The Need for Audiology in Skilled Nursing Facilities

Observations, Anecdotes,OBRA, State Laws and ASHA Guidance
Author: Kathy Dowd, Au.D.

Laws and professional guidance exist that are intended to foster hearing care for residents of skilled nursing facilities. There appears to be widespread reliance on observation for identifying hearing loss, and this leads to frequent, under-identification of hearing loss. The consequence is that residents often have hearing losses that impact their daily communication and possibly the outcomes of other screening and diagnostic testing (e.g., cognitive assessment) that is verbally administered. This discussion will first present selected laws and professional guidance advisements and then offer examples of unidentified hearing loss, and its consequences in this population. Finally, a specific recommendation for change is offered.

The Omnibus Budget and Reconciliation Act of 1987 was a large federal law encompassing regulation for many sectors, including the needs of skilled nursing homes. This law states that hearing and vision must be assessed within 3-5 days of admission to the nursing home. In response to this law, Medicare wrote CMS Minimum Data Set assessments for hearing and vision. The CMS MDS hearing assessment is basically an observation of a hearing problem by an assessment nurse, which can include simply asking the resident if they perceive a hearing loss. Research since the CMS MDS hearing assessment was developed indicates that hearing loss is severely under identified by use of this tool.

The Omnibus Budget and Reconciliation Act of 1987 states: REQUIREMENTS RELATING TO PROVISION OF SERVICES. — (1) QUALITY OF LIFE IN GENERAL. — A skilled nursing facility must care for its residents in such a manner and in such an environment, as will promote maintenance or enhancement of the quality of life of each resident, and SCOPE OF SERVICES AND ACTIVITIES UNDER PLAN OF CARE: A skilled nursing facility must provide services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with a written plan of care.

In addition to OBRA, many states have laws mandating a hearing assessment within 3-14 days of admission to the nursing home.  The reason for this mandate is to ensure quality of life and quality of care for the resident.

In 1996, the American Speech-Language Hearing Association (ASHA) published guidelines for Audiology services in skilled nursing facilities. They noted the incidence of hearing loss among residents in these facilities was 80%. The high incidence of hearing loss, and associated consequences presented in those guidelines, demonstrated the need for residents to have hearing testing. Specifically, these guidelines stated that “identifying and managing hearing loss often can reverse the diagnosis or lessen the severity of a confusional state”.  

A valid assessment of hearing is even more critical now, since CMS has implemented a new PDPM initiative in October 2019, that highlights cognitive issues among residents of nursing homes. Unfortunately, many speech language pathologists do not screen hearing before they do a cognitive test or treat for cognitive issues. Rehabilitation agencies that hire and deploy speech language pathologists to skilled nursing homes, do not give them the equipment to screen hearing.

Anecdotal example:
One speech language pathologist commented that her inpatient rehabilitation office had 12 audiometers in the basement; but would not get them calibrated for use.

Medical necessity for hearing assessment on admission to skilled nursing
Most residents come to skilled nursing facilities after hospitalizations for diabetes, cardiovascular events, kidney failure, severe infections, and traumas from accidents. Each one of these medical issues, in addition to ototoxic medications treatments, is associated with hearing loss.

Part of the conundrum with obtaining an audiological evaluation on admission to the nursing home is the absence of a referral to audiology on hospital discharge. One hospitalist confirmed that many of her patients are unable to hear well during their hospital stay and that she must wait for family visits to discuss diagnoses and plans of care. A speech language pathologist at another hospital stated she would refer for a hearing test, if she thinks the patient has a hearing problem. And if the person already wears hearing aids, then she does not refer for an audiology evaluation, assuming the patient has already been evaluated and treated for hearing difficulties. A central office nurse for a large southeastern hospital system stated the hospital personnel are already too busy to get everything done with service delivery, charting and other duties, to even be concerned about hearing loss. Therefore, the hospital patient is discharged to the nursing facility, with no referral for a hearing evaluation.

The CMS MDS hearing assessment given on admission to the nursing facility, has been found to significantly under identify hearing loss. This leads to false and inaccurate diagnosis of cognitive and disruptive behavior issues in residents who have hearing loss. Nursing staff often recognizes the need for better tools to screen for sensory impairments in residents. Sadly, few audiologists are contracted in skilled nursing facilities and may not know of the significant need for services in this setting.

Speech language pathologists (SLPs) performed aural rehabilitation for many years in the 1990’s, with no screening for hearing or referral to an audiologist for assessment and treatment to correct a hearing loss, based on the observations of an audiology practice with numerous contracts in nursing homes. Aural rehabilitation appears to have been abandoned a decade ago as SLPs moved into the realm of evaluating and treating cognitive linguistic problems in nursing home residents. Yet, even with this development, in many facilities there is no valid hearing screening before the cognitive evaluation and no amplification or medical treatment is considered before cognitive treatment.

Anecdotal example:
Invalid cognitive test. An older lady was admitted to the nursing home with a severe reaction to new medication. The nursing home told the audiologist daughter that her mother was evaluated and had a moderate cognitive issue. The daughter asked if her mother was tested using the remote microphone that came with her hearing aids. The nurse said no because it would have given the mother ‘an undue advantage’. The daughter went to the nursing home to discuss this with the staff, since the daughter did not believe there was a cognitive issue. At the nursing home, the nurse confirmed her mother was indeed moderately, cognitively, impaired and asked to walk to her mother’s room. When they arrived, the mother, in a private room, was lying in bed, laughing and talking. No one else was in the room. The nurse turned to the daughter and said, “See? She does this all the time!”. The daughter then said, ‘My mother is talking on the phone. She has Bluetooth in her hearing aids. She’s talking to family!’.  The audiologist says her mother was just fit with the hearing aids a few months before the medical crisis, and that a cognitively impaired person would not have been able to operate hearing aids with Bluetooth as well as her mother was able to.

Anecdotal examples of invisible/untreated hearing loss:
Unintended weight loss. One example of lack of proper assessment and treatment of hearing and communication disorders was seen during an ombudsman visit at a skilled nursing facility. The first room visited was a double occupancy room with 2 ladies. One lady was sitting by the window with the bed made and a bedside tray that was empty. The other lady was bedridden and in the process of eating breakfast. The ombudsman went to the lady by the window first. She introduced herself and her reason for the visit. The lady on the bed watched her carefully. As the ombudsman began asking questions about the resident’s care, the resident continued to stare at her with no emotions or response to the questions. Finally, the ombudsman said impatiently, ‘Well, let’s move on. This lady is out of it’. The ombudsman walked to the bedridden resident close to the door and successfully interviewed her about her care and an inquiry into any issues. Before leaving the room, the ombudsman in training asked if she could go over to the first lady to try to talk to her. Bending down close to the lady’s ear, she shouted, “Hi Ms. Smith. How are you today?” The lady smiled and said, “Fine, but I’m hungry”. The ombudsman in training leaned down into the resident’s ear again and yelled, “Did you get breakfast?”. She responded, “No and I’m hungry”. The experienced ombudsman said, “OMG, I had no idea. Tell her we will make sure the CNAs bring a tray.” Going on to the next room to visit, there was a lady in bed eating breakfast. When the ombudsman introduced herself and asked if the resident had any issues, the lady said, “Yes! And no one is doing anything about it. Almost every morning if I am in the bathroom when breakfast is served, the lady next door comes over and eats half my breakfast. No one is doing anything about this.” This example is one of many, showing how staff do not know that a resident cannot hear and are thinking there is no interest in eating, when in fact, the person does not hear them ask if they want a meal tray. Many staff and administrators speak of residents with cognitive issues or behavioral problems, when the current CMS MDS hearing observation or inquiry about hearing difficulties, does not reliably assess a hearing problem.

Disruptive behavior. In another example, a gentleman resident was evaluated by an audiologist and found to have a bilateral, severe, hearing loss. Hearing aids were recommended, but staff were skeptical. They stated this man was very physically combative. For example, when they came to take him for a shower, he physically fought with them (and was very strong). The audiologist felt it was still important to try the amplification based on the evaluation. The two-week follow-up visit at the nursing home, had a surprising outcome. The staff expressed amazement about how this man’s behavior had calmed down. He seemed much happier and engaging when the staff came to his room. Staff said they were able to explain what they were going to do, and he was now agreeable to taking showers and other activities, now that he could hear them.

Invisible hearing loss. A more recent conversation with a nursing home administrator indicated he felt there were behavior problems and cognitive issues amongst most of his residents. He did not provide hearing services in his facility and was concerned about losing hearing aids or keeping up with their care.
An Audiology SNF program
Unidentified and untreated hearing loss affects both health and quality of life.
It is important that new admissions to nursing homes are properly assessed for hearing loss, because they are likely to have medical history, medication history and current medications, as well as history of noise exposure, traumatic events, and hospital events, that may be associated with hearing loss. Hearing loss is an invisible handicap that is one of the most common unmet medical needs for adults. A referral to an audiologist ensures that hearing evaluation, auditory processing evaluation, and/or hearing management can be addressed.

OBRA 1987 states that a skilled nursing facility, “must conduct a comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity”. Residents admitted to skilled nursing facilities must receive quality care from staff, to ultimately enhance their quality of life. Many individuals in skilled nursing homes have hearing loss, which is challenging due to low incidence of hearing aid use and group communication situations that are common for social activities, interactive dining environments, and the need for telephone connection with loved ones. Busy staff and family members may not be aware of the impact of decreased hearing on quality of life, as well as caregiver burden. From initial assessment, to treatment, to use of communication access services, to a management program for listening tools, an audiologist can train and educate nursing home administration, staff, families, ombudsmen and residents on best practices for hearing and communication.

There is an urgent need for audiology management and monitoring of hearing and auditory processing in nursing home residents. These services must be onsite, with transportable equipment, using insert earphones and testing in a quiet location in the facility. Facilities accept between 15-40 new admissions every month, so the need for a hearing evaluation is constant.    
According to a recent publication entitled Hearing Loss: Why Does It Matter for Nursing Homes?: “Hearing loss disrupts communication, leaving those affected especially vulnerable to social isolation and depression. Our analysis of the MDS data suggests—but does not prove—that the previously documented failure, to recognize hearing loss in individual facilities, translates to a nationwide pattern of under-detection of hearing loss, among nursing home residents. Facilities should be aware that hearing loss is a recognized disability under the Americans with Disabilities Act (ADA). Nursing homes (as covered entities) are required to ensure “effective communication” with residents. In other words, recognition and accommodation are not just good clinical practice; they are required under the law.”

Specifically, there needs to be a validated screening of hearing, which might include one of several new online tools/apps (e.g., HEAR X; Sound Scout) and referrals to audiologists for hearing evaluation, auditory processing evaluation and/or the selection and use of hearing devices.

Hearing loss and its impact on residents in long term care facilities: Asystematic review of literature, Renée Punch, Louise Horstmanshof, Geriatr Nurs. Mar-Apr 2019;40(2):138-147
H.R.3545 - 100th Congress (1987-1988): Omnibus Budget Reconciliation Act of 1987, pp 161-2.
Guidelines for Audiology Service Delivery in Nursing Homes.
Risk factors for hearing impairment among U.S. adults with diabetes: National Health and Nutrition Examination Survey 1999-2004. Kathleen E BainbridgeHoward J HoffmanCatherine C Cowie, Diabetes Care. 2011 Jul;34(7):1540-5. doi: 10.2337/dc10-2161. Epub 2011 May 18.
The influence of cardiovascular health on peripheral and central auditory function in adults: a research review. Hull RH1, Kerschen SR, Am J Audiol. 2010 Jun;19(1):9-16
Cochlear function in patients with chronic kidney disease. Govender SM, Govender CD, Matthews G. S Afr J Commun Disord. 2013 Dec; 60:44-9.
Hearing Loss Prevalence and Management in Nursing Home Residents. Garahan, Margaret Bunce, et al.  Journal of the American Geriatrics Society (JAGS), vol. 40, no. 2, 1992, pp. 130–134
Exploring the sensory screening experiences of nurses working in long-term care homes with residents who have dementia: a qualitative study. Fiona Höbler, et al. BMC Geriatr. 2018 Oct 4;18(1):235.
Hearing Loss: Why Does It Matter for Nursing Homes? Ellen M. McCreedy, PhD, Barbara E. Weinstein, PhD, Joshua Chodosh, MD, MSHS, and Jan Blustein, MD, PhD, J Am Med Dir Assoc. 2018 Apr; 19(4): 323–327.
Kathy Dowd, Au.D. is the Executive Director of The Audiology Project, based in Charlotte NC. She can be reached at [email protected].