“For it may safely be said, not that the habit of ready and correct observation will by itself make us useful nurses, but that without it we shall be useless with all our devotion” (Florence Nightingale, 1859/2012, p. 112)1

As the model of medical care in nursing homes evolves, it’s becoming increasingly common for multiple providers to be involved in a patient’s care. Whether it’s an attending physician, one or more advanced practice providers (APPs), or a mix of both, the need for regular, effective communication is more important than ever.

In health care, "Agency" refers to the capacity of an individual or team to make decisions and take actions that positively affect their situation or events. I recall seeing this in action in the late 1990’s when a seasoned Director of Nursing (DON), new to our area, took over this position at a skilled nursing facility (SNF) where I was the Medical Director. She had an “Open Door” policy that encouraged employees to enter and approach her with their concerns. Our employees quickly learned she was a good listener and would listen even to personal concerns that were affecting the employees’ work. She had the ability to coach an employee or a group of employees with a similar problem and then develop with them potential innovative actions that might improve the problem(s). During her time as our DON, the facility developed and sponsored scholarships for certified nursing assistants (CNAs) to go to nursing school. Our employees listened well to our patients and their families and helped them take action during the rehab process to facilitate their recovery. In a brief period, our state and federal surveys improved to the point of back-to-back deficiency-free annual surveys. Unfortunately, her husband took a job out of the area, ending her time as our model “DON.”

“Doc, I was told at the hospital that my mom has dementia. Now that she’s here, I want you to tell me; does she have Alzheimer’s disease? Can you order a scan?”

May’s issue of Caring for the Ages had the attached article written by Robert C. Accetto, RPh, BCGP, FASCP. The Centers for Medicare & Medicaid Services (CMS) has revised guidance to surveyors (Appendix PP, State Operations Manual) for the use of Psychotropic Medications that went live in late April 2025. This article updates us on these revisions and provides explicit guidance for adhering to the revised informed consent process and the necessary documentation that it has occurred. All boxed (“black box”) warnings must be discussed and then documented in the prescriber’s notes. 

As long-term care clinicians, we manage a complex interplay of chronic disease, cognitive decline, and frailty. But one factor consistently tied to outcomes—and often underemphasized—is nutrition. For many of our residents, poor nutrition isn't just a consequence of illness; it’s a cause of functional decline, infections, and hospitalization.

I “retired” just prior to the pandemic, which flipped my script to “semi-retired.” Since 2024, I have worked maternity relief for a Program for All Inclusive Care of Elders (PACE) and since that ended, as a part time SNFist in a Continuing Care Retirement Community (CCRC) where I also will assess potential independent living residents and occasionally cover their geriatric clinic. In this capacity, I’ve reviewed medical records from Kaiser, Providence, and Sutter and am distressed by documents that are badly flawed with long lists of medical problems that aren’t accurate and misleading as well as superficial histories of the present illness that at most cover the prior 2 weeks of the patient’s illness and never document a social history. In addition, the minimalist HPI (History of Present Illness) of the ER doc is what I see cut and paste in the records of a patient’s chart by multiple providers throughout the duration of their acute hospitalization. I know that the pandemic badly stressed our health systems, but how can we provide “Care” that matters to our patients, with so little pertinent and accurate information?

A recent PALTmed Connect recommended this website (https://qi.ipro.org/sepsis/) to assist SNFs in the early recognition and management of Sepsis. A colleague of mine recently lamented that one of her patients had done poorly because of delayed recognition of sepsis. I suspect this is a frequent problem in SNFs where we have so many new nurses and a much lower nurse-to-patient ratio than occurs in the acute hospital setting. 

P.O. was a ninety-five-year-old man with dementia admitted to the hospital with a severe infection. He was admitted to the intensive care unit, and a “Do Not Intubate” order was written. Unfortunately, his mental status did not return to base-line. When he still had acute delirium, a speech therapist determined that he was at high risk for aspiration. His physician wrote the NPO order, and requested a gastroenterologist consider putting in a percutaneous endoscopic gastrostomy (PEG) tube. 

Many years ago, a woman in her 80s died of a preventable upper gastrointestinal (UGI) bleed. As the facility’s Medical Director, I became involved in this case after the disaster. This resident was at our facility for rehab and a community PCP was her attending physician. The facility podiatrist diagnosed acute gouty arthritis and prescribed the nonsteroidal anti-inflammatory medication indomethacin, which at the time, was a standard treatment option. However, this woman had a history of prior peptic ulcer disease, which the PCP was aware of and would not have permitted this Rx had he been aware of it. She died about 5 days later of a massive UGI bleed. This upsetting event resulted in a policy that all new prescriptions by other providers would require the approval of an attending physician. 

Turning on the Light podcast (Anyone Can Choose Leadership with Dennis Wagner and John Scanlon - Turn on the Lights Podcast | Podcast on Spotify) highlighted the key healthcare leadership themes in a just completed book by Dennis Wagner and John Scanlon. Leadership is distinct from management, administration, and observation. The book presents twelve essential leadership mindsets and methods drawn from years of experience and insights from respected figures. I agree with their assertion that Leadership is a choice and can be taught. Leaders view problems as a temporary setback to be overcome and usually do so by a team approach.

I have been a primary care doctor for over 36 years. Over that time, many of my older patients told me a goal of theirs was to get to age 100. It is a landmark birthday, that in 2024 only 0.03% of the US population achieved. The Today show on NBC, continues to honor centenarians by showing their images and briefly describing what they enjoy doing.

The regulatory framework for advancing excellence in cardiopulmonary resuscitation practices in nursing homes (NHs) is still evolving. The Patient Self-Determination Act (PSDA) was passed as an amendment to the Social Security Act in 1990. In advancing resident rights in nursing homes (NH), the Centers for Medicare and Medicaid Services (CMS) issued two related F-tags in 2012 and 2015 (e.g., F-tags 155 and 678, respectively). While F-tag 155 did not explicitly ban NH facility-wide no CPR policies, F-tag 678 §483.24(a)(3) directly addressed CPR practices in NHs. It required that “personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident’s advance directives.” While current American Heart Association guidelines require that staff “get and use the AED as soon as it is available,” the reality is that California does not require that NHs have AEDs. The CCR Title 22 §80075.1 on AEDS only states that “in an adult community care facility, a licensee is permitted to maintain and operate an AED at the facility if all of five requirements are met. States vary widely in AED requirements for settings, either by health codes or legislation.¹

CALTCM congratulates our own Dr. Noah Marco for his essay, “My Complaint about the Chief Complaint,” which received the runner-up award in a contest for best essay submitted to Caring for the Ages, the newsmagazine of the Post-Acute and Long-Term Care Medical Association (PALTmed). Dr. Marco’s column appears in the current March-April issue of Caring, which is always available to PALTmed members and non-members alike, without a paywall, at www.caringfortheages.com. Dr. Marco’s award-winning essay appears on page 14 of this issue, and can be found via this link: https://www.caringfortheages.com/article/S1526-4114(25)00017-4/pdf

The human body is a miracle of evolution. The synchronicity of the various systems is truly awe-inspiring. I mean, does anything else work like the human body? Every organ system, every cell, has a role, and we can’t operate without the direction of the brain. But…is the center of the human body the brain or the heart? Obviously, without the heart pumping blood, the brain can’t work.

PALTmed Connect is a website for Post Acute and Long-Term Care Medical Association (PALTMed) members to post questions related to the care of SNF patients. CMS has released new guidance this month to surveyors in the state operations manual regarding indications for Unnecessary Medications that update expectations for informed consent for psychotropic medications prior to their administration (CMS memo to surveyors QSO-25-07-NH).

To fully appreciate my mother’s story, I must describe it in the context of our long-term care (LTC) system. Drs. Rosalie and Robert Kane described the essence of LTC as “providing services for persons experiencing functional decline while living in their home, apartment, congregate living environments, or institutions.¹ Millions of caregivers, both unpaid and paid, provide LTC services for persons identified as having dementia.² Dementia is a general term used to describe “mental decline that is severe enough to interfere with daily living.” ³ At least half of persons with dementia in the United States are living in residential care and assisted living (RC/AL) facilities providing LTC services.⁴ These facilities are often components of continuing care retirement communities (CCRC), of which there are 2,000 nationally. ⁵

The history of tardive dyskinesia (TD) is intertwined with the development and use of antipsychotic medications.  TD was first observed after the introduction of first-generation antipsychotic drugs (also known as typical antipsychotics) such as chlorpromazine (Thorazine) and haloperidol (Haldol) in the 1950s. These medications revolutionized the treatment of schizophrenia and other psychotic disorders.

Agitation is a common and challenging symptom in Alzheimer's disease, characterized by restlessness, emotional distress, and aggressive behaviors. Managing these symptoms is crucial for improving the quality of life for both patients and caregivers.

As a solo practitioner in a SNF for 40+ years, I have developed a set of decision support tools accessible on my smartphone that address many of the questions that arise while caring for increasingly complex post-acute rehabilitation patients. I have been following the evolving literature on adaptation of AI (Artificial Intelligence) to clinical medicine in medical journals and podcasts, but have not seen practical uses for clinical problem-solving in the SNF setting.