Medical care in skilled nursing facilities (SNFs) in the United States

INTRODUCTION — Skilled nursing facility (SNF) care in the United States includes both long-term residential care and short-term post-acute or rehabilitative care. There are various terms used to describe nursing facilities that include nursing home (NH), nursing facility (NF), and long-term care (LTC) facility. In this chapter, we will use the term SNF in lieu of other terminology, recognizing that not all NFs or LTC facilities have beds that are certified by Medicare as “skilled.” Long-stay residents generally have custodial needs focused on assistance with activities of daily living. Because Medicare does not pay for “custodial” care, funding for these residents is private pay or through Medicaid. Shorter-stay residents typically have rehabilitation as a key component of their care and are funded primarily through Medicare or commercial insurers.

While the number of Americans living in SNFs for extended periods has fallen steadily over the past decade as an increasing proportion of older individuals remain in their homes or in assisted living facilities, the number receiving short-term nursing care has risen dramatically. In 2014, 1.7 million fee-for-service (FFS) Medicare beneficiaries were cared for in 15,000 SNFs, costing Medicare USD $28.6 billion. This represents 2.4 million SNF stays: 20 percent of all hospitalized FFS Medicare beneficiaries are discharged to a SNF. The majority of these facilities are the same institutions as those providing residential long-term care: 95 percent of SNFs provide both kinds of care [1].

SNF residents, whether short- or long-term, tend to be old, female, and have multiple impairments in their ADLs. Cognitive impairment is also widespread in this population, with 36.9 percent exhibiting severe impairment, 24.9 percent having moderate impairment, and 38.2 percent with mild or no impairment [2]. A relatively small number of individuals under the age of 65 also receive care in SNFs. This population often has different comorbidities and needs (ie, head injury, psychiatric illness, and substance use disorders).

SNF care represents a substantial segment of health care costs for older individuals: in the United States in 2010, $143 billion was spent on SNF care, of which 14 percent was paid by Medicare, 63 percent by Medicaid, and 22 percent privately [3]. The costs of care are covered differently, depending on whether the patient is receiving long- or short-term care:

●Long-term residents (most often referring to those residents whose stay extends beyond 90 days) live at the facility and are often described as receiving “custodial care.” Room and board costs for this group are generally paid for by Medicaid, long-term care insurance, or out-of-pocket by residents or their families.

●For most short-term patients discharged from a hospital setting, the goal is to return to the community. A subset of these patients may be at the SNF for short-term end-of-life care and some will require long-term care. Room and board costs are generally paid by their SNF benefit, which, in the case of Medicare, covers up to 100 days per benefit period if care needs meet specific clinical criteria. Clinical criteria include the need for rehabilitation to regain function due to deconditioning, and/or medical instability requiring frequent nursing and/or medical intervention. In the Medicare FFS system, a patient must be in an acute hospital as an inpatient for 72 hours (three midnights) to qualify for the SNF benefit. Although the benefit can last for 100 days, a substantial copay is required after day 21. The average length of stay in a Medicare-covered SNF post-acute episode is about 25 days and is declining because of value-based reimbursement strategies. Some Medicare-managed care and bundled payment programs can obtain a waiver of the 72-hour rule and directly admit patients to the SNF. The length of stay for these patients is generally shorter because of the financial incentives for care at the lowest level that is safe and feasible.

●Reimbursement for short-stay patients on the Medicare fee-for-service benefit changed as of October, 2019. Reimbursement is no longer based on Resource Utilization Groups, which incentivized rehabilitation therapy for higher daily rates. The new system is the “Patient Driven Payment Method” (PDPM), which is complicated but intended to drive reimbursement by the complexity of patient care [4].

Clinicians providing medical care in the SNF must be knowledgeable about regulatory, ethical, and epidemiologic as well as geriatric issues [5]. For certain conditions, such as heart failure, diabetes mellitus, and chronic obstructive pulmonary disease, medical management is similar to outpatient management. This topic will focus on those medical conditions in SNF patients that warrant a particular approach or heightened awareness. Many are geriatric syndromes that comprise constellations of symptoms that may have any of several etiologies. The topic will also address those regulatory, ethical, and epidemiologic issues that bear on clinician practice.

COMPREHENSIVE GERIATRIC ASSESSMENT — Comprehensive geriatric assessment includes an evaluation of the patient's functional, physical, cognitive, emotional, and psychosocial status. It is a cost-effective intervention that improves quality of life in a variety of settings [6] and is recommended for use in frail older adults by the American Geriatrics Society [7]. The skilled nursing facility (SNF) is an ideal environment in which to carry out comprehensive geriatric assessment since its population is at high risk and the length of stay is relatively long, even for short-term rehabilitation patients. In fact, a comprehensive assessment as well as periodic reassessments are required by law. (See "Comprehensive geriatric assessment".)

The Minimum Data Set — In the United States, the Omnibus Reconciliation Act of 1987 (OBRA-87) mandates that all SNFs complete a comprehensive evaluation of residents at the time of admission, an assessment that is intended to serve as the basis for the plan of care. A pivotal part of the assessment is the Minimum Data Set (MDS), a standardized instrument mandated by the Centers for Medicare and Medicaid Services (CMS). Completion of the MDS 3.0 serves as the basis for the creation of an individualized treatment plan [8]. Data from the MDS are also used to determine reimbursement rates for Medicare fee-for-service (FFS) beneficiaries and to measure quality of care in nursing homes, both for long- and short-term residents (table 1). A subset of these measures is posted on the CMS website, Nursing Home Compare, to help patients and families select a facility [9], and they are used in the calculation of the 5-Star rating, which is increasingly important to SNFs for bundled payment initiatives and relationships with Accountable Care Organizations.

A key component of the MDS is measurement of the individual’s ability to perform activities of daily living (ADLs) including transferring, ambulating, hygiene, toileting, communicating, and eating. For most short-stay patients, the focus is on achieving independence with these activities. The emphasis for long-term care residents is on preventing functional decline.

Goals for post-acute care (short-term patients) — Post-acute patients are typically expected to make gains in function and therefore usually receive some combination of physical therapy, occupational therapy, or speech therapy.

●Physical therapists focus on mobility, including ambulation with and without assistive devices, as well as wheelchair mobility. Stair training is provided when appropriate.

●Occupational therapists address hygiene, self-feeding, and dressing. Often they work together with physical therapists to address transfers to and from bed, chair, and toilet.

●Speech therapists address safety in eating and swallowing by advising on food and beverage consistency as well as chewing and swallowing techniques. They also assist patients who suffer from communication problems such as dysarthria, aphasia, or hearing impairment. They may train facility staff, family, and home caregivers in techniques to optimize communication.

To achieve home discharge, SNFs provide interdisciplinary care that incorporates physicians, advance practice clinicians, facility nurses, case managers, and social workers. Mental health clinicians and dieticians are often active members of the team as well. In addition to providing ongoing medical care for problems diagnosed in the acute care hospital and facilitating rehabilitation, SNFs must be alert for the occurrence of new problems. Nurses, recreation therapists, and certified nursing assistants (CNAs) will typically be the first facility staff members to recognize that a new medical problem is developing. Family members or other loved ones often notice subtle early changes in condition as well. Close communication with the attending clinician is important to assure that new acute medical conditions, drug side effects, or psychiatric issues such as depression are addressed rapidly and effectively. The Interventions to Reduce Acute Care Transfers (INTERACT) program has a variety of tools that facilitate these processes [10].

In addition to optimizing function and medical care, the interdisciplinary team must identify what home supports the patient will need. These supports may be provided by the family/loved ones and may also involve agencies such as home health agencies and area agencies on aging. Caregiver education is a crucial aspect of preparation for discharge to a home setting, with an emphasis on how to monitor and manage the patient's medical conditions and how to administer medications.

Family meetings — Family meetings are an important component of care in SNFs. Care planning meetings are recommended within the first few days of SNF admission. Additional meetings can be helpful for short-term patients with complex medical and/or psychosocial care needs prior to discharge, or whenever there is a significant change in condition in a long-term resident. Families or other loved ones are generally asked to participate in care planning meetings on a quarterly basis for long-term residents [11]. Such meetings serve as a means of learning and sharing information and can facilitate medical decision-making and advance care planning. Whenever possible, the patient and surrogate decision makers should attend the meeting along with key staff, including representatives of the rehabilitation team, nursing, and social service along with the attending clinician (physician, nurse practitioner, or physician assistant). Many facilities are now able to conduct these meeting virtually, which can enhance participation by caregivers and loved ones who are not living locally.

A useful format for these meetings includes the following steps:

●Review of the current medical situation to be sure that clinicians, patient, and family have the same understanding

●Review of advance directives currently in place, including whether the patient or resident is capable of making their own care decisions, the name of the surrogate decision-maker, and any agreed-upon limitations of care

●Review of treatment options, including an explanation of what can be done at home, in the SNF and at the hospital

CLINICAL ISSUES — Clinical care in the skilled nursing facility (SNF) setting is challenging because of the heterogeneity of the population and their vulnerability to adverse outcomes. The majority of SNF residents have multimorbidity as well as impaired cognitive function and/or mobility. These conditions make them especially susceptible to adverse events.

Evidence-based interventions and guidelines have generally been developed for much healthier populations. Thus, directly applying these evidence and practice guidelines to SNF residents could have unintended negative consequences. Specific examples include: the overtreatment of hypertension, which may contribute to falls and syncope; and the overtreatment of diabetes, which can result in recurrent episodes of hypoglycemia. Clinicians working in SNFs must use a person-centered approach to multimorbidity in order to prevent polypharmacy and diagnostic and therapeutic interventions that may cause more harm than good [12].

Vision and hearing — Impairments in vision and hearing are potentially reversible causes of impaired function and quality of life in nursing home residents. These impairments are also associated with falls and their complications.

●All residents should undergo the simple vision screening assessment included in the MDS. Residents who demonstrate moderate visual impairment or worse should undergo formal vision testing by an optometrist or ophthalmologist, unless they would not be expected to benefit from intervention due to severe dementia or other comorbidities. (See 'The Minimum Data Set' above.)

●Residents should undergo a screening hearing test using the whisper test and, when feasible, audiologic evaluation for a hearing aid if the screening test is positive. (See "Evaluation of hearing loss in adults".)

Simple remedies for visual impairment such as finding a missing pair of glasses can facilitate rehabilitation for short-term patients. In other patients, testing for refractive errors and supplying glasses to correct vision improves measures of quality of life and symptoms of depression at two months [13]. (See "Geriatric health maintenance", section on 'Vision screening'.)

In addition, cataract surgery in SNF residents can lead to significant improvements in vision, psychological distress, and social interaction when compared with matched controls [14]. A comprehensive vision restoration-rehabilitation program introduced in a random sample of nursing homes led to a higher rate of cataract surgery in eligible residents, compared with usual care facilities (31 versus 2 percent) [15].

Readily reversible causes of hearing impairment, such as impacted cerumen, should be corrected. Hearing impairment is found in 70 to 90 percent of older SNF residents [16]. Uncorrected hearing impairment adversely affects quality of life by leading to depression, cognitive impairment, and social isolation. In the long-term care setting, many individuals who have hearing aids are unable to use them independently and rely on assistance from certified nursing assistants (CNAs). Many residents with hearing impairment have not been evaluated for a hearing aid. In part, this reflects inadequate insurance coverage. Medicare pays for 80 percent of the cost of a hearing evaluation but does not cover hearing aids; Medicaid pays some or all of the cost of a hearing aid in 31 states [17]. (See "Presbycusis" and "Hearing amplification in adults".)

Dementia — Routine screening of new admissions is recommended, using tests such as the Mini-Mental State Exam (MMSE), the Mini-Cog [18], or the Brief Instrument of Mental Status (BIMS) [19]. The BIMS is included in the Minimal Data Set (MDS) 3.0, mentioned above. (See "The mental status examination in adults", section on 'Cognitive screening tests' and 'The Minimum Data Set' above.)

Dementia is widespread in the SNF setting, with 37 percent of residents diagnosed with severe dementia and 25 percent with moderate dementia [2]. Prevalence in the long-term population is even higher, as the behavioral and cognitive problems associated with dementia are a frequent reason for admission.

Mild to moderate dementia — Treatment for cognitive symptoms due to Alzheimer disease and other dementias is controversial [20,21]. One rationale for a trial of therapy, to maximize the potential that a patient continues to be able to live in the community setting, becomes moot once patients are admitted for long-term care but may be important for short-term patients to maximize the likelihood of home discharge.

A discussion of pharmacologic options for dementia treatment is presented separately. (See "Treatment of Alzheimer disease" and "Cholinesterase inhibitors in the treatment of dementia".)f

The treatment of dementia-related behavioral symptoms (agitation, wandering, aggression, and other symptoms) is often difficult in the SNF environment and is discussed separately. (See 'Behavioral issues' below.)

Advanced dementia — Very advanced dementia (Cognitive Performance Scale 5 to 6 on the MDS or MMSE score less than 10) engenders special challenges. A prospective study of 323 residents with advanced dementia followed for 18 months found a mortality rate of 54.8 percent, with 41.1 percent developing pneumonia and 85.8 percent developing problems with eating [22]. In the same population, during the last three months of life, 40.7 percent of residents were hospitalized, had an emergency department visit, were treated with intravenous medications, or underwent tube feeding.

Enrollment of patients with advanced dementia in hospice is sometimes problematic, given the difficulty of predicting six-month mortality [23]. However, adoption of a palliative approach to care is both feasible and advisable even when patients are not referred for hospice care. Discontinuing medications that are unlikely to provide benefit, such as lipid-lowering agents or cholinesterase inhibitors, can decrease costs of care and risk of adverse effects [24]. (See 'Hospice and palliative care' below.)

Delirium — New admissions to SNFs are screened for delirium utilizing the Confusion Assessment Method (CAM) (table 2), which has been incorporated into the MDS 3.0. This tool has a sensitivity of 94 to 100 percent and specificity of 90 to 95 percent [25]. While other instruments are available for screening, a review of 11 bedside instruments used to identify the presence of delirium in adults concluded that the best evidence supported the use of the CAM [26]. (See "Diagnosis of delirium and confusional states", section on 'Recognizing the disorder'.)

Delirium is a geriatric syndrome present in over one-third of hospitalized older adult patients, many of whom continue to have delirium on hospital discharge. In one study of 4744 admissions to eight post-acute facilities, one in seven patients was found to have delirium on admission [27]. Shortened hospital stays and the increasing age of the population are likely to increase these numbers. Delirium has been identified in 16 percent of all patients admitted to nursing facilities, affecting both long-term and post-acute residents [28]. (See "Diagnosis of delirium and confusional states".)

Delirium is associated with multiple adverse outcomes in SNF patients. In one study, for example, patients with delirium who were admitted to post-acute nursing facilities had a higher 30-day mortality, a higher hospital readmission rate, a lower likelihood of discharge home, and a lower likelihood of physical function improvement compared with patients without delirium [29].

The signs and symptoms of delirium can be subtle and transient, making detection difficult. This can be especially problematic for new admissions to SNFs when staff may be unaware of the baseline status of patients and thus not realize that cognitive, behavioral, or functional changes are new. Patients with delirium can be incorrectly thought to have dementia, depression, psychosis, or even "normal" aging. Clinicians in SNFs should incorporate observations of facility staff as well as the family members/loved ones of patients in order to identify and monitor delirium. (See "Diagnosis of delirium and confusional states", section on 'Recognizing the disorder'.)

Patients are often transferred to emergency departments for evaluation of symptoms related to delirium. While transfer can provide rapid medical assessment, it is a source of disruption and stress to patients, especially those with dementia. Additionally, it can be difficult for clinicians not familiar with the patient to assess for significant changes in cognition. While delirium is often described as a medical emergency and prompt evaluation is needed, consideration should be given as to whether a delirium evaluation can be performed by medical staff within the nursing facility using onsite laboratory and radiograph services. The Interventions to Reduce Acute Care Transfers (INTERACT) program contains a care path and other decision support tools for the evaluation and management of altered mental status without transfer to the hospital when safe and feasible [10].

Pharmacologic management of delirium needs to be tailored to the symptoms. Reviews have documented the lack of effectiveness of antipsychotics for the prevention and treatment of delirium in the hospital setting. These data can be extrapolated to the SNF setting as well [30,31]. More severe symptoms may require the use of antipsychotic medications when the individual is clearly psychotic, resisting needed care, or a danger to themselves or others. Whether atypical antipsychotics are more effective than typical antipsychotic medications in delirium management remains uncertain [32]. Antipsychotic agents are considered chemical restraints and their use is carefully scrutinized in the SNF setting. Supportive documentation for their appropriate use must be provided in the medical record. Benzodiazepines should generally be avoided unless the delirium is specifically caused by alcohol or benzodiazepine withdrawal. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis" and "Second-generation antipsychotic medications: Pharmacology, administration, and side effects".)

Primary prevention of delirium is probably the most effective treatment strategy [33]. An observational prospective study of delirious hospitalized patients showed that factors related to worsening delirium severity include: the number of room changes, the absence of a clock or watch, the absence of reading glasses, and restraint use [34]. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis", section on 'Prevention'.)

Delirium can persist for months in some patients and become more of a chronic rather than an acute condition. In one study of 551 patients admitted to 55 rehabilitation hospitals and 30 SNFs in 29 states, 23 percent of patients had delirium on admission and, at one week, only 14 percent of the cases of delirium had resolved [35]. The percentage of short-term nursing home patients with delirium two weeks after admission is one of five quality measures publicly reported by the Centers for Medicare and Medicaid Services (CMS) [36]. Failure to resolve delirium may necessitate that short-term patients transition to long-term care.

Behavioral issues — Management of behavioral disorders in the SNF is difficult, whether behavior issues arise from longstanding mental illness or from dementia. Misuse of psychotropic medications in older adults to address these issues leads to frequent adverse effects and deteriorating medical and cognitive status. To combat this problem in the United States, the Omnibus Budget Reconciliation Act of 1987 (OBRA–87), mandated freedom for every resident from medically unnecessary "physical or chemical restraints imposed for purposes of discipline or convenience." Measurement of restraint use is a CMS quality indicator for long-term residents. Nonetheless, a study of 16,586 newly admitted residents to nursing homes across the United States found that 28 percent received at least one antipsychotic medication in the year following admission [37]. While studies of nonpharmacologic therapies for behavioral issues in long-term care have shown promise, they typically require specialized staff or significant additional time commitments from staff, limiting their generalizability [38]. Dementia training for nursing facility staff is now a requirement in some states [39].

Agitation and psychotic symptoms — Over 80 percent of patients with dementia develop neuropsychiatric symptoms at some point during the course of their disease [40].

Managing dementia-related agitation and psychotic symptoms in the SNF resident is challenging. Agitation may be due to the dementing process or a reversible medical condition such as urinary retention or infection. Once acute medical problems have been excluded, clinicians should consider empirical treatment of pain. One cluster randomized trial of nursing home patients with dementia found that a systematic approach to the management of pain, compared with usual care, decreased agitation and did not worsen activities of daily living (ADLs) or cognition [41]. Studies indicate an increased mortality associated with use of either conventional or atypical antipsychotic medications for dementia-related psychosis, and the US Food and Drug Administration (FDA) in June 2008 has issued a black box warning that "antipsychotics are not indicated for the treatment of dementia-related psychosis" [42]. (See "Management of neuropsychiatric symptoms of dementia", section on 'Antipsychotic drugs'.)

While treatment options other than antipsychotic medications are available for behavioral symptoms (eg, mood stabilizers or benzodiazepines), there are no other medication options for delusions or hallucinations. The only recourse for clinicians is to inform the patient, family, and caregivers of the mortality risk associated with antipsychotic medications in older adults and to decide with them whether to proceed with treatment. The prevalence of the use of antipsychotic medications is a CMS quality indicator for both short- and long-term SNF residents.

If antipsychotics are used, sedating, highly anticholinergic medications such as chlorpromazine should be avoided, as should conventional antipsychotics such as haloperidol, which may cause parkinsonism. One population-based cohort study in nursing home patients found that the hazard ratio of death within 180 days of initiating treatment with an antipsychotic medication was twice as high for haloperidol as for atypical antipsychotics, even after adjusting for predefined potential confounding factors [43]. The atypical antipsychotics (eg, olanzapine or quetiapine) may be effective for agitation and psychotic symptoms in demented patients in SNFs [44], although this is not confirmed in all studies [45]. When possible, these drugs should be prescribed for short-term use with regular reassessment of risks and benefits. The use of these medications is discussed in detail separately. (See "Management of neuropsychiatric symptoms of dementia", section on 'Antipsychotic drugs' and "Second-generation antipsychotic medications: Pharmacology, administration, and side effects".)

Aggressive behavior — Aggressive behavior develops in 20 to 57 percent of individuals with dementia [46]. Such behavior is particularly troubling in the SNF where roommates are impacted and caregivers are compromised by violent outbursts. A useful framework for clinicians to use in responding to demented patients exhibiting aggressive behavior is as follows [47]:

●Assess the danger of the situation to the patient and others

●Establish an etiology of the symptoms

●Determine how severe and frequent the symptoms are

●Explore past treatments and caregiver strategies for similar problems that have been effective

●Institute nonpharmacologic strategies for behavior management if no underlying medical cause discovered

●Discuss with the patient's surrogate the risks and benefits of pharmacologic treatment

●Regularly assess the response to pharmacologic treatment, monitor for adverse reactions, and titrate to the lowest effective dose; consider a trial off of the medication if symptoms have been well controlled for three to six months

While the documented benefit of non-neuroleptic medication in this setting is limited, several nonpharmacologic strategies have been effective, including music therapy, cognitive stimulation therapy, and behavioral management therapy [47]. Caregiver education to help the staff manage difficult situations is paramount. (See "Management of neuropsychiatric symptoms of dementia".)

Wandering — Wandering or aimless walking around are difficult issues for SNFs because of liability concerns as well as a cultural emphasis on patient safety. SNF administrators often fear that a demented patient will leave the facility and get hurt.

Patients who simply enjoy walking in the facility and do not intend to leave the premises are frequently labeled wanderers. Creative approaches to allowing the patients freedom of movement without endangering their security include the use of door alarms, magnetized identification bracelets, enclosed patios, and circular corridors that promote contained walking.

Depression — We believe that screening for depression should be carried out on all SNF residents using validated measures [48,49]. In addition to the MDS, the short version of the Geriatric Depression Scale, which takes 5 to 10 minutes to administer, is appropriate for those with no more than minimal cognitive impairment [48]. The Cornell Scale for Depression in Dementia is appropriate for those with cognitive impairment (table 3) [49]. (See "Diagnosis and management of late-life unipolar depression", section on 'Screening instruments'.)

In addition, a prior history of depression should be ascertained in all SNF residents, as those with a history of depression are at risk of recurrence and should be considered for long-term maintenance therapy. One randomized trial of antidepressant treatment, psychotherapy, or placebo in 210 older individuals with major depression found a two-year recurrence rate of 37 percent in those maintained on paroxetine versus 68 percent in those on placebo and psychotherapy [50].

Some but not all studies support screening for depression in SNF residents. One multicenter trial found that residents in non-dementia SNF units randomly assigned to a multidisciplinary care program aimed to detect and treat depression had decreased prevalence of depression compared with those in units without the care program [51]. However, this benefit was not observed in dementia units, perhaps because of decreased adherence to depression assessment procedures in these units.

Depression is widespread and undertreated in SNFs. It is a CMS quality indicator for long-term residents. One study of 634,060 long-term residents in 4216 United States SNFs in 2005 found that 55 percent had depression during their first year. Depression was present at the time of admission for 33 percent and another 22 percent developed depression during the year [52]. Analysis of SNF residents in Ohio found a similar prevalence rate of depression but noted that 23 percent of those diagnosed with depression were untreated [53].

Untreated depression in the post-acute setting can decrease motivation, resulting in lack of participation in the rehabilitation program, thus impacting SNF length of stay and impeding the likelihood of successful discharge to home. In the residential setting, depression impairs quality of life by causing social isolation, loss of interest in usual activities, and problems with eating and sleeping.

Treatment of depression in older adults is discussed elsewhere. (See "Diagnosis and management of late-life unipolar depression", section on 'Treatment'.)

Psychotropic medications — There is an increased focus regarding the appropriate use of psychotropic medications in SNFs, including antidepressants, antipsychotics, anti-anxiety medications, and hypnotic medications. In some states, SNFs are required to obtain consent from the patient or the durable power of attorney when these medications are administered. Consent forms and medication orders need to include dose ranges for each psychotropic medication being administered. Patients and residents treated with antipsychotic medications must be monitored for extrapyramidal side effects. In addition, the indication for psychotropic medication use should be regularly reassessed and, when feasible, gradual dose reductions should be attempted.

Falls — Falls are a common problem in the SNF, with the mean incidence of falls reported to be 1.5 falls per bed per year [54]. The fall rate is a CMS quality indicator for long-term residents [55]. The cause is often multifactorial, with intrinsic factors such as gait disorders, visual impairment, and dementia as well as extrinsic factors such as environmental hazards and medications contributing. A meta-analysis of fall prevention programs in SNFs did not show a significant effect on the overall incidence of falls, although it did significantly reduce the number of recurrent fallers [56]. (See "Falls in older persons: Risk factors and patient evaluation" and "Falls: Prevention in nursing care facilities and the hospital setting".)

Deaths in patients who have had a fall may require reporting to the medical examiner/coroner. (See "Death certificates and death investigations in the United States", section on 'Deaths reportable to medical examiner/coroner' and "Death certificates and death investigations in the United States", section on 'Considerations for special populations'.)

Infections — In the SNF, infection is one of the leading causes of morbidity, mortality, and readmission to the acute care hospital. (See "Causes of infection in long-term care facilities: An overview".)

Frail older adults are at high risk of contracting a variety of infections because of impaired immune defenses, multiple comorbidities, nutritional deficiencies, and exposures within the SNF environment. In addition, patients with advanced dementia or multiple strokes often have impaired swallowing, which puts them at high risk of aspirating and developing pneumonia. (See "Approach to infection in the older adult", section on 'Increased risk for infection'.)

Age-appropriate immunizations for influenza and pneumococcus should be administered to all SNF patients; additionally, herpes zoster and diphtheria-tetanus boosters should be offered to long-term patients. Despite diminished vaccine efficacy in the SNF population, vaccination will help to both prevent infection in the immunized patient and prevent spread of infection within the institution [57]. (See "Standard immunizations for nonpregnant adults" and "Principles of infection control in long-term care facilities", section on 'Prevention of infection'.)

Clinicians must be aware of the epidemiologic challenges posed by SNFs. While the benefits of antibiotic treatment to the patient may be small, the public health risk of fostering antibiotic resistance with treatment may be considerable. Inappropriate antibiotic use in SNFs contributes to higher rates of antibiotic-resistant pathogens (eg, methicillin-resistant Staphylococcus aureus [MRSA], multidrug resistant organisms [MDO], and vancomycin-resistant Enterococcus) and to antibiotic-induced Clostridioides difficile colitis [58]. A study of 214 nursing home residents with advanced dementia found that over approximately one year, two-thirds received at least one course of antimicrobial therapy, with quinolones and third-generation cephalosporins most commonly prescribed [59]. Antimicrobial use increased significantly in the two weeks prior to death.

SNFs are increasingly implementing antibiotic stewardship programs to reduce the incidence of resistant organisms, antibiotic-associated drug interactions, and C. difficile infections [60]. Federal conditions for participation in the Medicare program require SNFs to identify an infection control practitioner and implement an antibiotic stewardship program. Many resources are available for these programs [61].

Evaluation for infection — Several factors may compromise the recognition of infection in SNF residents, including communication difficulties, medical comorbidities, and atypical presentations. Fever, as typically defined (temperature >100.4°F [38°C]), is absent in more than 50 percent of nursing home patients with serious infection [58]. (See "Approach to infection in the older adult", section on 'Fever definition'.)

Infection should be suspected in SNF residents who exhibit the following signs and symptoms [58]:

●New or increasing confusion, incontinence, deteriorating mobility

●Decreased food intake

●Change in behavior (eg, agitation, aggressiveness)

2008 updated guidelines from the Infectious Diseases Society of America suggest the following parameters for defining a fever in patients in SNFs [58]:

●A single oral temperature >100°F (37.8°C); or

●Repeated oral temperatures >99°F (37.2°C) or rectal temperatures >99.5°F (37.5°C); or

●An increase in temperature of >2°F (1.1°C) over baseline

Initial evaluation, often by nursing staff, should include assessment of respiratory rate, hydration, mental status, skin inspection, and evaluation of oropharynx, chest, heart, abdomen, and catheters if present.

Advance directives should be reviewed prior to further assessment. A complete blood count, with differential cell counts, is reasonable as an initial test if workup is consistent with the advance care plan. Blood cultures generally have a low yield and should be performed only when bacteremia is highly suspected. Pulse oximetry should be done for patients with tachypnea (respiratory rate >25 breaths per minute) or other respiratory signs and symptoms. Chest radiography should be ordered when hypoxemia is present (oxygen saturation <90 percent) or suspected.

COVID-19 — At the end of 2019, a novel coronavirus was identified as the cause of a cluster of pneumonia cases in Wuhan, China. Subsequently, the infection has spread throughout the world, resulting in a global pandemic. The coronavirus is designated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the illness it causes is coronavirus disease 2019 (COVID-19). The epidemiology and clinical characteristics of COVID-19 are presented elsewhere. (See "COVID-19: Epidemiology, virology, and prevention" and "COVID-19: Clinical features" and "COVID-19: Diagnosis".)

Features of the clinical presentation unique to older adults are also discussed separately. (See "Approach to infection in the older adult", section on 'COVID-19'.)

Treatment for older adults is the same as for younger patients. However, a discussion of thoughtful advance care planning under the guidance of palliative care or ethics teams is appropriate, due to the poor prognosis associated with severe infection in older adults. (See "Advance care planning and advance directives", section on 'COVID-19 resources'.)

Detailed information about management of patients with COVID-19 in the nursing home and skilled rehabilitation setting, including vaccination and other methods to prevent SARS-CoV-2 infection, is provided separately. (See "COVID-19: Management in nursing homes".)

Influenza — Influenza virus is typically brought into the SNF by staff or visitors and spreads rapidly among the residents who share rooms and eat in a communal dining room. Hospitalization rates soar during epidemics as frail older adults commonly develop cardiac complications, principally myocardial infarction and congestive heart failure, and pulmonary complications, particularly bronchospasm and pneumonia. In addition, many SNF residents affected with influenza infection experience a subsequent decline in functional status, including a decrease in independence in bathing, dressing, and mobility [62].

Every effort should be made to vaccinate residents against influenza in the early fall. For both long- and short-term residents, the influenza immunization rate is a CMS quality indicator. Vaccination of SNF staff has also been particularly effective in preventing resident morbidity and mortality [63]. (See "Principles of infection control in long-term care facilities" and "Principles of infection control in long-term care facilities", section on 'Health care workers'.)

If an outbreak of respiratory illness characterized by fever, nonproductive cough, and myalgias occurs, influenza should be suspected. The diagnosis of influenza is discussed separately. (See "Seasonal influenza in adults: Clinical manifestations and diagnosis".)

Emergence in the United States of influenza strains resistant to amantadine and rimantadine has led to the Centers for Disease Control and Prevention (CDC) recommendations for use of neuraminidase inhibitors zanamivir (inhaled) and oseltamivir (oral) for the treatment and prevention of both influenza A and B [64-67]. One study conducted in 548 frail older SNF residents, many of whom were vaccinated for influenza, found that prophylaxis with oseltamivir (75 mg daily) for six weeks, beginning when influenza was detected locally, reduced the incidence of laboratory confirmed influenza compared with placebo (4.4 versus 0.4 percent) [68]. Treatment doses and prophylactic use of neuraminidase inhibitors are discussed separately. (See "Seasonal influenza in nonpregnant adults: Treatment" and "Seasonal influenza in adults: Role of antiviral prophylaxis for prevention".)

Additional infection control measures should be instituted in the event of an influenza outbreak, including closing the affected units to new admissions and limiting the movement of both patients and staff from affected to unaffected parts of the SNF. A coordinated approach to respiratory infection can decrease the number of cases, hospitalizations, and deaths at a relatively modest cost [69]. (See "Infection control measures for prevention of seasonal influenza".)

Clostridioides difficile — C. difficile, another organism to which SNF residents are particularly prone, presents an infection control challenge [70]. Debilitated residents who are treated with broad spectrum antibiotics are highly susceptible to developing C. difficile diarrhea. The organism forms spores that can survive for considerable periods on fomites, thereby leading to high transmission rates. Fecal incontinence and poor personal hygiene, both widespread problems in the nursing home, compound the risk of spread. (See "Clostridioides difficile infection in adults: Epidemiology, microbiology, and pathophysiology".)

The diagnosis and treatment of C. difficile are discussed elsewhere (See "Clostridioides difficile infection in adults: Clinical manifestations and diagnosis" and "Clostridioides difficile infection in adults: Treatment and prevention".)

Asymptomatic bacteriuria — Asymptomatic bacteriuria can be found in approximately 50 percent of SNF residents. A variety of factors predispose older adult patients to develop urinary tract colonization [71]:

●Dementia

●Physical inability to get to the toilet

●Neurologic processes affecting the bladder

●A general rise in the incidence of urinary tract infection (UTI) with age that starts in childhood and continues throughout life

Diagnostic criteria for bacteriuria in older adults are the same as those for younger subjects. However, the presence of pyuria is not specific for UTI in older SNF patients [72]. (See "Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults".)

The treatment of asymptomatic bacteriuria in older adults does not prevent symptomatic infection, improve urinary function, or enhance survival. (See "Asymptomatic bacteriuria in adults".)

Pneumonia — Pneumonia occurring in the SNF setting is referred to as "nursing home-associated pneumonia" (NHAP) and is a leading cause of death in SNFs. Residents with advanced dementia, severe Parkinson disease, or other neurologic conditions are at high risk for aspiration pneumonia. (See "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults" and "Aspiration pneumonia in adults".)

Immunization with the pneumococcal vaccines is recommended for all individuals who meet specified criteria and who do not have evidence of adequate vaccination, unless the goal of care is exclusively to maintain comfort. The rate of pneumococcal vaccination is a CMS quality indicator for SNFs. (See "Pneumococcal vaccination in adults".)

Several studies have identified the importance of oral hygiene for the prevention of pneumonia in older adult (>65 years of age) SNF residents [73-76]:

●In a prospective study of 613 nursing home residents followed for one year, 112 (18 percent) developed radiographically documented pneumonia [73]. Inadequate oral care (hazard ratio [HR] 1.55) and swallowing difficulty (HR 1.61) were independently associated with pneumonia.

●The importance of oral care in preventing pneumonia and pneumonia death was illustrated in a trial of 417 patients (average age 82 years) who were in a SNF and at baseline had poor oral health [74]. Patients were randomly assigned to an oral care group (including nurses or caregivers brushing the teeth after every meal and hygienists providing professional care once per week) or no oral care. During two years of follow-up, patients in the non-oral care group had a significantly higher incidence of pneumonia (19 versus 11 percent in those receiving oral care, relative risk [RR] 1.67, 95% CI 1.01-2.75) and, among those who developed pneumonia, a higher incidence of death due to pneumonia (16 versus 7 percent, RR 2.40, 95% CI 1.54-3.74). The benefits of oral care were evident whether the patient had teeth or was edentulous.

Pneumonia can often be successfully treated in the SNF, with two studies showing comparable outcomes to patients treated in the hospital [77,78]. One of these studies showed that implementation of a clinical care pathway decreased hospitalizations by a mean of 12 percent [78]. Details of this pathway are presented separately. (See "Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care", section on 'Nursing home residents'.)

Obtaining a bacteriologic diagnosis of pneumonia is impossible in most SNF patients; thus, initial treatment is usually empiric. The most common bacterial pathogen causing NHAP is Streptococcus pneumoniae, with S. aureus and enteric Gram-negative organisms commonly found in the sickest patients [79]. (See "Treatment of hospital-acquired and ventilator-associated pneumonia in adults", section on 'Empiric therapy'.)

Tuberculosis — Screening for latent tuberculosis infection (LTBI) among individuals in SNFs has been a routine practice in the past [80]; subsequently, enthusiasm for routine testing and treatment of LTBI has waned [81]. The indications and approach for LTBI testing are discussed separately; no modifications to this approach are needed for patients in long-term care facilities. (See "Tuberculosis infection (latent tuberculosis) in adults: Approach to diagnosis (screening)".)

Infection in SNF residents with advanced dementia — The prognosis of infection in SNF residents with advanced dementia is poor, and antibiotic therapy has not been shown to improve outcomes. Initiating antibiotic treatment in patients with advanced dementia may not achieve either the goal of life prolongation or amelioration of symptoms. A study of fever episodes in 104 nursing home residents with Alzheimer disease found no difference in survival among those with advanced dementia treated with antibiotics and those treated with intensive comfort measures [82]. Studies have also found that antibiotic treatment was not more effective than oxygen and acetaminophen in alleviating suffering [83].

Regardless of the site of treatment, the long-term prognosis for residents with advanced dementia who develop pneumonia is poor: one study found a 53 percent six-month mortality, compared with 13 percent in cognitively intact older adults [84]. One prospective observational study found that SNF residents with advanced dementia who received antibiotic treatment for pneumonia had longer survival but lower scores on measures of comfort than those who were not treated for pneumonia [85]. This suggests that, among those residents with advanced dementia for whom comfort is the overriding goal of care, it is appropriate to withhold antibiotics and focus on palliative care. When antibiotics are elected, oral administration and treatment in the SNF may be more consistent with the goals of care than intravenous antibiotics or hospital care.

Tube-feeding, which is sometimes recommended for SNF residents with recurrent aspiration pneumonia, has not been shown to prevent aspiration [86] (see "Gastrostomy tubes: Uses, patient selection, and efficacy in adults"). Instead, the clinician should recommend palliative care in the nursing home setting. (See 'Hospice and palliative care' below.)

Pain — Pain is common in the SNF setting and is often undertreated. One cross-sectional study of 49,971 residents found daily pain in 26 percent of nursing home patients, of whom almost one-quarter received no treatment [87]. Undertreated pain places SNF residents at risk for a myriad of complications including depression, weight loss, delirium, functional decline, and skin breakdown. This supports the current use of self-report of moderate-to-severe pain as a CMS quality indicator in the SNF setting.

Even those with moderately severe cognitive impairment are able to identify if they have experienced pain in the preceding five days. Accordingly, MDS 3.0 incorporates resident interviews in the assessment of pain and measures the impact of pain on quality of life by asking whether pain has impaired sleeping or day-to-day activities [88]. When pain does impact these activities, therapeutic interventions should be considered, but the response to those interventions should be carefully assessed and monitored. Interventions should only be continued if they are effective and are not causing significant adverse reactions.

Pain can be persistent, acute, or related to end of life.

●Persistent pain, often caused by arthritis, is present in up to 80 percent of SNF residents [89].

●Acute pain related to a new medical or surgical condition is especially prevalent in short-term patients recently discharged from the hospital. Patients with postoperative pain represent a significant subset of this population.

●Pain at the end of life is common in the SNF, which is the site of 25 to 30 percent of all deaths. Malignancy is a common cause for pain at the end of life, but other conditions such as advanced dementia have been shown to cause similar distress [89].

Many nonpharmacologic approaches can be effective in managing pain, especially chronic pain associated with arthritis in the SNF population. These include heat, cold, massage, stretching, and strengthening among several others. When drug therapy is needed, all three types of pain should be treated using the World Health Organization (WHO) pain ladder, a three-step approach that uses non-opioids, weak opioids, and strong opioids coupled with adjuvant medications where appropriate [90]. Patients with pain should be assessed as to whether pain medications should be given "on demand" (prn) or on a scheduled basis and whether long- and/or short-acting preparations should be used. Patients with cognitive impairment who have persistent pain should be given scheduled analgesics as they commonly do not request as needed (PRN) medication when they may benefit from it. Anticipating the loss of bowel motility caused by opioids is essential. Bowel medication programs may need to be adjusted with escalations or reductions in opioid doses. (See "Prevention and management of side effects in patients receiving opioids for chronic pain", section on 'Opioid bowel dysfunction'.)

Persistent pain is common in frail and older adults. They frequently have cognitive deficits and impaired communication that make obtaining an adequate history challenging. For these same reasons, it can also be difficult monitoring the response to pain medications. An algorithm may be helpful in assessing pain in SNF residents with severe cognitive impairment (algorithm 1).

Persistent pain should be managed by following the WHO pain ladder, often using scheduled rather than prn medications and using nonpharmacologic modalities as suggested above. Use of nonsteroidal antiinflammatory drugs (NSAIDs) in this population carries substantial risks and should be avoided. Hence, acetaminophen and weak opioid analgesics are preferred over NSAIDs for most patients. Topical NSAIDs and lidocaine patches may be helpful in the management of persistent pain and acute worsening of arthritic symptoms.

Factors that contribute to uncontrolled pain in SNFs include using medications with insufficient potency and/or inadequate frequency of administration, particularly for patients recently transitioned from parenteral to oral medications. Post-acute patients typically require physical and occupational therapy, which can result in increased pain as activity increases. As mentioned above, use of prn medications in cognitively impaired residents commonly contributes to uncontrolled pain.

Post-acute patients typically have conditions that are expected to improve. Ongoing assessment needs to be made regarding optimal timing for gradual dose reduction of pain medications. Planning how opioids will be administered and tapered after discharge is essential and must be coordinated with the clinicians who will assume care post discharge.

Pain at the end of life poses unique challenges. Often patients are unable to take oral medications, necessitating that pain medications be administered via alternate routes. Transdermal and sublingual preparations of opioids can be particularly useful in the SNF setting. While subcutaneous injections can often be used in SNFs, the duration of pain relief tends to be shorter than with oral or transdermal preparations with an increased likelihood of suboptimal pain control. While some facilities are able to give pain medications via subcutaneous infusion pumps, most are not.

Staff resistance to opioid administration at the end of life is often related to fears of causing harm to the patient. Strong clinician and facility leadership coupled with educational programs for staff are essential to provide effective pain management to this population. In addition, hospice involvement can provide additional support and expertise in managing pain.

Nutrition and hydration

Nutrition — Both short-term patients and long-term SNF residents are particularly vulnerable to difficulties maintaining adequate nutrition and hydration. Patients admitted from the acute care hospital setting are at risk for weight loss because they may have been “nothing by mouth” (NPO) or on a restricted diet in the hospital for significant periods of time perioperatively or to obtain imaging studies. In addition, delirium, pain and gastrointestinal disorders can impact nutritional status even after such conditions resolve or improve. Institutional settings may not provide food choice offerings that match patient preferences. Chronic illness, depression and medication side effects can further cause or contribute to anorexia and weight loss [91]. Long-term SNF residents often have chronic, progressive illnesses that impact appetite, chewing, swallowing, and digesting of food, and some weight loss is unavoidable.

The CMS standards dictate that every SNF resident should be provided with sufficient food and fluids to maintain proper nutrition and hydration. Significant weight loss is a CMS quality indicator for nutrition and hydration in long-term SNF residents. Assessment for weight loss is part of the MDS quarterly reassessment process. Unintentional weight changes of 5 percent in 30 days and 10 percent in 180 days require care plan review. Studies indicate that unintentional weight loss of 5 percent is a marker for a 5- to 10-fold increased risk of death [92].

SNFs should document whether weight loss is expected or is unintentional. In residents who are terminally ill, weight loss may be unavoidable and palliative treatment plans should be in place indicating that low oral intake and weight loss is expected. If unintended weight loss is present, the resident should be assessed for remediable causes.

The interdisciplinary team is important in the prevention and management of weight loss. SNFs have registered dieticians who perform nutritional assessments and can make recommendations regarding diet and the use of nutritional supplements. The Mini-Nutritional Assessment (MNA) can identify patients with, or at risk for, malnutrition with 96 percent sensitivity and 98 percent specificity [93].

Interventions related to weight loss and optimizing nutrition need to be integrated with the patients' overall goals and a well-documented plan of care. Interventions by speech therapists, occupational therapists, or behavioral health clinicians may be indicated, depending on the etiology of the weight loss. Dysphagia, for example, is commonly associated with neurologic problems such as Parkinson disease, Alzheimer disease, or stroke. Post-acute patients may have oral infections (eg, thrush), inflammation related to radiation therapy, or dentures that are misplaced or ill-fitting. Speech therapists can identify the most appropriate food consistency and can work with patients to optimize chewing and swallowing techniques. Impaired dexterity, whether due to arthritis, stroke, or a recent fracture, can make it difficult for patients to use utensils. Occupational therapists can teach patients to use assistive devices such as utensils with thickened handles that are easy to grasp. Nursing assistants provide supervision, encouragement, and assistance with feeding. SNF staff members also teach family members and other caregivers how to manage these nutrition-related issues prior to discharge to home for short-term patients.

Long-term residents with advanced dementia often have difficulty chewing and swallowing. There is no evidence that percutaneous endoscopic gastrostomy tubes improve nutritional status or prolong life in the SNF resident with advanced dementia, the most common situation in which dysphagia occurs [94,95]. (See "Gastrostomy tubes: Uses, patient selection, and efficacy in adults".)

Depression is a major factor associated with malnutrition, and weight loss in older persons is a condition for which antidepressant medication is often indicated [96]. However, antidepressants can also cause anorexia (SSRIs) or anticholinergic symptoms such as dry mouth and constipation (tricyclic antidepressants). Evidence suggests that mirtazapine may be more effective than SSRIs in promoting weight gain, most likely because its mechanism of action is both serotonergic and noradrenergic [97]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Treatment of weight loss'.)

Oral supplements are often used in the management of weight loss. A meta-analysis of 15 studies in malnourished geriatric patients (including some patients in hospital as well as SNF settings) found a small survival advantage for patients provided with liquid diet supplements compared with no specific nutrition treatment [98]. Factors that may interfere with the success of oral supplements in the SNF include inadequate nursing staff time to deliver and assist with the between-meal supplements, interference with calorie consumption at meals, and unrealistic dosing schedules [99]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Nutritional supplements'.)

Megestrol acetate is an appetite stimulant that has been used in patients without a reversible etiology of weight loss. However, evidence of benefit is weak [100]. Because of potential adverse effects, megestrol acetate should not be used in most SNF residents. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Appetite stimulants'.)

Total parenteral nutrition (TPN) is sometimes advocated in the setting of weight loss. However, few SNFs have the clinical resources and expertise to manage TPN, and it is expensive. This modality of nutrition should be limited to short-term use for a reversible condition, and feeding via the gastrointestinal route should be restarted as soon as possible.

Hydration — Older individuals are at increased risk of hypovolemia due to an impaired thirst mechanism and age-related reduction in renin and aldosterone production that results in increased renal excretion of salt and water. This risk is magnified in cognitively impaired SNF residents who may be unable to articulate the experience of thirst and in physically impaired residents who may have difficulty procuring fluids. Medications such as diuretics further increase the risk of hypovolemia, especially when an acute medical condition diminishes appetite and fluid intake. Simple interventions such as regularly offering fluids to residents have been shown to significantly decrease the frequency with which dehydration develops [101].

The symptoms of hypovolemia in the nursing home population are often nonspecific, such as a change in mental status or falls. More specific signs of hypovolemia, such as orthostatic hypotension, dry mucus membranes, hypernatremia, and prerenal azotemia are typically associated with more profound degrees of volume depletion [102].

SNFs vary in their capability to start and maintain intravenous (IV) therapy. When a decision is made to provide artificial hydration, subcutaneous fluid infusion (hypodermoclysis or clysis) is an underused alternative to IV therapy for treatment of mild to moderate hypovolemia. Clysis may be useful in SNFs without continuous availability of nurses or clinicians to insert or maintain an intravenous catheter, for residents with poor veins or those who repeatedly remove intravenous lines secondary to agitation, and in those on hospice or palliative care for symptom relief.

Pressure injury — The prevalence of pressure injury (formerly known as pressure ulcers) is an important quality indicator in SNFs. Pressure injury is often painful and increases the risk for reduced mobility, infection, and death in the SNF setting [103]. Whether the pressure injury is an independent risk factor for mortality, or a marker for underlying comorbidities, is unclear.

MDS 3.0 requires assessment by SNF staff of patients for pressure injury based upon the Pressure Ulcer Scale for Healing (PUSH) tool. This tool standardizes documentation of pressure injuries based on location and size. In addition, pressure injuries are staged by a I to IV grading system based upon the degree of penetration into underlying structures. When the wound bed cannot be adequately visualized because of slough, wounds are "unstageable." (See "Clinical staging and general management of pressure-induced skin and soft tissue injury", section on 'Clinical evaluation'.)

As members of the care team, physicians and advance practice clinicians have an important role in the prevention, identification, and management of pressure injuries. They can identify risk factors and alert care team members, such as physical therapists, occupational therapists, and dieticians, about potential interventions. Primary care physicians and advanced practice clinicians should also examine patients with pressure injuries regularly, in addition to any wound care specialist who may be involved. Documentation in the medical record is critical in outlining the response to preventative and treatment measures.

SNF short-term patients and long-term residents are at risk for pressure injuries for a variety of reasons including immobility after surgical procedures, impaired nutritional intake, sensory and cognitive impairment, and incontinence. Hip fractures and strokes can lead to pressure injuries of the heel, coccyx, and sacrum because of pain and reduced mobility.

The extent to which pressure injury is preventable is controversial. In surveys of prevention practices among hospitalized Medicare beneficiaries, there was no link between documentation of a quality indicator, such as a turning schedule every two hours or using a pressure–reducing device and the incidence of pressure injuries [104]. However, these modalities are an integral part of pressure injury care. A cost-effectiveness analysis based upon a Markov model compared four potential strategies to prevent pressure injury in the nursing home setting [105]. Assuming a cost-effective threshold of USD $50,000 for one quality-adjusted life year (QALY), a foam cleanser for patients needing incontinence care and pressure redistribution mattresses for all residents were likely to be cost-effective. Skin emollients for dry skin and oral nutritional supplements for residents with recent weight loss were likely not cost-effective.

MDS 3.0 requires documentation of interventions put in place to manage pressure injury including pressure-relieving devices, positioning and turning protocols, and specific wound treatments. Pressure injury management requires an interdisciplinary approach for which the SNF environment can be well-suited. Nurses; dieticians; nursing aids; physical, occupational, and speech therapists; and wound care consultants all have roles to play in pressure injury management. Their services and interventions must be coordinated to develop, implement, and monitor a plan of care to meet the needs of a patient with or at risk for developing a pressure injury. The attending clinician must oversee this effort and enlist additional consultation when appropriate.

Pressure injuries are often associated with nutritional compromise based upon assessments such as prealbumin and albumin levels, calorie counts, and weight loss. Coexisting medical issues that affect appetite and nutrient absorption can further increase risk. Healing of wounds is thought to require higher protein intake over baseline. Small studies have found oral nutritional supplementation helpful in the healing of pressure injuries [106].

A variety of products may be used in the care of pressure injury. Product choice is based upon the specific characteristics of the wound: the presence of slough, the amount of exudate, and the size and depth of the wound. (See "Clinical staging and general management of pressure-induced skin and soft tissue injury".)

Vacuum-assisted closure devices are commonly used to assist with wound healing for both acute and chronic wounds. They decrease the need for frequent dressing changes but are costly. Few data indicate that they are superior to other commonly used modalities for the treatment of pressure injury. (See "Negative pressure wound therapy".)

Patients with terminal conditions may choose, or their families/loved ones may choose for them, to forgo interventions that could reduce the risk of pressure injury development or promote pressure injury healing. Examples include requests to minimize repositioning or decisions to decline surgical debridement or wound grafts.

Prevention of adverse drug events — Polypharmacy, often defined as taking five or more medications, puts patients at increased risk of adverse drug reactions and, especially in frail older individuals, is associated with risks of falling, delirium, and other geriatric syndromes [107]. While MDS 2.0 used nine medications as the threshold for worrisome polypharmacy, MDS 3.0 has eliminated the simple numerical approach. The focus is now exclusively on medications with a high risk of side effects, principally antipsychotics, anxiolytics, anticoagulants, and hypnotics. This change acknowledges that multiple medications are often used synergistically for many common conditions. However, the risk of medication-related problems is proportional to the number of medications taken. Nationally, 68.8 percent of residents in SNFs in the United States take nine or more medications and nearly 20 percent take antipsychotic medications [108]. (See "Drug prescribing for older adults", section on 'Polypharmacy'.)

Age-related pharmacodynamic and pharmacokinetic changes increase the vulnerability of older SNF residents to adverse reactions from medications. Drug accumulation is related to changes in the distribution and concentration of drugs due to increase in body fat and decreased hepatic and renal clearance. Enhanced central nervous system sensitivity to anticholinergic agents predisposes older patients to problems such as delirium, constipation, urinary retention, and gait instability.

Medication toxicity is a major cause of hospitalization in older patients [109]. In a study of risk factors for adverse drug events among nursing home residents, independent risk factors included: taking opioids, antipsychotics, or antidepressants; taking more than nine medications; and multiple comorbidities [110]. All SNF facility staff need to be alert to common medication-related side effects such as altered mental status, falls, constipation, and functional decline. It is also important for facilities to have a culture that encourages the reporting of adverse drug events or medication errors so that systems can be improved.

Several factors may contribute to polypharmacy in older adults. Frail patients often have multiple chronic diseases, each of which typically triggers a clinical algorithm designed to define optimal care. However, what is optimal for a patient with one disease is not necessarily optimal for someone with multiple conditions [111]. In addition, patients whose life expectancy is limited and whose goal of care is comfort may not be appropriate candidates for algorithms designed to prolong life. For such patients, it is reasonable to avoid intensive treatment of diabetes, hyperlipidemia, and hypertension and to forgo preventative treatment of conditions such as osteoporosis and hyperlipidemia.

Polypharmacy also results when the side effects of medication are interpreted as a new condition, which is then treated with an additional medication rather than by stopping or adjusting the dose of the offending medication. As an example, laxatives may cause diarrhea, leading to the prescription of antidiarrheal agents instead of discontinuing the laxative.

In addition, care transitions accentuate the risks for polypharmacy. Patients often go from hospital to the SNF with no explanation as to why certain medications are being given, why doses may have been changed, and what medications may have been purposely omitted. Nursing staff need to be encouraged to question orders if the indication for medications they are administering is unclear.

An accurate medication list that reflects prehospitalization medications and changes made during the hospital stay is often not available when patients arrive at the SNF. Effective medication reconciliation is the gold standard for all SNF admissions. When medication dosing or indications are unclear, family members, other informal caregivers, prior clinicians, and pharmacies must be contacted for clarification. When available, electronic medical records should be reviewed.

It is essential that new medications are monitored for effectiveness and, when ineffective, are eliminated. In addition, dosing should be titrated to the lowest possible dose that achieves the desired clinical result. (See "Deprescribing", section on 'Hospitalized patients'.)

Clinicians should identify and document the “target symptoms” that are being treated when new medications are initiated. This is particularly important with depression and dementia. Clinicians should be encouraged to treat with therapeutic doses for a reasonable trial period but to discontinue the medication if the response to the medication does not significantly reduce the target symptom.

The SNF can reduce unnecessary medication use through pharmacy consultants who review medication regimens and make recommendations to eliminate medications, modify dosages, or monitor parameters with clinical or laboratory tests [112]. Compared with usual care, involvement of a pharmacist to review medications on transfer from the hospital to the SNF and to communicate recommended changes to the attending clinician decreased the risk of a discrepancy-related adverse drug event [113]. In addition, a cluster randomized trial found that a pharmacist-led medication review decreased the rate of delirium in SNF patients [114].

The issuance of monthly medication sheets serves as an opportunity for reviewing medication regimens on long-term patients. As the SNF patient's status changes, medications that were once appropriate may no longer be necessary. A study in 22 nursing facilities in the Boston area found that 37.5 percent of patients with advanced dementia received at least one medication that was not appropriate in late dementia (most commonly acetylcholinesterase inhibitors and lipid-lowering agents) [24].

Clinicians should work collaboratively with pharmacist consultants and nursing staff to consider “deprescribing” medications that may no longer be necessary and potentially harmful (eg, proton pump inhibitors, cholinesterase inhibitors, statins) and/or when multiple drugs in the same class are prescribed (eg, antihypertensives, hypoglycemic, psychoactive medications, analgesics) [112]. (See "Deprescribing", section on 'Deprescribing specific medications'.)

Discharges from the SNF to home provide an opportunity to review and optimize the medication regimen. Schedules should be practical and patients or caregivers need to understand the indication and potential side effects of all medications. It is also important to be sure that patients can afford to buy their medications. Finally, the clinician(s) assuming care for the patient must receive an accurate medication list.

Urinary and bowel issues

Urinary incontinence — Urinary incontinence, affecting at least 57 percent of SNF patients [115], is associated with increased risk of hospitalization, UTI, and pressure injuries and significantly impairs quality of life [116]. The development of urinary incontinence is a CMS quality indicator for long-term residents.

Practice guidelines outlining an accepted approach to the diagnosis and management of incontinence [117] have been adapted for use in the SNF [118,119]. The diagnosis and treatment of urinary incontinence is discussed in detail separately. (See "Female urinary incontinence: Evaluation" and "Female urinary incontinence: Treatment" and "Urinary incontinence in men".)

Diagnosis and management of urinary incontinence in the SNF setting includes the following steps:

●Establish a diagnosis of the type of incontinence (stress, urge, overflow, mixed, or functional) with a targeted history and physical examination.

●Evaluate for potentially reversible conditions such as delirium, urinary retention, bladder infection, constipation, diabetes, excessive caffeine intake, or medications (eg, anticholinergics and diuretics).

●Institute prompted voiding, which was found to be somewhat effective at short-term follow-up in reducing daytime incontinence in two systematic reviews of randomized trials involving SNF patients with cognitive impairment and urinary incontinence [120,121]. One study among long-term residents suggested a persistent benefit four months after the intervention period [122]. Most trials used research staff to provide the prompting intervention, and it is uncertain whether implementation with usual nursing staff would be similarly effective, given constraints of added cost and nursing time.

●Individuals with urge and/or stress incontinence may benefit from learning and practicing pelvic muscle exercises, if feasible. Some physical therapists have expertise in teaching these exercises.

●Consider pharmacologic therapy with antimuscarinic agents for urge type incontinence, particularly in residents who are at high risk for falls due to urinary urgency. These drugs have been shown to be effective in older adults in the community, although the applicability of findings to the SNF population is uncertain [121]. Studies of these drugs in the SNF are generally of poor quality, and these patients may be particularly vulnerable to adverse effects (dry mouth, constipation, confusion). The extended-release forms of antimuscarinic medications appear to produce fewer adverse drug reactions and a lower incidence of dry mouth [119]. A beta-3 agonist (mirabegron) that does not have antimuscarinic side effects can be used for those with cognitive impairment or susceptibility to other antimuscarinic effects.

Because urge incontinence is associated with both cognitive and functional impairment in the SNF population, drug therapy must be combined with a toileting intervention such as prompted voiding. Individuals with severe cognitive impairment who do not cooperate with toileting interventions are not good candidates for drug therapy.

●Carefully selected individuals who are willing to undergo the risks, discomfort, and costs may benefit from further urologic, gynecologic, and/or urodynamic therapy. Examples of such patients include women with severe pelvic prolapse or stress incontinence, men suspected of having obstruction, and patients who have failed behavioral and/or drug therapy who are still bothered by their symptoms.

Fecal incontinence — The most common cause of fecal incontinence in the SNF population is constipation and fecal impaction with leakage of loose stool around the impaction. Treatment should therefore address the constipation. Laxatives, antibiotics, and hyperosmolar supplements can also contribute to fecal incontinence. Fecal incontinence that is associated with a neurologic disorder or end-stage dementia is usually managed supportively in the SNF population.

Acute urinary retention — Urinary retention is a common problem in the SNF. Unrecognized retention may be the etiology of pain, constipation, or agitation. It is especially common in men, due to prostate enlargement, but may be found in all adults in the setting of stroke or diabetes. It can also be triggered by anticholinergic medications such as antihistamines or tricyclic antidepressants. Many patients come from the acute hospital with an indwelling bladder catheter due to history of retention, especially after surgery, which needs follow-up in the SNF. An ultrasound bladder scanner, available in many SNFs, allows for quick and accurate diagnosis. The evaluation and management of acute urinary retention is presented elsewhere. (See "Acute urinary retention".)

Constipation — Maintaining continence and avoiding constipation are the two major goals of bowel management in SNFs. Constipation is common in SNF patients, with nearly 50 percent using laxatives regularly [123]. (See "Constipation in the older adult".)

Constipation can lead to anorexia, urinary retention, both urinary and fecal incontinence, social isolation, rectal prolapse, and fecal impaction which in turn increase the risk of hospitalization. Rarely, severe constipation results in intestinal perforation.

Recognition of constipation is impeded in patients with cognitive deficits and impaired communication abilities. Constipation may also be missed because of suboptimal communication amongst nursing staff.

Many medications cause constipation, including anticholinergics, opioids, iron, calcium and NSAIDS. Constipation can lead to polypharmacy if it is managed with laxatives rather than by eliminating or modifying the inciting medication(s).

Constipated patients should be examined to exclude fecal impaction. Sometimes liquid stool is passed around a fecal impaction, resulting in fecal incontinence and delaying the diagnosis of constipation. Urinary retention or incontinence may also be a symptom of fecal impaction. Fecal impaction requires suppositories and/or manual disimpaction to avoid further complications as well as bowel management strategies to prevent recurrence.

SNF patients recently discharged from an acute care hospital often have constipation related to inactivity, impaired oral intake, medications such as opioids, and hospital-related environmental factors. These factors often resolve as functional status, diet, and the overall medical condition improves. Accordingly, bowel medications may need to be initiated on admission but reduced or eliminated later in the course of the SNF stay.

Privacy, responsiveness, and flexibility around the timing of toileting are important factors in helping avoid constipation and incontinence. There is variation in SNFs both in types of medications used to manage constipation and the amount of staff time required to deliver constipation-related care [124].

ADVANCE CARE PLANNING — Short-term patients as well as long-term skilled nursing facility (SNF) residents are often older adults, frail, and have life-limiting conditions. They are at high risk for morbidity and mortality. Cognitive impairment from reversible or permanent causes is frequent. Planning for future treatment by establishing an advance care plan is essential in this population and should begin with identifying a surrogate decision-maker and establishing the goals of care. (See "Advance care planning and advance directives".)

SNFs in the United States, like other health care institutions receiving federal funding, are required by the Patient Self-Determination Act (PSDA) of 1990 to ask residents if they have an advance directive and, if they do not, whether they would be interested in information about advance care planning. Since implementation of the PSDA, the rate of completion of advance directives among SNF patients has risen to 55 percent [125]. Identifying a surrogate to serve as health care proxy when important medical decisions must be made is imperative since the majority of long-term SNF residents have some degree of dementia, and even cognitively intact older individuals are at risk of delirium should they become acutely ill.

Conversations between the SNF resident and the health care proxy can help prioritize among the patient's goals of care (eg, life prolongation, maintenance of function, maximization of comfort) and allow the proxy, working with the clinician, to infer what kind of approach to treatment would be most appropriate [126]. Living wills and instructional directives may also be of use. Short videos have also been shown to help patients and families/loved ones prioritize their goals of care and establish an advance care plan [127]. A systematic program to increase the use of advance directives in SNFs can reduce utilization of health care services (and therefore costs) without adversely affecting patient or family satisfaction or mortality [128]. Many web-based resources are available to assist SNF residents, their families/loved ones, and SNF staff in discussing and executing advance directives [129-131].

Assessment of decision-making capacity is needed to determine if a health care proxy needs to be activated. This assessment is often performed with the input from the SNF care team, including clinician, therapists, nurses, and social worker. Mental health clinicians may be asked to participate as well. This includes the ability to understand current medical issues and the ramifications of choosing or not choosing specific treatments. Facilities may require that the clinician meet specific documentation requirements to activate a health care proxy. (See "Legal aspects in palliative and end-of-life care in the United States", section on 'Decision-making capacity'.)

Do not resuscitate orders — Do not resuscitate (DNR) orders are the most common form of advance directive in the nursing home: 56 percent of residents have a DNR order, compared with only 18 percent with a living will [132]. Choosing whether to be designated DNR is especially important since, based on CMS rules, SNFs are required to initiate basic life support after a cardiac arrest unless a resident has a DNR order in place [133]. (See "Ethical issues in palliative care".)

Addressing resuscitation orders in SNF residents is important because the outcomes of cardiac arrest in such individuals is poor. Two small studies in geriatric care facilities reviewed the survival of patients after cardiac arrest [134,135]. One of these was a retrospective review of patients in a multilevel facility that offered a 24-hour on-site code team; 41 patients underwent CPR during the course of the study [134]. There were only four survivors of 60 days or more. Three of these were short-term patients who had previously been ambulatory and virtually independent in their activities of daily living (ADLs); they all returned to their previous level of function. The fourth was a fully dependent bed-ridden patient who returned to that level of care for a survival period of 100 days. Of the four long-term survivors, three of the arrests were witnessed, and one was indeterminate. No unwitnessed arrests resulted in long-term survival.

Other studies have reported that only 1 percent of individuals who arrested in a SNF survived to be discharged from the acute hospital [136].

A review of CPR in the SNF setting concluded that, for most long-term SNF residents, CPR is a futile procedure that can result in considerable discomfort and that a policy of having DNR be a default option may be reasonable [137]. Residents and their families/loved ones should understand that a DNR order only refers to withholding cardiopulmonary resuscitation in the event of cardiac or respiratory arrest and that no other treatments will be withheld unless otherwise specified.

Physician Order Form for Life-Sustaining Treatment — Advance directives should be portable; discussions about the goals of treatment or limitations of treatment should travel with a SNF patient who is subsequently hospitalized. In practice, however, advance directives often are not transmitted to the admitting hospital [138]. Moreover, many hospitals have a policy requiring that they re-address the issue of patient preferences for care and do not automatically follow wishes laid out in an advance directive. Use of a medical order that is valid across all sites of care such as the Physician Order Form for Life-Sustaining Treatment (POLST), introduced in Oregon and now available in many other states, can assure that patient’s wishes will be honored [139]. In addition, using the POLST as part of the advance care planning process has been shown in a retrospective cohort study to result in 98 percent of residents having orders about life-sustaining treatment beyond CPR, compared with 16 percent in residents with no POLST usage [140]. Some states use different terminology for these orders, including Medical Orders for Life-Sustaining Treatment (MOLST), and Physician Orders for Scope of Treatment (POST).

Hospitalization — In addition to specifying whether particular interventions such as CPR or intubation are desired, SNF patients and residents may request that they not be hospitalized at all.

One form of advance care planning that has been used successfully in several institutions is a system of defining levels of care. A sample schema designates the following:

●Level I – All forms of medical care, including attempted CPR and intensive care

●Level II – Hospital level care exclusive of CPR and intensive care

●Level III – Medical treatment available at the nursing home

●Level IV – Palliative care only

Implementation of such a system requires extensive education of staff, residents, families/loved ones, and clinicians but has the virtue of clarifying in advance the approach to be taken in the event of acute illness [141,142].

The likelihood of hospitalization is significantly increased in patients with dementia [143]. Restricting treatment to the SNF may be particularly reasonable in the case of severely demented individuals for whom transfer to another location can be traumatic and who will have difficulty undergoing the procedures available in the acute hospital. Discussion with residents and their families or other decision-makers about the goals of care may lead to a "do not hospitalize" order or enrollment in hospice. The Interventions to Reduce Acute Care Transfers (INTERACT) program website has educational tools available for these discussions and a decision guide on this issue for SNF residents and their families/other decision-makers. Orders to forgo hospitalization for those with advanced dementia are written for only a minority of such patients, with rates varying between states from 0.7 to 25.9 percent [144].

Hospice and palliative care — Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their loved ones. It does not have to be limited to end-of-life care and can be provided along with curative or life-prolonging treatments. With the growth of telemedicine, there is an opportunity to provide palliative care consultation virtually in SNFs. In addition, some hospice agencies have staff who can provide palliative care consultation.

One-quarter of all United States deaths take place in the SNF [145]. Moreover, among older decedents, 30 percent spent some time in a SNF in their last six months of life, even if they died in the hospital or at home; for decedents over age 85, the rate of antecedent SNF use is 40 percent [146]. Nonetheless, access to palliative care services has been limited. Most SNFs do not have palliative care consultation available [147]. Further, in a large national study, only 42 percent of bereaved family members whose loved one died in a SNF reported the quality of care as excellent compared with 71 percent of family members whose loved one was home with hospice [148].

For those patients at end of life, hospice services are available in the SNF setting. An important benefit of hospice care is that loved ones are eligible for bereavement services for one year after the death of the resident.

One study found that the quality of care of dying SNF patients improved with the addition of hospice, with the percent of families rating physical symptom control as good or excellent rising from 64 to 93 percent [149]. Hospice use in the SNF has been rising, increasing from 14 percent in 1999 to 33 percent in 2006 [150].

However, as mentioned earlier in this section, most long-term SNF patients receive custodial care and their room and board is paid by Medicaid. The hospice benefit can be activated for end-of-life care for these residents via their Medicare benefit. However, in some situations, short-term residents using their Medicare SNF benefit could become financially responsible for room and board charges by electing their hospice benefit since room and board is typically not covered by hospice on most patients unless they quality for the general inpatient hospice benefit. These decisions should be carefully reviewed ahead of time with SNF facility staff such as social work or case management. Hospice care in the United States, including eligibility, is discussed in detail elsewhere. (See "Hospice: Philosophy of care and appropriate utilization in the United States", section on 'The United States Medicare hospice benefit'.)

PREVENTING UNNECESSARY HOSPITALIZATION — Acute hospitalization exposes patients to the risk of hospital-associated delirium, iatrogenic infections, falls, and increases medical care costs. Hospitalizations may be unnecessary or avoidable for many skilled nursing facility (SNF) patients and residents for one of several reasons, including:

●The patient's goals of care are not consistent with acute hospitalization

●The condition can be appropriately treated in the SNF setting

●Appropriate preventive measures might have avoided the acute condition

Preventive interventions can decrease the risk of many "ambulatory-care sensitive conditions" that account for hospitalizations in older adults [151]. These conditions include influenza, bacterial pneumonia, heart failure, dehydration, duodenal ulcer, urinary tract infection (UTI), skin ulcers and cellulitis, and chronic obstructive pulmonary disease and asthma.

Several strategies have been proposed to avoid inappropriate hospitalization:

●Early recognition of medical problems with proactive treatment may avoid later need for hospitalization. A study of 25 SNFs using such an approach found a 17 percent decrease in hospitalization rate [152].

●Medication reconciliation can ensure that no clinically important medications have been omitted when patients are transferred between settings. (See 'Prevention of adverse drug events' above.)

●An alert to clinicians identifying hospice-eligible nursing home residents led to an increase in patients enrolled in hospice and to a 40 percent decrease in subsequent acute care admissions [153].

●A CMS demonstration project involving 143 SNFs with seven “extended care coordination providers” has developed multiple approaches to prevent avoidable hospitalizations [154]. All of these approaches involved implementation of one or more components of the INTERACT program [10]. One site in particular, that involved nurse practitioners in implementing the INTERACT program and evaluating acute changes in condition, had a 30 percent reduction in all-cause hospitalizations [155].

●Vaccination programs for influenza and pneumococcal pneumonia.

●Efforts to reduce potentially avoidable hospitalizations may result in increased antibiotic use to manage infections without hospital transfer. Thus, implementation of antibiotic stewardship programs is increasingly important for preventing unnecessary use or duration of use, resistant organisms, and complications that in and of themselves can cause hospitalization.

Rehospitalization — In response to the high rates of readmission to the acute care hospital within 30 days of discharge, Medicare now penalizes hospitals for such events [156]. Rates of potentially avoidable hospitalizations are now included in the 5-Star quality rating system, and SNFs have financial incentives to reduce potentially preventable readmissions. In addition, value-based reimbursement strategies, such as Accountable Care Organizations and bundled payments, incentivize the reduction of unnecessary emergency department visits and hospitalizations.

Rates of rehospitalization are even higher for patients discharged to SNFs than for other patients discharged from hospitals, reaching 25 percent within 30 days [157], and it has been estimated that as many as 69 percent of the readmissions from such facilities are potentially (probably or definitely) avoidable with high-quality skilled care [158]. Care transitions are particularly burdensome for residents with advanced dementia. One study of care transitions prior to death in 475,000 SNF patients with advanced dementia found burdensome transitions (transfers in the last three days of life, lack of continuity in nursing homes in the last 90 days of life, or multiple hospitalizations in the last 90 days of life) occurred in 20 percent of those studied [159].

SUMMARY AND RECOMMENDATIONS

●Patients entering a skilled nursing facility (SNF) should undergo comprehensive geriatric assessment. In SNFs in the United States, the Minimum Data Set (MDS) is a tool for the comprehensive evaluation of residents at the time of admission, as well as quarterly reassessment for long-term residents, and serves as a basis for development of individual treatment plans. (See 'Comprehensive geriatric assessment' above and 'The Minimum Data Set' above.)

●Behavioral issues can be difficult challenges in the SNF setting. Delirium is often unrecognized and should be considered as a potential cause of disruptive behavior. Delirium requires assessing for and managing underlying medical conditions, including electrolyte imbalance, dehydration, pain, and infection. Although antipsychotic agents are considered chemical restraints and their use is carefully scrutinized in the SNF, psychotic symptoms and aggressive behaviors may need to be managed with psychotropic medications, typically atypical antipsychotic medications. (See 'Delirium' above and 'Behavioral issues' above.)

●Depression is widespread and undertreated in SNFs. Selective serotonin reuptake inhibitor (SSRIs) are the drug of choice, and tricyclic antidepressants should be avoided due to the high risk of anticholinergic effects. (See 'Depression' above.)

●Falls are common in SNFs, and the risk of falls may be reduced by multidisciplinary interventions and by limiting medications that are associated with falls. (See 'Falls' above.)

●SNF staff and patients should be vaccinated for influenza in the early fall. In the event of an influenza outbreak, exposed patients should receive antiviral prophylaxis. Additional infection control measures should be instituted, such as limiting movement between affected and unaffected units of the SNF and closing affected units to new admissions. (See 'Influenza' above.)

●Debilitated patients who are treated with broad spectrum antibiotics are highly susceptible to developing Clostridioides difficile diarrhea. When C. difficile is diagnosed in a patient with diarrhea, universal precautions should be supplemented with enteric precautions. (See 'Clostridioides difficile' above.)

●Pain is common and often undertreated in the SNF setting. Pain at the end of life poses unique challenges; transdermal and sublingual preparations of opioids can be particularly useful in end-of-life care. (See 'Pain' above.)

●Unintentional weight loss is correlated with increased mortality and requires evaluation for reversible causes, such as depression, oral or neurologic issues, or medication side effects. There is no evidence that percutaneous endoscopic gastrostomy tubes improve nutritional status or prolong life in the nursing home resident with advanced dementia. Oral nutritional supplements may be modestly helpful. (See 'Nutrition' above.)

●Policies to regularly offer fluids may prevent dehydration. When artificial hydration is indicated, subcutaneous fluid infusion may be an alternative to intravenous fluids. (See 'Hydration' above.)

●Pressure injury management requires an interdisciplinary approach. Patients with pressure injuries often are nutritionally compromised and may require increased protein intake for wound healing. (See 'Pressure injury' above.)

●Care transitions accentuate the risks from polypharmacy. Pharmacists and clinicians should regularly review medication lists, with recognition that indications for treatment change as patient status changes. (See 'Prevention of adverse drug events' above.)

●Changes in reimbursement and financial penalties are increasing pressure on SNFs to reduce potentially avoidable hospitalizations, 30-day readmissions, and emergency department visits. Multiple interventions are available to assist SNFs in achieving these goals. (See 'Preventing unnecessary hospitalization' above.)

●Advance care planning is an important part of SNF care. In addition to addressing issues around resuscitation, residents should be given the option of limiting other interventions, as well as choosing not to be hospitalized in the event of illness. (See 'Advance care planning' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Muriel Gillick, MD, who contributed to an earlier version of this topic review.