Awareness of the Red Flags in Elderly Advocacy


To receive Medicare or Medicaid reimbursement, nursing homes must undergo yearly inspections by state accrediting organizations which follow state and Federal standards and guidelines regarding quality care. Every nursing care facility that wishes to be reimbursed, funded, or benefit from government funds and financing must undergo a thorough survey process which may last anywhere from a few days to a week or more.

Understanding the survey process and the types of things that surveyors look for in nursing homes and assisted living facilities can help patients and their families choose the best care facilities for their loved ones. For the sake of simplicity regarding this article, we are using the term nursing home to define any type of elderly care facility.

What Surveyors Look For

Surveyors offering accreditation and certification to elderly care facilities initiate inspections on a yearly basis that look at a variety of different things within the nursing home or other care environment.

The inspection or survey team not only observes and researches nursing care processes, but also interactions between staff and residents, the nursing home environment, cleanliness, and the overall state of physical and mental wellness of its residents. For example, long-term care facilities and nursing homes must follow a variety of standards of care in:

  • Resident rights.

  • Admission, transfer, and discharge rights.

  • Resident behavior and facility practices.

  • Quality of life.

  • Resident assessment.

  • Nursing services.

  • Dietary services.

  • Physician Services.

  • Specialized rehabilitative services.

  • Dental services.

  • Pharmacy services.

  • Infection control.

  • Physical environment.

  • Administration.

Dental and vision based services are usually offered off site, with regular appointments and transportation offered by and facilitated by the staff at the nursing home. State and Federal guidelines and regulations determine the definitions, specifications, and scope of each of these requirements for accreditation and certification.

Survey results are to be made available to all nursing home residents, their families, and the community. In addition to the resident's rights, surveyors and inspectors ensure the rights of residents to free choice, such as choosing their own physicians and ensuring access to any information regarding advanced care. Patients also have a right to confidentiality, and a right to voice grievances. State surveyors focus very carefully on grievances voiced by residents or their families and typically investigate all grievances for resolution.

Surveyor Guidelines

Surveyors pay special attention to the safety and security of residents in nursing home environments. They'll look at accidents in bathing facilities, falls, room accidents, and what triggers falls in any given environment. They may check for handrails along hallways, in bathrooms, and on beds when necessary for patient safety. They'll assess the safety standards of the facility, including disaster plans, emergency evacuation plans, and access to emergency transportation and services.

Surveyors will also determine whether activities meet measurable objectives and meet the interest, abilities, and preferences of residents. Activities should also offer residents with continuation of life interests as well as the ability to connect within their community.

In the area of nutrition, state surveyors will look at facility menus, food preferences, food preparation, and serving methods depending on the capabilities and mental status of residents. They'll check the weight of residents to make sure that they are neither underweight nor overweight, and that dietary menus are well balanced and nutritious.

State surveyors will also carefully inspect medical records for errors in medications, treatment protocols, and care plans. Care plans must be evaluated and revised as the patient or resident's physical and mental status changes and offer measurable outcomes and objectives. Care plans are designed to maintain resident independence and the resident's needs, strengths, and preferences.

Surveyors will also look for red flags, such as:

  • Bedsores or decubitus ulcers.

  • Lack of bathing, grooming, and basic hygiene of residents.

  • Inadequate pain management.

  • Falls.

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In a nursing home, falls occur occasionally, but a nursing home that has an unusually high number of fall incidents may initiate a red flag. The presence of bedsores on patients is also a red flag for state surveyors. These red flags are called tags or deficiencies. The number of tags or deficiencies a nursing home facility receives is directly related to its efficiency, quality, and standard of care.

It is relatively rare that a nursing home does not receive a few tags during yearly state inspections. Anything from a catheter bag tube hanging too close to the floor, to a resident not having water in their room can result in a deficiency tag by state surveyors. For example, a sample page from The Long Term Care Survey guidelines offered by state nursing home inspectors for the State of Colorado may read something like this:

Investigative Protocol - Hydration


  • To determine if the facility identified risk factors which lead to dehydration and developed an appropriate preventative care plan; and

  • To determine if the facility provided the resident with sufficient fluid intake to maintain proper hydration and assistance.

Task 5: Use.

Use this protocol for the following situations:

  • A sample of resident who flagged for the sentinel event of dehydration (QM/QI 7 0.3);

  • A sampled resident who has one or more of the following QM/QI conditions:

* Prevalence of fecal impaction;

* Residents with urinary tract infections;

* Residents who lose too much weight;

* Prevalence of tube feeding;

* Residents whose need for help with daily activities has increased; and

* Any of the three pressure ulcer QM/QI: 12.1, 12.2, or 13.3.

  • A sampled resident who was discovered to have any of the following risk factors: vomiting/diarrhea resulting in fluid loss, elevated temperatures, and/or infectious processes, dependence on staff for the provision of fluid intake, use of medications including diuretics, laxatives, and cardiovascular agents, renal disease, disfavor, a history of refusing fluids, limited fluid intake, or lacking the sensation of thirst.

  • As you can see, observations, procedures and determination of compliance to guidelines are very detailed and comprise hundreds of pages of rules, regulations and guidelines that must be followed by nursing home staff and facilities in order to be accredited.

Bedsores are a major red flag for nursing homes, as bedsores are commonly caused by patients having to remain in the same position for too long. State guidelines require that nursing home residents be transferred or resituated every 2 to 3 hours in order to prevent pressure sores, skin injuries or skin tears.

Cleanliness such as clean and brushed hair, clean and clipped fingernails, proper skin care, and clean clothes of residents are observed by survey staff, as is the overall wellbeing and comfort of residents. State surveyors will check medical records and nurse's notes to determine whether pain medication is adequate or if residents are being under- or over-medicated.

One of the most important aspects of surveys is in the area of risk management. Bruises, fractures, or injuries due to carelessness, lack of supervision, or improper care by nursing home facilities may result in serious infractions, fines, and deficiencies that may seriously hamper the ability of the facility to accept new patients. In severe or life threatening cases, a nursing home or facility may be shut down and residents transferred elsewhere.

Flags or deficiency tags are expected to be resolved within a certain period of time. Following that period, state inspectors will return to ensure that such infractions or deficiencies in a facility have been addressed and corrected.
Understanding Deficiency Tags

Seniors or any family member considering placing a senior or elderly loved one in a nursing home should know how many deficiency tags a nursing home has and their severity. Site Improvement Program, the Department of Human Health and Services and the Centers for Medicare and Medicaid Services (CMS) determine enforcement of nursing home quality.

Deficiency tags are categorized as follows, the first letter designates isolated incidents, the second letter designates a pattern, and the third letter in each category designates widespread observance:

  • A, B, or C = no actual harm, with potential for minimum harm.

  • D, E, F = no actual harm, with potential for more than minimal harm that is not immediate jeopardy.

  • G, H, I = actual harm that is not immediate jeopardy.

  • J, K, L = immediate jeopardy to resident health or safety.

Consumers may be comforted to know that the average of nursing homes inspected in the United States today range in the A through F category. As of 2001, states which had the fewest deficiencies included Virginia, Vermont, New Hampshire, and Massachusetts. The states with the highest deficiency rates included California, Nevada, Washington D.C., and Arizona. However, residents in all states must realize that the inspection standards among certain states differ as to differences in quality of care, case mix, as well as surveyor practices.


Elderly patient advocates must always be aware of situations or scenarios where less than acceptable standards and quality of care are noticed. While no one is perfect, and no one facility is perfect, staff at nursing home facilities should always strive toward perfection and the utmost in compassionate, caring, and quality care.

Death and Dying


As an elderly patient advocate, you need to know the types of documents and situations that may be involved in the death and dying process of patients. Most of the time, you will find that seniors have already made decisions and determinations regarding end-of-life care. Your understanding of DNRs (Do Not Resuscitate), powers of attorney, advance directives, and the responsibilities involved in honoring the last wishes of the elderly may prove to be challenging and intimidating, but may also involve your interaction with and closeness to some of the kindest, most compassionate individuals you'll ever have the opportunity to meet.

Understanding End-of-Life Documents

Seniors today have enormous access to printable forms and information regarding end-of-life documents available on the Internet. Knowledge and information regarding the dying process has made today's seniors and the coming generation of baby boomers (those born between 1946 and 1964), the most informed and educated generation regarding documents that should be made available to other family members, doctors, legal representatives, and advocates.

Some of the most common documents involved in end-of-life care include:

  • DNR or Do Not Resuscitate orders.

  • Powers of Attorney.

  • Advance Directives.

A DNR order means Do Not Resuscitate. As an elderly patient advocate, it is your responsibility to ensure that people involved in elderly care are aware of what this document means. A DNR order means that no attempt to revive the individual is to be initiated on anyone who has created such an order and passed these orders out to family, doctors, or legal representatives.

However, advocates should be aware that a DNR order is not the same type of document as a living will. Living wills generally outline or describe an elderly person's last wishes. On the contrary, the DNR order is a legal medical order that has been issued by a physician upon the direction of the patient that specific lifesaving treatments or methods are not to be used on an individual.

These lifesaving methods may include but are not limited to CPR, mechanical ventilation, tube feeding, or extreme measures to save life, such as a surgical operation that may extend life for a short period of time, but that will not offer a cure for a specific condition.

A Power of Attorney document is a legal document that enables an elderly person, or any person over 18 years of age, for that matter, to designate another person to take care of their personal, business, or financial affairs in the event that they are unable to do so themselves. There are different types of powers of attorney, including medical, financial, and business. In elderly care scenarios, advocates will most often come across powers of attorney that have power over multiple decisions regarding a person's life, including their medical care and treatment, their financial status, as well as their personal and business affairs.

Advocates should be aware that powers of attorney do not totally strip seniors of their legal powers, but are only enforceable during certain times. For example, a regular power of attorney may only go into effect if an elderly person experiences a medical condition that prevents them from making decisions for short period. Powers of attorney are usually limited in duration, for example 3 to 6 months.

A durable power of attorney remains in effect for as long as a person is incapacitated or until a person dies. Power of Attorney documents are generally constructed to meet specific needs of the senior and must adhere to the laws of the senior's state of residence. In most cases, a common durable power of attorney document may include information such as:

  • The name of the person giving over power or authority.

  • The name of the person who has been designated to act as the individual's decision maker.

  • The name of a person designated as a backup or replacement to the first power of attorney in the event that the first person can't perform the requested duties or obligations.

  • A specific list of the power or duties been given, for example, medical or financial, or both.

  • A specification or explanation for how long or under what circumstances or scenarios the power of attorney document will be valid.

A Power of Attorney document, regardless of what type it is, must be signed, witnessed, and sealed according to requirements and regulations of the state in which it has been issued. Powers of Attorney documents need to be issued for each state in which a representation may be needed. Advocates can advise family members or powers of attorney that originals should be filed with local County Recorder's Office, with the senior's legal representative or attorney, and to keep a copy themselves.

Advance directives are specific documents that decide specific health care decisions of the individual creating those directives. While a Power of Attorney places a large number of decisions in the hands of the elderly person's representative, advance directives communicate the preferences of not only the elderly individual, but also possibly other family members in regard to the type, duration, and complexity of medical care to be offered to a loved one.

An advance directive may determine whether a senior wants to be hooked up to a ventilation machine or to receive extreme lifesaving measures in the event of a terminal illness. For example, advocates should talk to seniors and their family members regarding their wishes for end-of-life care. Does Mom want to be placed on life support for no longer than 48 hours or two weeks? Does Dad want CPR to be given in the event of a heart attack in a hospital or nursing home environment? Advocates realize that many individuals are put through extremely intense and extraordinary measures, medical treatments, and procedures that extend life, but don't necessarily improve quality of life.

An advance directive typically includes two documents, a living will and a health care proxy document. Living wills outline an individual's wishes regarding medical care that may sustain life. A health care proxy is the same as a power of attorney for specific health care needs and allows someone else to make decisions regarding treatment in that person's stead.

Advocates should be aware that nearly 70% of deaths that occur in hospital environments occur after decisions by family members to disconnect or those who refuse life-sustaining treatments, but that are not directly related to the patient's wishes themselves. Advance directives should be available and signed by all individuals over 18 years of age. Such documents are free, easy to fill out, easy to sign, and easy to provide to family, doctors, and other important individuals in someone's life.

Advance directives should take a number of factors into consideration, including the feelings of individuals regarding dying, their religious beliefs, their opinions and feelings regarding life-sustaining medical treatments such as surgical procedures, mechanical ventilators, feeding tubes, and other extraordinary measures to prolong life in the event of incapacitation.

Advance directives will also determine what illnesses or diseases will be treated and which should be left alone. For example, a patient diagnosed with terminal prostate cancer may have very different wishes regarding end-of-life care than an individual in what is believed to be a temporary or medically induced coma following an automobile accident.

Most advanced directives designate that a certain amount of time for life sustaining efforts such as mechanical ventilation, tube feeding, or other measures be taken. Some people specify that if they're in a coma for more than two weeks, to literally pull the plug. Others may decide to remain on life support for six months, while others prefer no life support measures at all, depending on their age as well as their general physical and mental condition.


An elderly patient advocate must be knowledgeable regarding the attitudes and general considerations involved in the aging process. The senior advocate, due to their very specific career path or interest, should be caring and compassionate individuals who like to be around seniors and who get along with others easily. Often acting as a bridge between seniors, their families, and medical care providers, advocates offer valuable contributions to quality standards of care in home-based, assisted living and nursing home environments.

Whether a layperson, a family member, or a professional, we all have a responsibility to stick up for our seniors and to make sure that they're treated with compassion, dignity, and respect regardless of their background, their economic status, or their geographical location.