The Stories That Never Make the Survey Report

I spent the first part of my career as a journalist, which meant I was trained to look for the story. Years later, after an unexpected career change landed me in long-term care, I discovered that nursing homes have no shortage of them.

The difference is that most of these stories would never have made it past an editor.

A resident walks ten feet farther in therapy than he did the day before. A CNA knows which blouse a resident will choose before she opens the closet. A housekeeper notices that someone who normally says good morning has suddenly stopped talking. A husband comes every afternoon to sit beside his wife, even when she no longer seems entirely certain who he is.

None of this is breaking news. There is no press release. Nobody calls the state. Yet if you spend enough time inside a nursing home, you begin to understand that these ordinary moments can carry extraordinary significance to the people living them.

Unfortunately, they are also among the hardest things about nursing home care to measure.

We measure almost everything else.

We track falls, infections, weight loss, pressure injuries, antipsychotic use, rehospitalizations, staffing hours and dozens of other indicators. We conduct audits. We hold quality meetings. We investigate incidents. We prepare plans of correction. Surveyors arrive with laptops, interview residents and staff, review records and observe care. Eventually, their findings become part of the public record.

All of that matters. I have spent enough years as an administrator to know why it matters.

But a survey report can tell you whether a facility met a regulatory requirement. It cannot completely tell you what it feels like to live there.

That distinction has stayed with me throughout my career.

Families searching for a nursing home understandably want something objective. They look at ratings. They read inspection reports. They compare staffing information. Some tour several buildings, taking notes as they go. They should. Those tools exist for a reason.

But when families walk through our doors, I sometimes wish I could tell them to look beyond what can be printed on a comparison sheet.

Watch what happens when a resident passes a staff member in the hallway. Does the employee know the resident's name? More importantly, does the resident know theirs?

Listen to the dining room. Not simply for whether the meal looks appetizing, but for conversation. Look at the residents who are not participating in the scheduled activity. Is anyone paying attention to them?

Notice the small things.

Those small things have occupied much of my thinking about long-term care because they are where institutional care becomes personal.

A nursing home is, by definition, an institution. There are medication passes, treatment schedules, staffing assignments, dietary requirements, care plans and enough documentation to make anyone who entered healthcare because they "wanted to help people" reconsider some of their life choices.

For the people who live there, however, it is something else.

It is home.

That word creates an uncomfortable standard for those of us who run these buildings because nursing homes do not look much like the homes most residents left behind. There may be a roommate on the other side of a curtain. Meals arrive according to a schedule. Someone may need assistance simply to use the bathroom. Privacy, independence and spontaneity—things most of us barely notice while we have them—can suddenly become precious commodities.

That is where the people who work in nursing homes become important in ways that rarely appear in their job descriptions.

A CNA may be responsible for helping someone get dressed, but how that CNA does it can determine whether the resident feels assisted or helpless. A social worker may solve a problem that looks administrative on paper but has been keeping a family awake at night. A therapist may celebrate three steps that would mean nothing to the rest of us because everyone in that therapy gym knows how hard those three steps were.

A nurse may finish a medication pass and still take another minute to answer the same question she answered ten minutes earlier.

A housekeeper may know more about a resident's day than anyone realizes simply because she has been listening while she cleans the room.

These moments are difficult to quantify, and perhaps that is why we don't talk about them enough.

We tend to discuss nursing homes at the extremes. When something terrible happens, it can and should receive scrutiny. When a facility achieves an exceptional result, we celebrate it. Between those two points, however, is where most nursing home life actually occurs.

It happens on an ordinary Tuesday afternoon.

Someone is waiting for a daughter who said she would visit after work. Someone else is trying to get strong enough to go home. A resident is complaining about dinner. Two roommates are negotiating control of the television. A nurse is calling a physician. A CNA is trying to convince someone to take a shower. Somewhere in the building, someone is laughing much louder than seems necessary.

This is long-term care, too.

When I began writing Would You Leave Your Parents Here?, I found myself returning to these moments. I did not want to write a manual about running nursing homes, and I certainly did not want to pretend the industry has no problems. I wanted to write about the part I had witnessed for more than two decades but rarely saw represented when nursing homes were discussed publicly: the everyday lives unfolding inside them.

The title came from a question I have asked staff over the years.

Would you leave your parents here?

It is not a regulatory standard, and I would not recommend adding it to the survey protocol.

But it has always been useful to me because it makes quality personal.

If this were your father waiting for his call light to be answered, how long would feel acceptable? If this were your mother sitting alone at lunch, would you notice? If this were your spouse being helped into bed, how would you want someone to speak to them?

Regulations give us standards. Data gives us information. Surveys give us accountability. We need all three.

But none of them relieves us of the responsibility to notice the human being standing—or sitting, or waiting—in front of us.

After all these years, perhaps that is what the journalist in me still looks for when I walk through a nursing home. Not necessarily the biggest story in the building, but the smallest one.

Because sometimes the story that will never make the surveyreport is the one that matters most to the person living it.