Opinion: Keeping Nursing-Home Residents Safe Should Not Mean Taking Away Their Choices

In a nursing home, few events create more concern than fall. A fall can mean a fracture, an emergency room visit, hospitalization or a lasting loss of independence. Families worry about it. Staff worry about it. Residents worry about it.

That concern is justified. But an important question can get lost in our efforts to prevent the next fall: What does the resident want?

For an older adult who has spent a lifetime making decisions about where to go, when to get up and how to live, entering a skilled nursing facility should not mean that every decision involving mobility suddenly becomes someone else’s.

As California physical therapists who work in nursing-homes, we confront this tension every day. We have an obligation to reduce avoidable harm. But we also care for adults who may value walking to the dining room, using the bathroom with assistance, getting outside or continuing to do part of their own daily routine even when those activities involve some degree of risk.

Good care requires us to consider both.

Federal nursing-home regulations already establish an important principle: person-centered care should place the resident at the center of decision making. Residents have the right to participate in their treatment and care planning, and care plans are expected to incorporate their goals and preferences.

California similarly recognizes that residents of skilled nursing and other long-term-care facilities retain their civil and human rights. The California Department of Aging specifically identifies residents’ rights to information about their care and to consent to or refuse treatment.

Those rights should have practical meaning when we talk about mobility.

Consider a resident who can walk short distances with a walker and assistance but has recently experienced a near-fall. The safest response may sometimes be to change how that person moves. But the conversation should not automatically end with, “use the wheelchair from now on.”

Instead, the care team can ask: What contributed to the near fall? Has the resident’s strength changed? Is pain affecting mobility? Are medications causing dizziness? Is the walker appropriate? Does the resident need different footwear, more assistance, a toileting schedule or therapy reassessment? And importantly: What activities does the resident want to continue?

The answer will not be the same for everyone.

One resident may decide that walking to meals is important enough to accept assistance and reasonable risk. Another may prefer a wheelchair for longer distances while continuing to stand and transfer. Someone recovering from surgery may temporarily need more support but hope to regain greater independence.

That is what individualized care is supposed to look like.

Physical activity itself is an important part of healthy aging. The federal Centers for Disease Control and Prevention notes that physical activity can improve physical function, help older adults continue daily activities, and reduce fall risk when appropriately performed.

Yet in institutional settings, everyday opportunities to move can disappear surprisingly easily.

A staff member may complete a task because it is faster. A wheelchair may become the default transportation after an illness. A family member, understandably frightened by a fall, may ask that a loved one no longer walk.

Each decision may come from a desire to protect the residents. But collectively they can change the resident’s daily life.

The solution is not to minimize fall risk. It is to make shared decision-making about mobility a more deliberate part of nursing home care.

California can lead in several practical ways.

Facilities can make resident mobility preferences part of routine interdisciplinary care planning. When a resident can participate, the discussion should include what activities matter most to that person, the foreseeable risks and benefits, what assistance is needed, and what changes would trigger reassessment.

Families also need better education after a fall or decline. Hearing that a loved one is at “high risk for falls” can understandably create fear. Families should also understand the potential consequences of prolonged inactivity and the ways nursing, rehabilitation, physicians, restorative staff and caregivers can work together to support safer movement.

And California’s long-term-care system can continue emphasizing person-centered care not merely as a regulatory phrase, but as something residents experience in everyday decisions including whether and how they move.

This does not mean every resident should walk. Some people cannot do so safely because of their medical or functional condition. Others may choose not to. Clinical judgment remains essential.

Nor does resident choice mean that facilities abandon their responsibility to identify hazards or prevent avoidable injuries.

It means safety should be achieved with residents, not simply for them.

Nursing home residents do not stop being adults with preferences, priorities and personal definitions of quality of life when they enter a facility. For one person, avoiding virtually all physical risks may be a priority. For another, maintaining the ability to walk a short distance, stand at the sink or get outside may be worth accepting reasonable assistance and risk.

A high-quality nursing home should protect residents from avoidable harm while preserving as much independence, dignity and choice as their circumstances allow.

Keeping someone safe should not require taking away their voice.

Pradeepika Samagh is a California physical therapist, director of rehabilitation and certified fall-prevention specialist.

Arjun Dutt is a physical therapist and director of rehabilitation with experience in skilled nursing, geriatric rehabilitation and interdisciplinary care.

This article first appeared on California Health Report and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.

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Previously Published on calhealthreport.org with Creative Commons License

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