Hip Fracture 2: An Inside View of Skilled Nursing

(Last Updated On: January 17, 2022)

A Patient’s View of a Highly Rated SNF (Skilled Nursing Facility)…

skilled nursing, nurse

This blog about skilled nursing is the second part of a multi-blog article:

When you suffer disease, injury or simply old age, two institutions are critical for your care. Those are the hospital and the skilled nursing facility (SNF, pronounced “sniff”). I have previously discussed hospitals in connection with my prostate and heart surgery. This blog, on the other hand, offers a patient’s view of a skilled nursing facility.

Personal note as of April 17: Nola came to Honolulu and together we flew home last week. I visited my Michigan doctors for guidance and started outpatient physical therapy. It’s now 9 weeks after my hip surgery and for 4 weeks I’ve been allowed 50% weight bearing on my left side. My orthopedist has taken new x-rays and a CT scan to consider whether to allow more weight. More news will follow.

Skilled Nursing as One Step to Getting Well

A hospital and its associated emergency room provide high skill procedures and intensive care to carry you past the point of crisis. However, due to cost and the demand for its services, the hospital will not stick by you to the point of wellness. As soon as possible – typically, sooner than the patient believes is appropriate – the hospital will discharge you to continue your recuperation elsewhere. Unless you can go directly home, that elsewhere is likely to be a skilled nursing facility. A SNF, compared with a hospital, provides less personalized yet still highly trained medical care. More importantly, the SNF is equipped to continue that care for the days, weeks or even months that your recovery may require.

Skilled Nursing as a Key Part of the CCRC

An earlier series of blogs discussed Senior Life Planning, the planning-ahead that everyone should do in advance of the needs of old age. The facility at the center of senior life planning is a continuing care retirement community (CCRC), which can house and care for you no matter how your needs may increase in the future. And the heart of the CCRC is skilled nursing, which helps residents transition from independent living, to assisted living, and if necessary to a continual need for nursing care. Because skilled nursing is the essential skill set, a search for senior living should pay particular attention, not to the facility’s pristine landscaping and elegant design, but to the quality and quantity of the skilled nursing available.

For a CCRC, skilled nursing is a “core competence” – a sophisticated skill set that is at the heart of its business. It is widely accepted in management that the core competence of a business should never be outsourced, but must be solidly rooted within the heart of the business and nourished as a competitive advantage. Therefore, it may amaze you that there are CCRCs that actually outsource their nursing services! A CCRC that does this is (in my opinion) no more than a real estate development designed to separate seniors from their money using visual appeal. It does not demonstrate an honest intent to provide the continuing care which the CCRC promises its residents.

An Inside Perspective of a Skilled Nursing Facility

skilled nursing facility activity room

This Villas activity room overlooks downtown Honolulu and the Pacific Ocean (click to enlarge)

As mentioned, my hip fracture has made me an involuntary resident of Honolulu for eight weeks. It has also made me the grateful recipient of skilled nursing services, which I get to observe from the perspective of a resident or patient. I will touch on these services, and how the reality aligns with optimistic press releases on the one hand and scathing user reviews on the other. I will also reveal some new lessons I have learned while relying on skilled nursing and rehab therapy for my recovery.

Nurses and Nurse Aides Have Clearly Defined Jobs

When Medicare assesses the staffing level of skilled nursing facilities, they look separately at nurses and nurse aides. Nurse categories include Registered Nurse (RN), which requires the most training, and Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN). A nurse aide is a Certified Nurse Assistant (CNA).

Certain procedures can only be carried out by nurses. These include dispensing medications (orally or intravenously), changing dressings, collecting samples (such as blood or urine) and care of breathing/feeding/catheter tubes. In general, any procedure that invades the body, including the care of wounds, lies in the province of nurses.

Nurse aides work under the supervision of a nurse and carry out supporting duties. These include answering call lights, recording vital signs (blood pressure, pulse rate, body temperature, blood oxygen), serving and feeding meals, transporting patients and making beds. Aides also assist patients with activities of daily living including dressing, bathing and using the toilet.

Skilled Nursing Facilities Have Many Aides But Fewer Nurses Than Hospitals

nurse with patient

In a hospital setting, the condition of patients is rapidly changing and there are many tasks that only a nurse is allowed to perform. Therefore, a hospital is likely to have more nurses than aides on staff. Conversely, in a skilled nursing facility the patients tend to be in a more stable condition, requiring more aide than nursing support. Thus a SNF will probably have fewer nurses than aides.

Here are specific examples: the orthopedic section of Queen’s hospital has one nurse for every five patients, and one nurse’s aide for every eight patients. The Villas, a rehab-intensive SNF, has one nurse for every eighteen (!) patients and one nurse’s aide for every eight patients. These two facilities are each investing their staffing dollars in a way that reflects their different charters.

Understanding Hospital and Skilled Nursing Ratings and Reviews

A survey of Medicare’s ratings for medical facilities suggests that hospitals and skilled nursing facilities are sometimes understaffed. However, in my experience even the best ones are not over-staffed. Patient requests arrive unpredictably, and now and then there is a traffic jam in desired services. At those times, I have seen nurse aides helping patients assigned to other aides; nurses assisting with aide duties; and supervisory nurses stepping in to help in any way they can.

There are also special tasks that require joint effort by two or even three aides, such as moving a large, passive patient, or giving a shower to a patient who requires much assistance. These jobs understandably interfere with the ability of those aides to respond to any other patient calls.

Because of these crunch times, ringing the call button may not bring help for what seems like a very long time. This is true even when the staff members are working well as a team.

When I study skilled nursing facility ratings on yelp.com, I often see a mix of Ones and Fives. The Ones come from reviewers who are outraged because their loved one waited too long, suffering pain, for the answer to a call button. The Fives come from reviewers who know “how bad things could be” and who are grateful for the good things: caring staff and overall satisfactory service.

You probably know that I’m a fan of objective reviews. However, I do not simply count up star ratings. I read reviews carefully to see which ones seem realistic, internally consistent and not one-sided.

Rehab Therapy is a Frequent Accompaniment to Skilled Nursing

assistive devices for therapy

Assistive devices for therapy: walker; crutches; sock aid; reacher

When Queen’s Medical Center gave me two hours notice before my discharge, I had to quickly select a skilled nursing facility. Fortunately, the hospital staff and my surgeon were unanimous in pointing me toward The Villas at St Francis Medical Center. The Villas happened to have one bed available. A ten-minute scan of Yelp reviews and Medicare nursing home reports convinced me that I should grab that bed, selecting the Villas for my recovery.

Most SNFs provide modest amounts of occupational therapy and physical therapy. However, The Villas is remarkable in providing 2 or more hours of therapy per day per resident. As a hip fracture patient, I would need considerable therapy to build and sustain muscle strength while I waited for my bones and tissue to knit. The emphasis on therapy plus The Villas’ high quality made it easy for the Queen’s orthopedists to point me there.

Lessons Learned About Skilled Nursing


This discussion leads to a few things I learned from my experience as a skilled nursing patient:

  • There will always be times when the call button does not bring quick help. Therefore, try to plan ahead so that you are able to wait if necessary.
  • If you are able to go to the bathroom on your own, or take a walk down the hallway unassisted, great! Stay out of bed, get out of that chair, make walking a major exercise. Many of your co-residents cannot do anything without assistance, because of medical restrictions while they are healing or because of frailty. They need and consume a disproportionate amount of nurse aide time that you don’t require.
  • Sometimes, you may have a special request that will take considerable time. Examples are when you need supervision to take a shower, or when an aide needs to transport you to an activity elsewhere in the building. If this is the case, be ready to say “yes!” the moment the aide asks or even hints “are you ready now?” If you say, “wait just a minute” the aide is likely to go help another guest, not returning for much longer than you expected.
  • The physician in charge, and the nurse practitioner who acts as the doctor’s deputy, each spread their time over many patients. If either of them arrives to see you, drop whatever else you are doing! Otherwise, it may be a long time before they stop by again.
  • A patient newly arrived on the floor consumes more staff resources: vital signs, x-rays, assessments, documentation. These activities may delay services for other patients until the start-up transient has passed.

Scary Observations

When a person enters a skilled nursing facility, it’s often caused by an accident: a fall or, in the case of Honolulu’s heavy traffic, an automobile accident. However, I learned that “accident” doesn’t quite capture the randomness of what happens.

Consider the successive roommates I had while recovering from my hip fracture:

  • The first was an 88-year old man living alone, but who had a neighbor to check on him. He fell in his home and normally would have pushed his necklace button to summon help. However, the button was on the charger, not on his body! And the neighbor had already left for the day. The man lay on the floor for over 8 hours before receiving help.
  • My second roommate was 87, living with a housemate whom he didn’t often see. He fell in his home and normally would have used his cell phone to call for help. However, the cell phone was on top of a high dresser, out of his reach. He lay on the floor for 9 hours before the housemate came to check on him and called 911.

One Backup Is Not Enough

skilled nursing call button

In other words, each of these gentlemen, living in their own home, had a call button system to summon help. But in each case, by some mischance the call button was not available to them. By the time they received help, the long delay lying injured left them more debilitated than if they had received rapid medical attention. A nurse told me of an even more unfortunate case: a woman who lay for several days before receiving help. When she reached the emergency room she had multiple medical problems and infections constituting a bona fide emergency.

It is obvious that an older person living alone or mostly alone needs a reliable way to summon help. What is not obvious is that one lifeline is not enough! If you are helping a family member set up a lifeline service, think “belt and suspenders.” And then think, “another pair of suspenders too!”

Living at home offers no ideal solution to personal safety. A web-linked nanny cam can help, as can call buttons. However, some sort of group living situation (assisted living, SNF, group home) is the safest answer for most elders.

Miscellaneous Insights

rehab bliss with retro headphones

Some other observations go beyond the topic of skilled nursing:

  • If you will be in a hospital or skilled nursing facility, bring earphones. Otherwise, if you have a roommate, you cannot avoid a steady diet of his/her taste in TV programs.
  • In addition, bring long cords for your electronics. An extension cord and a cube tap wouldn’t hurt, either. The electrical outlets will be on the wall behind you, out of reach and nowhere near where you want to use your devices.
  • There’s a trend in newer hospitals and skilled nursing facilities to offer only private, not semi-private, rooms. This might affect your choice of a place to receive medical care. A private room would protect you from certain hazards. For example: drawing a roommate who turns on the TV in the wee hours when you would rather sleep; or a champion snorer.

Hawaiian music program

  • The Villas offers a variety of resident activities. Some, like Hawaiian folk songs, I find enjoyable. Others may not appeal at first glance: bingo, ball rolling, cupcake decorating and the like. But as I log week after week in an institutional setting, my views are softening. I can see the genuine value these activities have for many of my wheelchair-bound fellow residents. In addition, any form of socialization is certainly good for a person’s health.
  • In a SNF, stuff happens. Take it in stride. What kind of “stuff”? Someone repeatedly calling out “Help me!” or “Aaarrgh!” A procedure behind a privacy curtain causing a cry of pain. A toilet accident not yet cleaned by staff. A resident pushing the call button so often that it burdens nursing staff. A non-responsive resident, causing a flurry of activity.

Concluding Thoughts

In Honolulu, I was a resident of a skilled nursing facility for seven weeks. My observations make me very sympathetic to the continual demands on nurses and especially on nurse aides. They also make me more than ever convinced that living alone as a very elderly person is a risky proposition, no matter how you prepare for what may happen.

Have you experienced skilled nursing, either as a patient or a family member of one? What observations can you add to this blog’s summary? For more about Art’s hip fracture “adventure” see Hip Fracture 3: Recovery Worries etc.

Image Credits:
– Nurse/doctor adapted from DarkoStojanovic on pixabay.com
– Man in hospital adapted from J4P4n on openclipart.org
– Nurse from Clker-Free-Vector-Images on pixabay.com
– Other images by Art Chester


Hip Fracture 2: An Inside View of Skilled Nursing — 9 Comments

  1. So nice to see you are doing well back home. Thank you for all the wisdom and valuable detail you put into your wonderful blogs; it is such a blessing to many, I’m sure. Great comments, too. I will say, however, I think you’re much too young to have had so much experience with serious surgeries, hospitals, skilled nursing, etc! Good writing always seems to come from close personal experiences, or so I’m told, but I hope you will be allowed good health to pick much more fun topics henceforth. Be well, and heal up quickly!

    • Rick, many thanks for your good wishes! Too young, eh? Your flattery will get you everywhere! : ))

      Think of it this way: now that I’ve used up some bad luck, that leaves more good luck ahead of me!

  2. Your post, and observing Kaye’s experience with a hip break, indicate hospitals are like restaurants in that they like to turn customers !
    But, if your are the customer and the service provider does not meet your expectations, you are ready say adios sooner rather than later !
    Glad you making progress on your recovery and back at Gross Pointe. Guess if you have an injury, Hawaii is not a bad place to have it happen ?
    Happy Trails ahead !

    • Thanks for your cheerful wishes, Joe! Yes, it seems that good hospitals have no trouble filling their beds, so they are in a hurry to turn them over.

      I agree that there are worse places than Hawaii to have an accident – provided you can get to one of the few good hospitals. If I didn’t have good insurance, it would have been a costly adventure.

  3. My 93-year-old mother fell and broke her hip in February. Her situation is similar to yours, in that she was transported to a hospital, had hip surgery, was in the hospital for about a week and then with only a few hours warning discharged.

    I had to make a sudden decision when notified about the discharge which of the two SNFs in her small town in New Mexico she should be taken to. It seems to be typical that the discharge notice is a surprise for most, with most people thinking they would have more time before a discharge was going to occur, and are therefore unprepared to make such an important decision as the location where post-operative care will be received.

    Like you, I think I made the right decision, but it doesn’t change a basic fact — if you or a relative end up in a hospital in any situation where rehabilitation or therapy are going to be involved, you (or the people who will be making decisions about your health care) should be using the time spent in the hospital to prepare IN ADVANCE for making the decision about the SNF the patient is going to. That’s the time to do research and maybe even visit the facility you are considering before the time clock starts running (and stress ratchets up) on moving the patient from the hospital.

    • Thanks, Charles, that is VERY wise advice. In fact, if there are many choices, select both a #1 and a #2 SNF. The availability of beds changes day by day, especially at highly-rated facilities, so you may need a backup option when the decision day actually arrives. The SNF I chose had one and only one (male) bed available on the day I had to choose.

      Now that I think about it, both at the hospital and at the nursing home hints were given in advance of the actual notice that I would be discharged. A nurse or doctor would say something like, “when you’re eventually discharged…” or something like that, indicating that the staff had begun to discuss a discharge date. I didn’t hear it as advance notice at the time, but looking back I see that I should have asked more questions at that moment.

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