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All the King's Horses and All the King's Men

September 1, 2006
by Robin A. Bleier, RN, LHRM-FACDONA, and Rob J. Becht, Esq., CNHA, CHE
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Ronald Reagan...Christopher Reeve... How can nursing homes be "perfect" when even the "best" have bad outcomes?
        A few years ago, America lost two great men in a relatively brief period. The first was former President Ronald Reagan, stricken by Alzheimer's disease. The second was actor Christopher Reeve, well known as Superman, suffering from pressure ulcers related to his quadriplegia. This article asks how each man's tragic condition and subsequent death might have been judged had either been a skilled nursing facility resident, and the implications of the answer.

Similar, yet Different
Each man's medical circumstances varied. President Reagan was an elderly man living with a severe chronic disorder affecting first his cognitive functions and then his physical functioning. Reagan's chronic medical condition slowly robbed him and his family of his wonderful memories and cognitive function, and his ability to complete the simplest activities of daily living, such as bathing, walking, and eating. On the other hand, Christopher Reeve was a middle-aged man, completely disabled following an accident occurring at the prime of his life. His injury resulted in mass physical decline and deterioration, yet he remained cognitively intact. Even though the two men had completely different medical and psychosocial factors, there were commonalities experienced by both.

Each received healthcare services which, from all accounts, were extraordinary, readily described as "the best that money could buy." Both men had positive, optimistic outlooks on life before and during their illnesses. Both had incredible family support. However, neither could overcome his individual medical plight. Regardless of the significant financial resources that were aggressively directed to manage their medical conditions, care, and services, each experienced falls, fractures, alteration in skin integrity, and infections during their medical treatment course.

And that's with the best that money could buy!

Unfortunately, certain diseases and conditions cannot be reversed. Certainly this is no one person's or institution's fault. Often, these medical conditions and their related declines cause other comorbidities that result in unavoidable patient declines, anticipated negative outcomes and, ultimately, death.

Yet sadly, often family members and loved ones become bitter when a patient's outcome does not end the way they desired. When the result is pain and suffering or even death, the proverbial finger of guilt is frequently pointed at the healthcare provider, even when logic and medical information indicate otherwise. While death by natural causes can still be found on death certificates, many consider death someone's fault-something that could have been avoided. This is especially true when a patient resides in a skilled nursing facility. Family members often harbor unrealistic expectations of patient prognosis in a healthcare setting. Statements such as "they should have known" or "they should have prevented this" come forth, even when medical indications or a medical prognosis justifies the clinical care that was delivered and the patient's ultimate outcome.

"All the king's horses and all the king's men" could not put either Ronald Reagan or Christopher Reeve back together again. Had either of these men resided in a skilled nursing facility with the same medical conditions and outcomes, how would the care they received have been judged? The recently revised Centers for Medicare & Medicaid Services (CMS) Federal Interpretative Guidelines for Pressure Ulcers (F314) state that healthcare facilities, specifically skilled nursing facilities, may be cited for deficiencies when residents experience med-ical outcomes similar to those suffered by Reagan and Reeve. A conclusion from this might be that unrealistic expectations are placed on skilled nursing facilities through implementation of the new federal Interpretative Guidelines. As a result, facilities might be placing themselves at risk for deficiencies simply by accepting individuals for admission who have alteration in skin integrity or are at risk for this.

Perception Drives Litigation
Television, radio, newspaper, and billboard advertisements suggest that if a nursing facility resident's outcome did not end the way desired, then someone did something wrong and "they" should pay. The ongoing negative perception of care delivered in skilled nursing facilities, coupled with the maladies of chronic medical conditions experienced by patients, leads many to initiate professional liability or malpractice actions against skilled nursing facilities. Facility ownership, administrative staff, corporate staff, and even facility clinical staff are often named in such lawsuits.

Had either Reagan or Reeve been a skilled nursing facility resident, would the skilled nursing facility have been subject to litigation because of the maladies experienced by each of these men? Instead of the perception of care being "the best that money could buy," Reagan's or Reeve's hypothetical skilled nursing facility care would have been judged much more harshly, given public sentiment and the regulatory environment. Therefore, one must ask whether the threat of future license and certification citations and professional liability litigation subjects skilled nursing residents, with chronic conditions like Reagan and Reeve, to not being accepted to the facility of their choice because of the risks to the facility posed by their chronic ailments, clinical risk for skin alteration, or other maladies resulting from chronic medical conditions. Skilled nursing facilities dedicated to serving their local community and meeting the needs of their residents must obviously find a way to cope with these factors and still accept such chronically ill individuals.