A: Pressure injuries affect up to 2.5 million U.S. patients per year, and conservative estimates of cost ranges from $9.1 to $11.6 billion per year., according to the Agency for Healthcare Quality and Research.

Complications include pain, scarring, infection, prolonged rehabilitation and permanent disability. They are largely preventable, and 60,000 patients die each year as a direct result of pressure injuries. 

They are common across the healthcare continuum; pressure injury prevalence in long-term care ranges from 4.1% to 32.2%.  Despite these pressing concerns, pressure injuries are not a specific item on the research funding agenda of the Centers for Disease Control and Prevention and are not a recognized public health issue. 

The statistics on pressure injuries are eye-opening when compared to more widely recognized public health threats. Pressure injuries cause more deaths in the U.S. per year than car accidents and guns combined.  

Given their prevalence, morbidity and cost, it is puzzling that pressure injuries are an underappreciated public health issue. Perhaps it’s time to face this issue squarely by recognizing its importance and scope and increasing funding toward research on pathophysiology, prevention, and treatment.

Medical education concerning wound care also needs a boost. Most doctors receive little training on pressure injuries. However, the imperative for physicians to become more involved in wound care has grown with the aging demographic and improved technologies that prolong life.

Preventing and curing pressure injuries is a multidisciplinary endeavor that will require better allocation of resources to research, technology, systems improvement and manpower.

It was around 1996. Of course, getting the new toy to actually work was a bit of a challenge back then. First, there was the sign-up sheet. Yes, a team of editors shared the lone computer with World Wide Web access. Each person could use the magic machine for a half hour. Not a minute longer.

Then there was the matter of getting a typed-in URL to actually appear, watching elements slowly assemble and hoping the desired destination wouldn’t time out.

Back then, what we were really learning was patience. But we felt newly empowered. It was as if our ability to grasp knowledge had changed. For, indeed, it had.

By today’s standards, things were remarkably primitive. But it’s amazing how long people will embrace a mediocre-or-worse status quo. At least until a better option comes along.

A similar phenomenon appears to be happening in this field. In many ways, senior living is the best thing that ever happened to the aged — and their stressed out children.

Dignity-preserving care outside the home has never been so abundant. For a relatively new invention, it has evolved, diversified and filled in niches at warp speed.

Yet for all the progress, this sector is much like our office’s internet capabilities circa 1996. The current stock of long-term care facilities offer an amazing improvement over their predecessors. But what we now have available will be laughed at as appallingly inadequate in a few short decades. Perhaps sooner.

I have no doubt that what’s ahead for this sector will put current realities to shame. Let’s just hope that future operators will be better able to master the caregiving, staffing, payment and other big-ticket challenges that seem so universal today.

What I strongly suspect is that many current obstacles will be overcome. But new, unexpected problems also will arise.

Will the sector be able to meet new demands? Will completely different approaches to eldercare and housing nullify the reality that currently exists? Who knows?

What is guaranteed is this: Long-term care will be different. Try not to be left behind.

Read O’Connor’s blog each Monday at www.mcknights.com.

Lisa Morris, a consultant pharmacist and executive director of clinical services at Consana, recommends parallel approaches. First, look for signs that staff may be abusing substances; simultaneously, look for indications of diversion.

Physical signs of a staff member’s substance abuse can include memory loss, nausea, sweating, tremors or headaches. Behavioral or financial patterns also can signal abuse. Those who divert are often absent after a diversion. When working, they may volunteer to do med pass and insist on administering controlled substances. Look for staff who request off-peak shifts or who arrive early or stay late. Some who divert controlled substances sell them; watch for staff who make disproportionately large purchases.

To identify possible diversion, look for tampering: pills that are taped back in a medication card, changes in liquid medications’ viscosity, or powder on capsules’ outsides. Be alert for quantity loss as well, including missing bottles, cards or liquids. Monitor for poor pain control among residents despite narcotic administration, frequent refills of controlled substances, or frequent apparent wasting of drugs by one nurse or unit.

Closely examine medications at high risk for diversion, including morphine, fentanyl and hydrocodone. Lastly, monitor for differences between count sheets and pharmacy manifests.

Prevention is the key to limiting drug diversion. Have and follow clear policies on controlled substances, including administration and how expired or discontinued medications are handled. Reducing opportunities for diversion will prompt fewer instances that need to be detected.

Please send your nursing-related questions to Amy Stewart at ltcnews@mcknights.com.

That’s just one of the stark findings from the McKnight’s 2022 Outlook Survey, in which industry leaders reported feeling largely pessimistic heading into the new year.

Leaders also remained highly concerned about rebuilding census, tighter regulatory compliance and Medicaid reimbursement rates.

McKnight’s Long-Term Care News garnered 317 responses from nursing home owners, administrators and top nurse managers who filled out online surveys from Dec. 10 to Dec. 30.

After two years of pandemic conditions, a majority of respondents continued to be somewhat satisfied with their jobs, giving an average rating of just under 6 (out of 10), though that represented a slide of about 12% from a year earlier. When asked about optimism for the industry as a whole, only 19.8% said they were more optimistic about what 2022 will have in store.

About 58% were less optimistic about 2022, and 22.4% expected a “neutral” outlook.

“Skilled nursing leaders no longer see the light at the end of the tunnel,” said Cara Silletto, president and chief retention officer of Magnet Culture, a recruiting and retention firm serving the skilled nursing industry. “The tunnel is getting darker and deeper. No one sees the end of the pandemic in sight.”

The survey found that 98% of respondents said “having enough staff” was a top-four concern, 10 percentage points higher than a year earlier.

Meanwhile, worries about census eased a bit, with 61% of respondents listing it as a top-four concern, versus 82% a year ago. Expectations about when pre-pandemic census levels might return, however, slid heavily during the last 12 months.

Nearly 75% of operators had to limit admissions in 2021 without enough staff to serve all would-be residents, and 60% expected to do so again in 2022.

Notably, 50% said skilled census likely wouldn’t match pre-pandemic levels until 2023 (28%) or 2024 or later (22%).

More agency staffing ahead

The needs for contract and agency staffing could actually worsen, according to survey respondents.

About 39.4% said they expect to use more temporary staff in 2022, and another 26.2% said they would use the same amount. Another 9.8% expect to use less, while 24.6% of respondents said they do not or will not use contract or agency workers.

Meanwhile, worries about tighter compliance and more regulation came in as the third-most common top concern, with 56.8% checking that box.

As for how long staffing challenges will last, providers aren’t optimistic. Many have lost confidence since last year’s survey.

About 21.5% thought they’d get back to full staffing levels sometime in 2022. But more than two-thirds envision labor shortages lasting longer. About 22% predicted a 2023 recovery, while 31% said 2024 or later and 25% said never.

Signs of hope

Amid the negatives, some found a modicum of hope. Fifteen percent said their buildings had already returned to pre-pandemic census levels, with about 12.4% expecting to do so in the first half of 2022 and 20.5% in the second half.

Returning to full operations also has been a relative bright spot for many respondents, although overall expectations were tempered during the last 12 months. In late December, 26% said they had already resumed all normal activities, including group dining, visitation and day trips.

Another 37.6% anticipated they will in 2022. Many providers — nearly two-thirds — said they stand ready to add new or expanded services in 2022.

More comprehensive results can be found at mcknights.com.

The information will first be placed on the consumer-facing Medicare Care Compare and then in July be incorporated into the Five-Staring rating system. Staffing averages have been posted there for a decade.

The moves intensify pressure on providers that are facing a historic workforce shortage with no clear end in sight.
Researchers have associated nursing home staff turnover with lower star ratings and poorer outcomes.

“The publication of these statistics (by CMS) has been a long time coming,” said UCLA health economics assistant professor Ashvin Gandhi, who in 2021 found national turnover rates to be much higher than previously believed.

The brains of people without dementia had a buildup of plaques and tangles containing normal tau proteins, while the brains of those with dementia had a different form of tau.

Alzheimer’s may be caused by brain cells’ slowing ability to do proper clean-up, University of California, Riverside, researchers theorized. Tau proteins left too long may change and lead to the development of dementia.

Between February and April 2020, one month before and after COVID-19’s first wave began in the U.S., nursing home employment dipped just 3%. Skilled nursing’s double-digit drop followed in the months after, and rates continued to sag while most other healthcare sectors rebounded.

Though healthcare workers left nursing homes, they didn’t necessarily leave the workforce. Researchers found no significant unemployment changes for RNs, LPNs, or aides.

That means the Medicare payment system was working as intended during the six months before and just after the pandemic was declared in 2020, investigators told McKnight’s.

“We didn’t see any changes in ADL scores at discharge,” said Momotazur Rahman, P.h.D., of Brown University’s School of Public Health. “That would imply that there was too much therapy provided before.”

The researchers reviewed records for about 200,000 patients, one-fourth of them admitted post-PDPM.

Guidance issued just before Christmas applies to those whose symptoms abate or those who can produce a negative COVID test. The move was meant to help relieve staffing shortages as nursing homes and other providers struggled with a COVID surge.

“We know how challenged nursing homes and all long-term care facilities have been in keeping their staff healthy and working. If you’re boosted, you can keep working,” said the CDC’s Arjun Srinivasan, M.D. “You can not only serve your patients but you can also help your fellow staff members.”

The updated guidance led to wide confusion, especially as the agency issued different advice for the general public around the same time. The quarantine and isolation recommendations take into account a healthcare worker’s vaccination status if they are exposed or infected with the disease.