Myth No. 1.
In calculating the PPD (per patient day), the only important factors are the number of residents and the number of hours of direct nursing care provided.

Dependency and acuity are not components of the PPD but are necessary in determining if there are sufficient numbers of appropriately prepared staff to care for the residents. Outcomes that the PPD may be sufficient but that care needs are insufficient include increased numbers of residents with facility-acquired pressure ulcers; falls; increased numbers of residents with significant weight loss; elopements; and increased complaints by family and residents regarding medications, treatments, toileting, bathing, and assistance with meals.

Myth No. 2. Certified nurse assistants (CNAs) need to focus primarily on the delivery of care, including bathing, dressing, grooming, and eating.

Although these basic services are essential for resident care, the opportunity to encourage full participation by CNAs in the observation and interventions of residents with behavioral needs is missed.

CNAs are most intimately knowledgeable in the needs of the residents yet are often ignored when it comes to understanding why residents display behavioral issues. Providing a program on the ABCs of behavior—Antecedent, Behavior, and Consequences—supports CNAs’ ability to recognize the triggers that lead to problematic behaviors and to identify meaningful interventions to reduce these behaviors.

For example, Mrs. Miller was admitted two weeks ago from the hospital and will likely need to remain in the facility as a long term care resident. She is rarely visited by her family, experiences bowel and bladder incontinence, and leaves at least 25 percent of her meals uneaten.

At lunch one day, she threw her tray on the floor. Hearing the crash, several staff members rushed to her room. The staff showed concern as well as disapproval.

Caregivers tend to focus on the behaviors displayed, in this case the lunch tray contents on the floor, and the use of both positive and negative attention to the resident. However, caregivers fail to focus on the antecedent of the behavior: why Mrs. Miller threw the contents of her lunch on the floor. By encouraging the CNA staff to think about why the behavior occurred and to explore interventions to address the reasons for the behavior, resident care will not only be enhanced but also the skills and job satisfaction of the staff.

Myth No. 3. Frontline staff with GEDs or high school diplomas have sufficient knowledge of English to document, follow tray cards, and read material safety data sheets.

Facilities that experience errors in meal delivery may need to determine if the tray line staff have adequate ability to read the tray cards. Functional illiteracy is common in society and may be even more common in the nursing care center profession than in other sectors of the economy. Administrators may see potential employees asking to take their applications home with them, coming to the facility with someone else, or claiming that they need to return the application later as they failed to bring their glasses.

People with limited literacy skills will not freely admit to it during the interview process. If an administrator has large numbers of staff with literacy issues, a system may be needed of color-coded diet cards or other systems that use pictures, photos, or symbols to describe food preferences and diets.

Myth No. 4. Families feel very comfortable while visiting in the facility.

A range of feelings from guilt to frustration to helplessness are common in visitors to long term care facilities. There is an inherent discomfort felt that revolves around how much care the family member can or should provide while visiting, how vocal they should be in advocating for the resident, or how they see their role as “supervisor” of the staff during their visits.

Harnessing their energy in a positive way is the key to establishing an environment that encourages family members to constructively identify issues and bring them to the attention of the administrator—and should be the goal of the facility. Having family members involved with Family Council, recommending speakers or topics of interest, or being on a volunteer committee may be helpful in acknowledging the role of the individual. Having the staff understand the perspective of the visitor can also be used to enhance discussions about dignity and residents’ rights.

Myth No. 5. In reviewing incident reports, administrators should simply review the documents and ensure that the director of nursing and the medical director do the same.

Incident reports should be used as a means of identifying trends and patterns of issues that will lead to the formulation of interventions to minimize additional problems. Plotting out the day of the week, the time of the day, the place, and the nature of the activity during the time of the fall will help determine if staffing, education, or other interventions are needed.

The medical director should focus specifically on residents who fall to determine if orthostatic hypotension or other medical factors may play a role in falls.

The consultant pharmacist should be provided with information about residents with falls to address the possibility that medications impact the frequency of falls, determine if additional vital sign parameters need to be implemented, or to offer recommendations to alter medication timing to improve care delivery.

The trends, rather than the number of incidents, should be reported and discussed by the Quality Assurance and Performance Improvement committees.

Myth No. 6. The purpose of the Resident Council is to provide the residents with a forum for their complaints, such as meals, call bell responses, and missing underwear.

Although these are the top three complaints heard across the country, all issues really do need to be addressed in the Resident Council. If residents feel that complaints are made but are not sufficiently addressed, they will stop coming to the meeting and begin calling the ombudsman or the Department of Health to have their concerns addressed.

An effective way of managing these concerns is for the therapeutic recreation director to complete a Concern Form for each complaint, to have the department head take the form into the resident’s room to discuss the matter, and to work with the resident in formulating plans to address the problem. The final step is to revisit the issue with the resident to complete the loop of complaint-response‑resolution.

Myth No. 7. In devising an activities calendar, the therapeutic recreation staff should plan the events and then invite residents to attend what they believe would be appropriate activities.

The traditional way of devising an activities calendar has been to arrange for music, religion, exercise, and other programs and plug the residents into the schedule. Facilities now are adopting an alternative approach of assessing what activities the resident enjoyed prior to coming to the facility and devising a calendar around these common interests.

Resources such as the California Older Adults Pleasant Events Schedule ( provide an inventory of over 300 items that residents or their families can complete by identifying the most important activities for that individual. As baby boomers age, facilities need to identify activities that will enhance the experiences and lifestyles of this generation of residents who may expect WiFi access to coffee at all hours, trips out of the building, or other programs that may be different from the more mainstream programs.

Myth No. 8. It is best if all staff work set shifts: 7-3, 3-11, or 11-7. Making alterations in these schedules to accommodate staff will only cause confusion or error.

Increasingly, facilities are finding that having four-hour shifts or alternative schedules that allow for overlap between shifts provides an opportunity to have continuous coverage during the change of shift. Accommodating the needs of the mostly female, single, head-of-household mothers may decrease lateness and absenteeism because the schedule changes may provide an opportunity for selected staff to accommodate their needs.

These alterations may require an increased supervision of the off-schedule staff and may impact union contracts, but in the end may enhance the quality of the care and evidence of the administration’s support of the staff.

Myth No. 9. Coming to the facility off-hours allows administrators to catch people doing something wrong.

Frontline staff can become alienated from administration if they have little or no contact with them. Some staff may use the excuse that their minimal contact affords them the ability to ignore the established policies and procedures of the organization. Administrators should come to the facility on nights, weekends, and holidays to see how processes are being performed, how supervision is being provided, and how unexpected issues impact the staff. This approach supports that the administrator will catch the staff doing something good, rather than highlighting problems and finding fault.

Myth No. 10. The nursing home administrator’s style of management makes no difference to staff turnover.

Research has shown that the management style of the administrator and the director of nursing have a direct impact on turnover rates and staff satisfaction. Since most nursing schools provide little or no formal education in management and leadership skills, the administrator will need to provide this support for the nurse managers and supervisors, as well as demonstrate how these skills translate into improved care.

Ilene Warner-Maron, RN, PhD, is assistant professor, health services director, Interdisciplinary Health Services, at Saint Joseph’s University in Philadelphia. She can be reached at (610) 660-1586 or The first two articles of this series, respectively on the nursing department and clinical services, can be found in the Caregiving section of