1. Marked emotional or physical changes. Look first to your loved one. You should be concerned if she is less able to function as usual, has stopped taking part in activities, or has become withdrawn and uncommunicative. If Mom is experiencing emotional abuse—such as being ignored or talked down to—she may be agitated and withdrawn, fearful, or experience loss of weight or appetite and sudden changes in mood or sleep pattern. Physical abuse or neglect may be a concern if Dad has unexplained bruises, pressure ulcers, or skin tears, particularly in areas that are not regularly visible, like the upper back, hips, and thighs.
Careful, though: These are potential clues, not proof, of bad care. “The problem is that some of these changes represent the inevitability of the underlying disease, and not poor care,” says Josh Uy, assistant professor of geriatric medicine at the University of Pennsylvania’s Perelman School of Medicine. Mom might think a staff member was condescending when he was just using a term of endearment. Bumping the nightstand can cause an alarming bruise on an elderly person using a blood thinner like Coumadin. You’ll need to observe the staff with Dad, stop by unexpectedly on various days and at different times, and ask staff to explain anything you find worrisome.
2. Unanswered or deflected questions. “I don’t know, but I will find out” is an acceptable response—but not regularly, and you shouldn’t get the feeling there’s something to hide. “If staff are evasive with your questions, unable to answer your questions, or refuse to discuss your loved one’s care with you, this is a big red flag that care may be suboptimal,” says Amy Jo Haavisto Kind, an assistant professor in geriatrics at the University of Wisconsin School of Medicine and Public Health.
Some questions, such as, “My mom is losing weight, what is the plan?” should always have a ready answer. “If all a person gets is blank stares or a dismissal—’Old people just do this, don’t worry about it’—then that is concerning,” says Uy.
What’s the ultimate wrong answer? “I get more concerned when someone says, ‘This is how we do things here,’ and has no desire to help,” says Jatin Dave, a physician at the Brigham and Women’s Hospital‘s Center for Older Adult Health.
3. Frantic, discordant, or inadequate staff. A busy, thin-stretched staff may be unavoidable at times, experts say. But does it always feel chaotic when you visit? Are staff working well together, or do they seem to have bad attitudes? At meals, do they talk only among themselves or do they mingle with residents? Does important information get lost between shift changes?
Don’t overlook the leadership. Is the director nowhere to be found and unknown to residents? “I have never seen a place with strong, involved leadership that had bad care,” says Barbara Bowers, associate dean for research at the University of Wisconsin-Madison’s School of Nursing, who researches long-term care delivery.
4. High staff turnover. “Some regular staff turnover is an unfortunate reality at most nursing homes,” says Kind. “However, if you notice that your loved one’s nursing home constantly is training new staff to the point that no one on the staff knows your loved one—well, it is time to look for a new nursing home.” Consistent staff-resident pairing is important in the quality of care Mom gets.
5. “I don’t want so-and-so to care for me.” Your loved one should never feel distressed or uncomfortable around any staff member, experts say. Even if Dad suffers from cognitive problems, “take these statements seriously and investigate them thoroughly with the nursing home leadership,” says Kind. “They may be signs of mistreatment or neglect.”
And even if Dad doesn’t say anything, observe him when staff enters the room. Does he seem happy? Or is he anxious, fearful, or uncomfortable?
6. Constantly ringing phones and unanswered call lights. It should raise an alarm if the nursing staff doesn’t have the time to pick up the phone, says Elisa Gil-Pires, section chief of geriatric medicine and palliative care at Saint Francis Hospital and Medical Center in Hartford, Conn.
And if Mom says she’s waiting a long time after pushing the call button, “find out for yourself,” says Erin Hilligan, a licensed nursing home administrator at Ebenezer Ridges, a long-term care facility in Burnsville, Minn. “Put the light on. Note if the delay is during a specific time of day—shift change or a meal time, maybe. Then bring up your concern to a staff person and note how it is handled.” Of particular concern, adds Sewell, is if Mom says something like, ” ‘I waited as long as I could for someone to help me to the bathroom and then I just could not wait any longer, and so I got up on my own.'”
7. Dehydration and malnourishment. “One of the most frequent and insidious signs of neglectful nursing home care is dehydration,” says Kind. “If a nursing home does not have the adequate number of high-quality staff, residents in that home may not receive all of the food or fluids they need to remain hydrated and nutritionally sound. Meals may even be completely missed.” Act immediately if you suspect this is occurring, Kind says.
8. Status quo reigns. Ask staff what improvements the nursing home has recently put in place, especially since your loved one moved in. In particular, ask about anything they told you would be updated by now. “It is easy to identify nursing homes that are trying to improve and ones that are trying not to get shut down,” says Uy.
9. A bad feeling. Ultimately, your gut knows. “Most of these warning signs will be the family member’s concern that something is not right, or a feeling of uneasiness when they visit,” says Gil-Pires.
