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Nursing Home Errors Punish the Vulnerable
Records reveal deaths, injuries, a broken promise
By MIKE CASEY
© 2004, The Kansas City Star
An aide at an Independence nursing home wheeled 82-year-old Beatrice DeJaynes into a bathroom not long after midnight. DeJaynes pitched forward, striking her head on the floor.
A nurse noted DeJaynes' skyrocketing blood pressure, but instead of calling a doctor sent a fax. Only when DeJaynes' skin became cool did the nurse call the doctor, who ordered her sent to a hospital.
Within a few hours the great-great-grandmother died of a severe head injury.
DeJaynes' death in 2002 was only one of the deaths and injuries found by The Kansas City Star in inspection records of area nursing homes.
In one of the first computer studies of its kind, The Star analyzed recent inspections conducted at the 132 nursing homes metrowide that received federal funding.
The Star's analysis identified 11 nursing homes that were each hit with at least seven violations for harming residents or jeopardizing their safety.
Inspection records for the 11 homes documented the deaths of three residents, amputations of residents' legs twice, 24 injuries from preventable falls and 37 avoidable or poorly treated bedsores — some so awful that the wounds exposed muscles and even bones.
DeJaynes' death, detailed by investigators, resulted in two serious citations against Regency Care Center, which did not admit to the inspectors' findings but quickly corrected violations.
All told, 145 residents were affected by failures in the four Kansas and seven Missouri homes.
Problems extended far beyond the 11 homes. The Star found that a majority of homes in the area — 60 percent — were cited by inspectors at least once for harming residents or putting their safety in jeopardy.
The findings stunned even some who hear many complaints about nursing homes.
“That's incredible,” said Ann Hartmann, president of the Missouri Coalition for Quality Care, a nonprofit advocacy group for residents.
“That shouldn't be allowed to happen. What are we doing for our elderly? We need to change what's happening ASAP.”
Factors contributing to violations in the 11 homes, The Star found, were staffing shortages, training problems and communication breakdowns. (See accompanying story on page A-24.)
Nursing home industry officials said that improving care would cost taxpayers more money. For example, they estimate that Medicaid, the primary government program for nursing homes, fails to cover about $12 — or about 10 percent — of a resident's daily expenses in both states.
Nursing home officials also pointed out that most homes provide good care.
Indeed, The Star's analysis found some homes with just a few minor violations, and four will be profiled in the newspaper next Sunday.
More and more people here and across the country will search for good homes in coming decades. As baby boomers age, the nation's 65 and older population will double to 71 million in 2030, challenging America's commitment to the elderly.
Taxpayers already are picking up two-thirds of the nation's nursing home bill, which totaled $111 billion in 2002, through the Medicare and Medicaid programs.
Besides paying the bills, America has pledged to provide the best care possible for its most vulnerable citizens. In 1987, Congress passed the Nursing Home Reform Act, which promised the “maintenance or enhancement of the quality of life of each resident.”
But The Star's analysis found that care often fell short of that promise.
The newspaper researched the three most recent inspection periods at each home that appeared in the database, which was produced in April. In general, the inspections dated from late 2000 to early 2004. Inspectors visit homes about once a year and cited most for serious violations.
Of the 132 area homes:
- 35 percent failed at least once to prevent falls and other accidents.
- 30 percent did not prevent avoidable bedsores or treated them poorly.
- 27 percent failed to treat severe burns properly, give pain medication or perform other necessary medical services.
Sickening as they are, said nursing home expert Charlene Harrington of the University of California, San Francisco, those findings are probably not unusual.
Nursing home care “is lousy all over the United States,” she said.
Tougher enforcement
Residents would be safer if regulators more strictly enforced nursing home standards, Harrington and others said.
“The enforcement system goes out and gives these citations,” she said. “But they let these facilities stay in the program, and they never follow up.”
Indeed, The Star found that the two states and the federal government rarely use the maximum penalties available, such as revoking licenses and ending all federal funding to a home.
Even the area home with the highest number of serious violations in one year — the home where DeJaynes lived — was able to address its problems and escape maximum penalties.
Regency Care Center was visited three times in three months in 2002 by Missouri inspectors:
- In March, they found 11 serious violations, including failure to prevent falls.
- In May, they returned and found Regency had not corrected all problems — in fact, inspectors cited the home for nine more serious violations, including failure to prevent falls.
- In June, investigators found four more serious violations.
By the end of the year, Regency was up to 26 serious violations.
The federal government barred Regency from collecting money from new Medicare and Medicaid residents for about 2½ weeks. The government also proposed the maximum $10,000 fine in DeJaynes' death and then reduced the fine to $7,500 in a settlement with the home.
Regency provided additional training in emergency treatment and took other steps, but said that did not mean it agreed with the inspectors' findings. The home would not discuss DeJaynes' death, but in a statement said it had corrected all violations and is working to provide quality care.
When told about the penalty, DeJaynes' children were angry.
“That's an atrocity,” said Connie Arnold, a daughter.
The DeJaynes family this month filed a lawsuit alleging wrongful death and negligence. A lawyer for Regency said he had not seen the suit but that the home investigates claims and defends itself in lawsuits if necessary.
But Darrell Hendrickson, Missouri's chief of nursing home enforcement, said the penalties worked, as evidenced by Regency's improved record. The home was cited for one serious bedsore violation in September 2003. It had no serious violations in 2000 or 2001.
Regulators also steered clear of heavy penalties in a death eerily similar to DeJaynes' at a home in Lawson, Mo.
In 2002, Myra Bloder was found on the floor in front of her bathroom at Smithview Manor. Staff put an ice pack on a 2-inch bruise above her left eye but never called a doctor or family member as policy required. Instead, according to inspection reports, a nurse sent a fax to the doctor's office — which was closed.
Throughout the night, Bloder, 74, became increasingly confused, aides told inspectors. At about 4 a.m., her body jerked. Within an hour, nurses called a doctor and Bloder went to a hospital.
She had suffered a head injury and died several days later.
Missouri regulators issued two serious citations against Smithview, and federal regulators denied the home payments for new Medicaid and Medicare admissions for a week and a half.
Bloder's husband, Doyle Bloder, said he was not impressed with the enforcement action against the home.
“I don't think that is much of a penalty, really,'' he said.
Smithview disagreed with some of the inspectors' findings, saying Bloder appeared to be normal until 4:45 that morning. The facility, however, had taken steps to hire additional staff and provided more training about quickly contacting doctors and families.
The home, now called Lawson Manor and Rehabilitation Center, would not comment to the newspaper about the death, but said it had corrected all violations. An interim inspection earlier this year found no deficiencies.
No threat
Regulators need to clamp down on homes that have repeatedly injured residents without serious consequences, said Catherine Hawes, a Texas A&M University professor who has conducted numerous studies on nursing homes.
“Some bad actors regard sanctions as a mere cost of doing business,” Hawes said.
But a federal official said nursing home enforcement is based on correcting violations, not punishment.
“We call it a remedy and not a sanction,'' said Paul Shumate, a manager in the local office of the Centers for Medicare and Medicaid Services. “These are things to encourage you to get into compliance.”
And current fines and other measures do force nearly all homes to fix problems, he said.
Shumate acknowledged that regulators' approach to enforcement isn't the total answer — it may address current violations, but isn't as good at preventing future problems.
But, he said, piling on more fines doesn't help either. That just makes it difficult for someone to buy a troubled home because the new owners become responsible for the penalties, he said. And the ultimate federal punishment of terminating a facility's government contracts creates problems for residents who must be transferred to other homes, he noted.
Kansas and Missouri officials say the enforcement system is working.
In fact, the states are far from the weakest in enforcing nursing home standards, according to one study based on 1999 data. It ranked Kansas as the 11th toughest state and Missouri as 26th.
For its part, the nursing home industry says current enforcement based on inspections and penalties doesn't work.
It “cannot, will not and never has led to quality in health-care systems,” said Chip Roadman, recent president and chief executive officer of the American Health Care Association.
“How do we avoid just the state swooping in in a punitive fashion and only looking at the bad side, which is very demoralizing for any organization?” he said.
Roadman and other industry officials suggested the government instead provide more consulting help to nursing homes, which can improve care.
But some lawmakers are trying to make their enforcement systems stricter.
Missouri legislators last year took a step toward stronger penalties by raising the maximum fine from $10,000 to $25,000 a day. Nursing home advocates say it's too early to judge the results.
Sometimes federal authorities have levied heavy penalties.
In a civil settlement, the Justice Department alleged that Woodbine Healthcare and Rehabilitation Centre in 1999 falsely claimed that the Gladstone home properly treated a resident who suffered from repeated maggot infestations and another who had penile gangrene. Woodbine denied any wrongdoing but paid $25,000 to settle the case in 2002.
Congress now is considering a measure that would further toughen federal regulations of nursing homes.
One version of the bill offers a stick and carrot with new civil and criminal penalties against negligent nursing homes as well as subsidies to hire, train and retain nursing home workers.
Better inspections
Inspections of homes in Kansas and Missouri could be tougher, too, according to federal reports.
Federal inspectors who sampled a few homes discovered state inspectors missed dozens of violations.
In 2002, federal officials accompanied Missouri's inspectors at one Kansas City nursing home. In that inspection, state regulators cited the home with serious violations and other infractions.
But federal authorities found that state inspectors failed to pursue abuse allegations aggressively or cite the home for leaving a resident in urine-soaked clothing. State inspectors also didn't thoroughly investigate a resident's bedsore that exposed muscle, tendons and ligaments.
On its 2003 report card, the federal government said Missouri inspectors missed 40 violations at six homes. The state just partially met a federal enforcement standard, and the report recommended additional training for inspectors.
Federal regulators gave Kansas' inspectors a better grade but still found they missed some violations.
Just weeks after Kansas inspectors found no infractions at one home, federal regulators cited the facility in 2002 with a dozen violations, including two serious ones such as failing to properly treat bedsores.
In April 2003, Kansas inspectors found six minor infractions at another home. The next month, federal regulators cited the home with three serious violations.
Federal officials say their inspectors have smaller caseloads than state regulators and can spend more time finding infractions. They also called Kansas' and Missouri's shortcomings isolated.
Officials in both states say the inspectors are doing a good job and that the federal officials inspected homes at a different time when conditions may have been worse.
“The industry over the years has thought we were too tough, and we have thought we've done the process correctly,” said Greg Reser, who oversees nursing home enforcement in Kansas.
Hendrickson said his staff in Missouri does “reasonably well” given its work force and state law. He said his agency will ask the legislature for additional inspectors next year.
U.S. Sen. Kit Bond, a Missouri Republican who is chairman of the Subcommittee on Aging, said it was clear that inspections and enforcement need to be stronger. His committee has heard many horror stories about mistreatment of nursing home residents across the country.
“The documented serious abuses and serious neglect show that we have to do a better job inspecting nursing homes,” Bond said. “Somebody is not doing their job.”
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