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Bigger Patients, Bigger Challenges: For Patients of Size, Proper Care Can Be Elusive

      When you’re big, numbers matter. Like the 76 inches of my 83-year-old father’s height versus the 80-inch length of a standard hospital bed. We became well acquainted with these numbers after my dad fell 2 years ago and entered a long cycle of stays at more than half a dozen hospitals and nursing facilities.
      At 6 feet 4 inches tall and weighing 280 pounds, my father is not compatible with standard hospital beds. Nor, it turned out, is he compatible with standard nursing facilities. Again and again, nursing facilities refused to accept him because of his size and immobility. Those that did take him in often failed to provide the equipment he needed: he injured himself and set back his rehabilitation by banging his feet in his sleep against railings in standard-sized beds.
      “They were unable to give me any alternative other than to bear it,” said my father, Ralph Dotinga, who has since recovered and lives in an assisted-living facility near San Diego. Our experiences were far from unusual: people of size face tremendous challenges in American nursing facilities. Often they’re turned away or are forced to accept substandard care.
      “We should be able to provide the resources they need, and it should be something we do really well,” said John Alexander Harris, MD, MSc, an assistant professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of Pittsburgh. But in reality, he said, “it’s a challenge all the way around.”

      Skyrocketing Obesity Rates Across the Age Span

      Dr. Harris, who studies the health disparities that obese people face, said there are misconceptions about the patient population in nursing homes. “People think of them as filled with elderly, frail, thin people who are relatively easy to care for,” he said. In fact, “in the United States, about 30% of people in nursing homes are obese, and about 14% to 15% are severely obese,” he said.
      The numbers reflect the growing size of Americans of all ages, including the elder population. According to a 2016 report from the Centers for Disease Control and Prevention, the percentage of people aged 75 who are considered obese — with a body mass index (BMI) of 30 or more — shot up from 19% in 1988–1994 to 33% in 2013–2016. In the latter period, 2% had BMIs of 40 or more.
      By law, hospitals must treat people of all shapes and sizes when they need emergency care. And federal law requires hospitals to maintain appropriate bariatric equipment so they can care for patients who are morbidly obese, said Shenbagam Dewar, MD, ABOM, a clinical assistant professor with the Department of Geriatric and Palliative Medicine at the University of Michigan. However, these laws don’t apply to nursing facilities.

      Turning Away the Largest Patients

      Lori O. Smetanka, JD, knows the drill: call a nursing home, ask about space for a person of size, get rejected. Repeat. And repeat again.
      “Nursing facilities can often be really selective in regard to who they admit because they feel they don’t have the staff, capability, or equipment to provide the care that a person needs,” said Ms. Smetanka, who is the executive director of National Consumer Voice for Quality Long-Term Care, a nonprofit customer advocacy group. “Individuals might linger in a hospital for weeks at a time or even more before they’re able to find a location that’s suitable for them.”
      And those locations might not be anywhere nearby. “We hear all the time about people who have been forced not only out of their communities but hundreds of miles away from family and friends, even having to go to other states,” Ms. Smetanka said.
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      By law, hospitals must treat people of all shapes and sizes when they need emergency care. These laws don’t apply to nursing facilities.
      Image by cocoparisienne from Pixabay
      There are few statistics about how often nursing facilities reject patients even if they have space for them. However, a 2014 study reported on the results of a survey of 360 nursing homes in Arkansas and Pennsylvania. Two-thirds said patient size was a barrier to admission, and 6% flatly refused patients weighing 325 pounds or more (J Appl Gerontol 2014;35:286–302).

      Equipment Needs

      Moderately obese people like my father may only need a few types of special equipment, but severely obese patients can come with a vast array of unique needs.
      Bariatric patients may require nonstandard equipment such as beds, toilets, phlebotomy needles, examination tables, wheelchairs, walkers, Hoyer lifts, mattresses, and underwear. Other needs might include trapeze bar systems over beds and specially sized gowns, slippers, stretchers, friction-reducing sheets, bedpans, armchairs, tape measures, incontinence pads, slings, blood pressure cuffs, scales, shower chairs, commodes, and therapy tables.
      “It is not typical for a center to have specialty equipment on hand,” said Holly Harmon, RN, MBA, LNHA, FACHCA, the vice president of Quality, Regulatory & Clinical Services with the American Health Care Association, a trade group that represents care providers such as nursing homes and assisted living facilities. “In many cases, facilities must purchase high-cost equipment specifically for each patient that may not be reimbursed. There can also be a lag time from the date of ordering the equipment for purchase or rental to the date it can be delivered. This can impact the timeliness of the center being able to admit the patient.”

      Families Stepping In

      By law, nursing homes must provide appropriate care for the patients they accept — but this is no guarantee, as my family discovered. One nursing home accepted my father with a promise to provide an extended-length bed, which never appeared. And only after I had nagged the facility’s top executives for months did they refund the over $250 copay for the ambulance that took my father to a facility that could actually meet his needs.
      There were other hassles as well. After various delays and errors, we stopped waiting for appropriately sized wheelchairs and walkers to be ordered and delivered when my father entered a skilled nursing facility. Instead, we hired delivery services at our own expense to transport my dad’s own extra-large wheelchair and walker from facility to facility as needed.
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      With Greater Size Comes More Staff Needs

      Larger patients can require a tremendous level of nursing support. “Bathing an obese adult takes two certified nursing assistants with a combined time of 105 minutes with special equipment compared to 45 minutes for nonobese with one CNA and no equipment,” said Dr. Dewar. “It can take as many as six CNAs to help move a 600-pound resident from the bed to a shower gurney while using a Hoyer lift.” Also, she said, “additional CNAs are often needed to change body positions and assist with mobility to reduce the likelihood of pressure ulcers.”
      Unexpected challenges can face caregivers, too. For example, “there’s no way to do CPR on someone who’s bariatric,” said Traci Clark, RN, director of nursing at Creekside Rehabilitation & Behavioral Health in Santa Rosa, CA, in a presentation at the California Association of Long-Term Care Medicine’s annual meeting in 2017. Although it’s possible to perform the Heimlich maneuver on a bariatric patient, she said, two people may be required. “My arms will not go around a 56-inch chest,” she said. “These are some of the things that no one thinks about.”

      Difficult Choices for Nursing Homes

      Even if a nursing facility does want to serve patients of size, the expense — and risks — can seem overwhelming. But there are ways to overcome the obstacles and provide appropriate care to patients of size, experts say. Proper training is especially crucial. For example, research suggests that properly trained staff members do not face a higher risk of injury from caring for larger patients, Dr. Dewar said.
      Caregivers can also be trained to avoid bad habits, such as needlessly treating obese patients differently. “Staff members have reported that they’re less likely to get them up and out of bed in the morning,” said Dr. Harris. “They think they’d rather move the smaller people first, rather than the one who takes 35 minutes.”
      Joy Stephenson-Laws, JD, a Los Angeles–based health industry attorney, urged facilities to set appropriate prices. “Caregivers should not necessarily base their charges on a ‘normal weight’ patient with medical conditions,” she said. “They have to anticipate that roughly 40% of their patient population may be obese, requiring extraordinary services and equipment, and set their prices accordingly.”Caregivers have to anticipate that roughly 40% of their patient population may be obese, requiring extraordinary services and equipment.– Joy Stephenson-Laws, JD
      Another strategy is to push for reform and changes in the regulations governing nursing facilities. Ms. Smetanka said her organization has asked federal Medicare officials to require nursing homes to accept patients of size, although so far that’s been a no-go.
      For now, she said, “we hope that nursing homes are carefully and honestly evaluating the needs of the residents and not just randomly refusing to admit them because of reasons that might be overcome with a bit of thought or attention.
      Randy Dotinga is a San Diego-based freelance writer.