The reasons for placing a loved one in an assisted living facility often boil down to one word: safety. When a sick or frail individual no longer can care for him or herself, the safest place may be such a community, where both medical care and physical safety can be assured.
Assisted living communities have numerous tools – some mandated by state and federal guidelines, some by individual rules – to protect their residents. There are numerous safety concerns, but the top three are:
- Infections, including COVID-19.
Keeping residents safe while allowing them some freedom isn’t easy, and safety programs do not follow a one-size-fits-all approach, says John Mastronardi, executive director of The Nathaniel Witherell, a short-term rehab and skilled nursing care center in Greenwich, Connecticut. Each resident has a personalized care plan because “they still have a personality and preferences you want to pay attention to that can inform and drive the care plan. The crux of this is getting to the core of that person’s preferences if you possibly can, then tailoring a plan of care so that they can thrive as best they can, safely.”
The Centers for Disease Control and Prevention names falls as one of the leading causes of fatal and nonfatal injuries among people age 65 and older. In the past, those at high risk for falls were often restrained from moving, but the Centers for Medicare and Medicaid Services now precludes using restraints except where medically necessary.
Fall prevention begins at admittance, when the resident is screened for his or her risk of falling. The Agency for Healthcare Research and Quality also recommends rescreening quarterly, annually and when health conditions change.
To minimize risk, assisted living facilities:
- Adjust medication to minimize side effects like dizziness and drowsiness. “We have a consulting pharmacist look at their meds, and at least monthly we try to trim them when we can,” says Dr. Elaine Healy, medical director and vice president of medical affairs at United Hebrew in New Rochelle, a senior living campus in Westchester County, New York.
- Manage chronic and acute medical conditions carefully. Conditions like low blood pressure, Parkinson’s disease, arthritis, diabetes and many others increase fall risk. “Most falls occur near the bed and in the bedroom. They might have low blood sugar, don’t realize it, get up too fast and end up falling,” Mastronardi says.
- Schedule bathroom breaks and other potentially unsafe behaviors. “We look at residents’ habits. If they are an early riser, we would anticipate them being active early and make sure their needs are met for eating and toileting, and engage them in activities to keep them busy and not want to move around,” Healy says.
- Provide physical and occupational therapy. This can help residents work on balance, walking gait and strength.
- Fix, adjust or remove environmental hazards, such as beds, walkers, flooring, furniture and clutter. For example, “We may use a raised-perimeter mattress to keep them from rolling off the bed or trying to exit the bed,” Healy says. Some beds are motorized to lower it closer to the floor.
- Make sure personal items are safely within reach. This ensures residents don’t have to reach too far to retrieve these items.
“We want to hit the sweet spot that maintains the resident’s function while protecting them. It’s a continual process of assessment and planning,” Healy says
Wandering into unsafe areas or out of the facility – known in the trade as elopement– is a major concern for residents with Alzheimer’s disease or other forms of dementia. As with falling, each resident is assessed for risk of wandering and planned for accordingly. Ways to prevent wandering and elopement include:
- Security equipment. Cameras and security systems at all entrances and exits.
- Monitoring. Checking on communal areas and residents’ apartments or rooms.
- Secure entrances and exits. Locked memory care units with doors that require special codes to open.
- Wander guards. Residents wear wrist bracelets that activate an alarm if they go past a detector at an elevator or staircase, Healy says.
- Security awareness. “The security stations have pictures of everyone at risk,” Healy says.
- Personal adjustments. Mastronardi remembers a resident who liked to walk so fast the staff had a hard time keeping tabs on him. “I said, why don’t we start a walking program with him. One of the nursing staff can walk with him at a specified time,” he said. “Yes it is more time-consuming, but it helped him tremendously. He didn’t get anxious and stressed.”
“Often you don’t look at the person holistically,” Mastronardi continued. “The point is, you want to keep the individual’s personhood intact. Keep them safe, but understand they have preferences.”
Seniors are at high risk of serious complications from infection – and this was true even before COVID-19. Infections such as the flu, colds, pneumonia and Clostridium difficile, or C. diff, can spread quickly in a nursing facility.
The coronavirus pandemic has made everything worse, of course. Trying to keep residents masked and socially distant has been extremely difficult. Fortunately, other infection control measures have always been in place:
- Influenza and pneumonia vaccination. “We educate staff, residents and families about informed vaccination and the importance of getting vaccinated,” Healy says.
- Hygiene. These facilities have been following the drill for years: regular hand-washing, sneeze/cough control and strict cleaning policies. Masks and other personal protective equipment are now required as well.
- Surveillance. Healy says they monitor CDC and state Department of Health advisories about flu in the community to stay aware of outbreaks. “We also monitor residents and staff for symptoms of flu,” Healy says.
- Testing. During the coronavirus pandemic, Mastonardi says his staff and residents are tested weekly for the coronavirus, as CDC guidance suggests.
- Outbreak mitigation. During the pandemic, no visitors are allowed, but in normal times, facilities discourage visitors or employees from coming if they are ill. If an outbreak occurs, they try to isolate those with symptoms into one area of the facility. They also encourage loved ones to connect through phone or video chat.
COVID-19 has devastated elder care facilities. “It’s turned the nursing home world on its head,” Healy says. “It’s ironic that we have always tried to maximize freedom and socialization, but now we are at the other extreme. It’s a terribly sad thing.” If there is any benefit to be seen, it is that infection safety precautions have been heightened, Mastronardi says. Safety, to be sure, has become everyone’s concern.