, on how to read inspection reports, so when a CMS surveyor goes to a nursing home based on a complaint or just based on a general survey, how to actually be able to go onto the Nursing Home Compare website and read a report to get more educated on a particular nursing home.

And then we had him on in December of 2018 talking about – oh, I’m sorry, nope – yeah, in December of 2018, we had him on talking about the Long-Term Care Community Coalition’s website, NursingHome411.org – that is Richard’s pride and joy, his baby. That’s his organization. And that website, which is NursingHome411.org, and we’ll talk about that later on in this episode, but that is a fantastic resource if you have a loved one in a nursing home. So this will be his sixth appearance on the show.

For those of you who don’t know about Richard Mollot yet, Richard Mollot is the executive director of the Long-Term Care Community Coalition, a nonprofit organization dedicated to improving care for seniors and the disabled through legal policy and research, advocacy and education. Richard has served on a number of state and national consumer government advisory groups relating to such issues as dementia care, nursing home and assisted living standards, mandatory managed long-term care, and nursing home financing and quality improvement.

He has written and presented trainings on a variety of long-term care issues, including nursing home laws and regulatory standards, assisted living law and policy, dementia care and the use of antipsychotic drugs, caring and planning for the aging, and what seniors need to know about long-term care and elder justice.

Richard is a graduate of Howard University School of Law and a member of the Maryland bar, and we are excited to have him back for the sixth time today. Richard, welcome back to the show, times six.

Richard: Thank you. Thanks so much for having me. I really appreciate the opportunity.

Schenk: Excellent. Well great. Well Richard, I really wanted to have you on because, again, the audience, as I mentioned at the top of the show, the audience knows that you work for Long-Term Care Community Coalition. You’re the main guy. You are the guy in terms of long-term care advocacy, but something they might not know is you have a lot of videos and they’re easily searchable and easily findable on your website or on YouTube.

And one of them that you did in the not too distant past – and these are webinars and instructional webinars that run the gamut from you talking about residents’ rights in some of them, how to file grievances in nursing homes and others, but the reason why I wanted to have you on the show this particular instance is because I watched a webinar that you did about infection control and infection control procedures in nursing homes, why that’s important, how that can lead to trouble if they’re not doing what they’re supposed to be doing, and I thought that was such an interesting topic that I wanted you to address on this episode. So that’s kind of the genesis as to why we had you back is to talk about infections.

So from a broad standpoint, Richard, in your research and your experience, is infection a serious problem? Is it a cause for concern in nursing homes?

Is infection a serious problem in nursing homes?

Richard: I’m a consumer advocate as you know, and these are all issues in resident care that I care about and focus on, but the infection control problem to my mind is just astounding. I continue to – everything we do is based on data and we’ll talk a little bit about that later on in the program, some of the information that we collect, but I’m shocked to see how pervasive infection control and prevention problems are. In fact, according to the CDC and to other federal data, from 1-3 million infections occur in nursing homes every year, and up to 380,000 residents die from them.

Schenk: My goodness.

Richard: Considering we have a 1,400,000 residents any given day in nursing homes in our country, the fact that 380,000 have deaths that are the result of poor infection control and prevention is just – it’s almost incredible to me, but it’s actually the facts. This is data, federal data. So it’s something that everyone needs to be thinking about. Everyone needs to be aware of and cognizant of for your family members, of course if you’re a resident, if you’re an attorney or someone else who’s working with the residents or families, but that is something to really clue in on and be, again, cognizant of and on guard for all the time.

Schenk: That’s an amazing stat and those are CMS stats? Is that right?

Richard: Pardon me?

Schenk: Those are CMS stats?

Richard: No, CDC.

Schenk: CDC.

Richard: CDC and other federal data, so this is the Office of Disease Prevention and Health Promotion, which I believe is part of the CDC.

Schenk: Got you. So it seems to me by the numbers a massive problem in nursing homes.

Richard: Yes.

Schenk: So my question then is does the federal regulations that govern the operations of nursing homes, is infection control or that kind of protocol, is that in that regulations?

What are some regulations governing infection control in nursing homes?

Richard: It is. And it’s in it in a number of places, so there are requirements specifically around infection control and prevention, and then there are also requirements around having a safe environment, including sanitary, including sheets. A lot of the things you normally wouldn’t think of especially in a healthcare setting, you expect that the sheets would be laundered appropriately, you expect that there would be things to prevent vermin, including flies and other things that carry disease, from coming in as well as, of course, that there are all staff who care for residents, who come in contact with residents, are trained and held accountable for maintaining really important protocols about cleanliness.

So the requirements all speak to that, but I think it’s important to remember obviously the requirements are the foundation, but it is – it’s incumbent upon facilities to provide a safe environment. I mean if you’re not providing a safe environment where people aren’t getting infections, what are you doing?

Schenk: Right.

Richard: People go to nursing homes for skilled nursing, but we all assume that the environment is that people and the residents are not going to be harmed by the environment itself, whether or not the care is great is another story, but the fact again that there are so many, hundreds of thousands of deaths as a result of infection is so obviously concerning to everybody.

Schenk: So we have infection being acknowledged by the CDC as being a problem in nursing homes. We have federal regulations governing infection control in nursing homes. What are some of the basic protocols for infection control that would be implemented by the nursing home?

What are some basic infection control protocols for nursing homes?

Richard: Well something really basis that we all can keep an eye on is people washing their hands. Washing hands – that is key. We hear that if you ever go into your supermarket to use the bathroom or a restaurant to use the bathroom, you almost always see a sign that says, “Employees must wash hands.” There’s a reason for that, and when you’re talking about vulnerable population that’s being treated, people might be touching their mouths or their eyes or providing medications through intravenous drugs, etc., of course the ramifications of those practices are increased incredibly. So just a basic hand washing is so important.

But I think also looking out for basic cleanliness in the facility – are the bedsheets laundered regularly for your resident? Are the halls and the corners of the bedroom, are they kept clean, mopped, etc.? What happens if there is an accident, some urinates or something on the floor? There’s blood on the floor – is that cleaned up right away and in an appropriate way?

But really, again, I think it’s just basic – are people washing their hands? Are they changing when they use an indicator for someone when they’re checking people with diabetes? Are they washing their hands in between if they need to change someone who might be in a diapers? Are they removing their gloves and washing their hands and putting on new gloves, etc., when they do something else with that resident? All those things are just so, so basic. I mean some of the stories that we’ve seen are just from unclean linens, linens that have not been cleaned appropriately.

Schenk: Right. So back – this is a while back now, but in December of 2018, we had you on the show as a guest to guide us through your website, which is NursingHome411.org, and all the great resources that website has for families with a loved one in a nursing home. Is there any way that someone can use your website to research infection control? Are there any materials about infection control on the site?

What are some resources to research infection control?

Richard: Thanks, and I really appreciate it. Everything that we have on the website is absolutely free to use, to download, to share with others. And I would say for families and residents and those working with them especially, a lot of this information can be used even to talk with families in resident councils, to talk to the staff to let them know as well as for advocacy if you need to file a complaint, etc.

But what you can do is if you just go to the website, again NursingHome411.org, there is a search button at the bottom of the left-hand side. You can just search for any issues. So I, in fact before this program, just searched for infection and I came up with a whole bunch of resources that we have. So we have an issue alert on that that gives people some basic background information. We have some news alerts that has some of the information that we’re finding to let people know what a serious problem this is, some of the reporting that’s been out there, because sometimes – you can imagine with 700,000 deaths, the repercussions for residents can too often be tragic.

And then we also have – we publish a lot of data in user-friendly formats as much as possible as we can, all of them from the federal database, and we put them into sortable files. So we have periodically, we publish data on nursing home infection control and prevention citations, so people click on that and download it or open it up and search for either their state or their nursing home to find out if their nursing home’s been cited.

It’s just really important to mention an article noted from Kaiser Family Foundation a few months ago, as prevalent as these issues are – prevalent was the word that they used – there’s almost never any punishment. We’ve talked before about the issue in terms of lack of enforcement across the country for nursing home safety, protocols for the care standard, etc., and this is one where we can easily see the tragic result of lack of enforcement. So enforcement is valuable. You can see if your facility has been cited, but that is not really the end of any query. You then want to be on the lookout to make sure people are watching their hands, etc., that there’s basic cleaning, that it’s want you’d want to have for yourself and your loved one that’s happening in the nursing home on a pretty rigorous basis because they’re caring for so many people.

Schenk: So let’s say then that an audience member, a loved one of a nursing home resident goes in, doesn’t see nurses washing their hands, doesn’t see nurses putting on gloves maybe changing a catheter or something like that, or they notice a linen is dirty in a particular spot since last week so they know the linens haven’t been done. What is a way in which they can file a grievance or start a grievance with the actual nursing home?

How can a resident file a grievance against a nursing home?

Richard: Well there are a couple of ways. What I would suggest, one, is they access the long-term care ombudsman. That’s often a very good place to start. I think you’ve had ombudsmen on your program before, so every nursing home resident has access to the long-term care ombudsman program. If someone comes in on a regular basis, you can speak to them. Most nursing homes have their number, it’s usually a toll-free number, posted too, and they can help you formally file a complaint with the facility. So they generally are very helpful, I think, or can be very helpful in navigating some of these issues and being the first place to start.

Every nursing home now since 2017 is required to have a grievance officer, so that grievance officer – it doesn’t have to be someone who’s just sitting in an office like Lucy from the “Peanuts” cartoon waiting for grievances, but it has to be a single person that’s identified in the facility. I can be a director of nursing. It can be someone in social work. And that person, under federal requirements, is required to take in any complaints that a resident or family has and to basically follow through with that complaint, whether it be on the floor or up to administration and get back to that resident or the family, and the resident or the family member is entitled to get an answer to their grievance in writing if they ask for it.

So in short, it’s going to that grievance officer, you are always entitled to get your grievance, have your grievance heard through that officer and have some written record of what the result was. Now the facility is not required to do what you want and the grievance can be about anything, but a facility is required to respond to your grievance, and if it’s not going to – give you a written response, I should say – and if it’s not going to respond by changing or making some change or doing what you’re asking them to, they have to provide you with a reason as to why not, and again, that’s part of what you can ask to have provided in writing.

What are the Long-Term Care Ombudsman?

So those are two ways, and of course, another first line before maybe filing a complaint would be talking to the staff on the floor, saying, “Look, I’m concerned.” But it may vary – an individual’s comfort level may vary if you are seeing an individual who is not washing his or her hands and you feel like you’re concerned there may be retribution if you complain about an individual, then you might want to do something that goes through the ombudsman program or through a grievance process or speak to someone that you trust. But if it’s more something like the linens aren’t clean, something that is more about an object rather than a person, then you may want to first complain with people on the floor or go to the resident council if you’re a resident on the council or the family and start talking about the issues there and then addressing them with the appropriate people in the facility.

Schenk: Yeah, those are two excellent, excellent points, and I would like to reiterate that the Long-Term Care Ombudsman Program, particularly in Georgia, these guys work their butts off on behalf of nursing home residents, and they can do all types of great things that can resolve issues. They can walk into that nursing home and basically mediate the dispute by sitting at a table with the residents’ representative and the administrator of the nursing home representative and work things out and be kind of like a bridge to care.

Richard: Yeah, exactly.

Schenk: I’ve seen that. I’ve seen them say, “You know what? I think you should do this, this or this,” and a lot of times they have the respect of the nursing home and it gets changed that way. But either way, they’re a great resource here in Georgia and I mean in Georgia and across the country, but particularly in Georgia. Our long-term care ombudsmen are the best.

In terms of filing the grievance, I think you’re absolutely right, Richard. A lot of times it’s going to depend on the – I don’t know – the confrontation level of the resident’s representative. So if you see your loved one, their sheets are never clean, maybe you don’t want to confront the CNA or the staff because you’re not comfortable doing that, so maybe filing the grievance through that process with the grievance officer is better because there may or may not be anonymity to that. And if you don’t think you can get anonymity through it and you don’t want to call the long-term care ombudsman, then it might be something that depending on how egregious the infection control problem is, it may be something you call the whatever the state regulatory agency – so in Georgia, the Department of Community Health. So you call the Department of Community Health and you would file a complaint with them, and depending on how backlogged it is, I know in Georgia it can get really backlogged, but depending on how backlogged it is, they can come out and they can do a survey based on your complaint and they may get cited, they may not.

But I know – I don’t know if we’ve talked about this in the past, Richard, but infection control can be a big problem, especially here in Georgia. We’ve seen and had cases dealing with everything from maggots in wounds to bedpans next to where toothbrushes are. So it can get pretty bad and lead to pretty bad problems.

How does the Georgia Department of Community Health investigate complaints?

Richard: Yeah, and I think those are all really good recommendations. I would just mention that in terms of what the state agency has to do, the Department of Community Health, if there is a risk to someone’s well-being, then they should be getting in there as quickly as possible. So there are different ways in which it’s expected that those state agencies are going to be responding to a problem.

So you also want to think about how you are expressing the problem. One other thing we’ve been recently putting on our website are forms for families and residents used to track their complaints. So if you call up your state and you say, “Look, the sheets look dirty. It’s been happening for a long time,” you may not get the response you want where if you say, “This is June 6. I’ve raised this issue with the administration in March. I was told it would be fixed and it was fixed for a couple of days and then it happened again in April. I work around and it didn’t make a change in April and here we are in June and this is something of which I’m very concerned.” You have a record that you kept that is hopefully easy to keep but also useful for substantiating any concerns that you have down the road, whether it be with the state, with the facility or with the help of an attorney.

Schenk: Exactly. I’ll tell you, the linens, they get me because I worked in a restaurant many, many years ago where generally in restaurants, you contract out the linens, like the tablecloths and napkins, and so like once a week, whatever, the linen company comes in, takes the linens and drops off the cleaned, pressed linens in the little foldies, the little folded stacks or whatever, and the nursing home – I’m sorry, the restaurant owner was like, “I don’t want to do this. I think I can do it cheaper by just having a couple non-commercial washing machines,” and he tried to wash all these napkins and stuff, and obviously that didn’t work out. It was terrible. They didn’t get cleaned but they were still trying to use them, and I can only imagine that this probably happens in the minds of some of these administrators – I can save some dollars by cutting corners on these linens, maybe not laundering them as often as they should. By saving 10 and 15 cycles in a year, that equates to X amount of dollars. And that’s a lot of times how these companies think and that can lead to problems.

Richard: Yes. And that’s again the thing with the infection control and prevention. I mean a lot of it is just basic handwashing, and it just drives me nuts to think that we need to really explain this to people, especially people who are providing this care that you need to wash your hands after you go to the bathroom or touch someone else’s bowel movement, etc. But you’re so right – you don’t need to go in necessarily with a magnifying glass every day, but when you are there in the facility, look around. Do you see holes in screens? That’s where bugs can come in. If you see the sheets have not been cleaned, if you see that the floors are dirty and not yet cleaned – those should be really strong signals that there’s a problem.

Schenk: And I don’t know if you find this in your research, Richard, but is that something that when a surveyor comes, I don’t feel like they’re really looking at that, like linens or infection control type stuff? Very rarely do I see in complaints, “Okay, observed CNA not washing hands,” or whatever. I didn’t know if that was your experience as well.

Richard: It is and that gets to the Kaiser Family Foundation report that I mentioned earlier that found how pervasive these problems are across the country. And they said they were rarely cited and penalized and that’s exactly what we found, that they said we have this citation data but you cannot rely on that as saying, “Oh my facility wasn’t cited, therefore it’s clean,” because too many of the states and the state surveyors just are not paying attention to these things as vital as they are, as much as we’re healing the alarms now of the rate of death, etc., that they’re just not paying attention. And it’s not just the things that we talk about but the equipment that touches residents, that are used to provide medications to residents, that sometimes there’s dirt caked on it, you may see vents and stuff that are not clean, and citations for that are pretty rare given the scope of these problems.

Schenk: Right. Well Richard, this episode has flown by. We have really covered a lot of ground in terms of infection and I think we’ve given the listener a lot of good resources, but again, I really want to reiterate to the audience that they can go to NursingHome411.org, which is your website, basically, or the website of the Long-Term Care Community Coalition. And it is chock-full of resources. But I really encourage people, if they want to continue the discussion, they want to continue to learn about infection control, to go to that website and watch that webinar you did on infection control. It’s really great. And then do what you said, actually – search “infection” and look at the articles that come up and look up the information that comes up to learn more about that, because at least in Georgia, it’s a problem and that’s a place people can go and learn more about it. But again, Richard, you are a fantastic friend of this podcast. This is your sixth time.

Richard: Wow. Well thanks. Just before you go, I have to tell you I so happened to be listening to one of your podcasts this morning. I was just having a cup of coffee around 7:30 before I needed to get started for work and I put it on. It was on pressure ulcers actually. You had a great guest and you guys do such great work and it’s a terrific public service. I really appreciate the opportunity when you have me on, so thank you.

Schenk: I appreciate that Richard. Thank you. Thanks for listening. That’s fantastic. So not only is he a listener, he’s a guest, so that’s great.

Richard: Yes.

Schenk: So anyways, Richard, thanks so much and we look forward to having you on again in the future.

Richard: Thanks. Bye-bye.

Schenk: All right. Always a pleasure to have Richard on the show. Infection can be a serious problem, and if you see something, say something in the manners in which we laid out in this episode. That’s what I would recommend. But that is going to conclude this particular episode of the Nursing Home Abuse Podcast. The Nursing Home Abuse Podcast comes out, it drops, it publishes, it debuts two times a month, every other Monday in the morning, usually about 6 a.m. You can catch a fresh episode then, so in another couple weeks, we’ll have a new episode for you. You can catch us online, which is at NursingHomeAbusePodcast.com or on our YouTube channel, or you can check us out anywhere you get your podcasts from. And with that, we’ll see you next time.