Proper Care in Nursing Homes?
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JIM LEHRER: The nursing home story as reported by Susan Dentzer of our health care unit, a partnership with the Henry J. Kaiser Family Foundation.
SUSAN DENTZER: Shockingly poor care in many of the nation’s nursing homes has been a black mark on the health care system for decades. Earlier this week, at a two-day hearing of the Senate’s special aging committee, California resident Ellen Curzon told lawmakers that in some respects little has changed. Curzon told them of her late husband, Oswald, a retired postal carrier who suffered two devastating strokes in the early 1990’s. By January 1994, she could no longer care for him at home, and she made the difficult decision to commit him to a nursing home. That’s when his condition sharply deteriorated.
ELLEN CURZON, Widow of Nursing Home Resident: In six and a half weeks he lost thirty-five pounds, developed decubitis ulcers on the buttocks, and became so dehydrated he flinched when touched. He was also bruised on the arms from bed restraints. Due to his weight loss his dentures no longer fit correctly and were causing sores in his mouth, which made it extremely difficult for him to chew. Every single day I had to literally hunt for someone to change him, because when I arrived about 10 AM, he was always wet. One day he was in bed when I got there and had evidently been given an enema. The bed was full of the enema water and the feces, and it appeared as though he’d been lying in this for hours.
SUSAN DENTZER: Many of the nation’s 1.6 million nursing home residents have long suffered similar indignities, so a federal law passed in 1987 imposed tough new standards on homes. Yet, senators learned this week that even though the rules are on the books, they aren’t always being enforced by the federal government or the states. That’s especially true in California. Alleged abuses at some of the state’s more than 1400 nursing homes were the primary focus of this week’s hearings–abuses that have devastating consequences for people like Curzon’s late husband.
ELLEN CURZON: I called frantically one morning and demanded that he be placed in a hospital. Twelve hours later he was finally admitted to the hospital. Due to severe dehydration, his kidneys were failing, and he had lost the ability to swallow, so a feeding tube had to be inserted into his abdomen.
SUSAN DENTZER: Curzon believes this disastrous nursing home stay precipitated her husband’s death. Next, the committee heard from former nursing home resident and World War II veteran John Davis. He told of how he lost his nursing home room mate to poor care.
JOHN DAVIS, Nursing Home Resident: And he had a problem with choking if he was too flat when he ate, and they moved him into a room by himself and just let him choke to death, because I always hollered loud enough that somebody would come and do something about it.
SUSAN DENTZER: Sen. Charles Grassley, who chairs the Special Aging Committee, released a new report from the General Accounting Office, Congress’s investigative arm. The report pinpointed serious problems in California facilities.
SEN. CHARLES GRASSLEY, Chairman, Special Committee on Aging: In my opinion these findings are the equivalent of a national scandal.
SUSAN DENTZER: The report pinpointed serious problems in California facilities. The GAO found that nearly one in three California nursing homes have been cited by state inspectors for violations that cause death, seriously jeopardize residents’ health and safety, or were considered to have constituted substandard care.
SEN. CHARLES GRASSLEY: We’re not speaking about a nursing home resident or two. We’re not describing a mistake or two.
SUSAN DENTZER: Although the focus was California, the GAO reports said that problems were endemic to the system. It took aim at the federal agency that oversees nursing homes, the Health Care Financing Administration, for failing to enforce the law. As a result, homes are often inadequately staffed and fail to provide appropriate levels of care. Dr. Kathryn Locatell was former a physician and geriatrician at the medical center at the University of California-Davis. She described what she considered poor quality care at a nursing home with which the medical center was affiliated.
DR. KATHRYN LOCATELL, Geriatrician/Medical Director: While I was employed by the university over the past year I’ve seen two stage four decubitus ulcers to the bone. The wounds are entirely preventable. There’s never a recent that a patient should suffer from this type of wound if they’re just getting adequate nursing care. Regarding malnutrition and dehydration, I have had many, many of my patients experience unexplained weight loss, unexplained. Unexplained means, gee, look at the chart, they’re eating 83 percent this week. They ate 79 percent last week of a full portion. There’s no medical way that these people could lose weight while consuming the amount of food that’s documented.
SUSAN DENTZER: One problem, the GAO says, is that the timing of mandatory federal inspections of nursing homes, known as surveys, is often entirely too predictable. Because nursing homes usually know exactly when inspectors are arriving, they can staff up to adequate levels and spruce up the facilities just in time for the survey.
KATHLEEN DUNCAN, Former Certified Nurse Aide: You know, when you talk about surveys, and you ask that the surveys come, and you think that they’re supposed to be a surprise. They’re not. No. You guys go on a relatively predictable schedule. If you hit one-if you come into the area and you go to one nursing home, you generally kind of follow a round of-you could draw a circle on the map.
SUSAN DENTZER: Another problem the GAO cited was that records of the care given nursing home residents are often falsified to mislead federal and state regulators.
PATRICIA LLOYD, Former Licensed Vocational Nurse: Every month all of the records were taken to the director of nursing office, the lines were drawn, and the records were pored over. These patients’ records were often rewritten and at times totally fabricated with the participation and ratification of our top administrators.
SUSAN DENTZER: And the GAO said that even when regulators are aware of problems, they often fail to take action. One such problem is inappropriate use of physical restraints on patients in violation of federal law.
DR. CHARLENE HARRINGTON, University of California, San Francisco: 50 to 90 percent of their facilities are in restraints, and 14 facilities have 90 percent of their residents in restraints. This is totally unacceptable. And these-we know who these facilities are right now. We have data on all of them. We have all their historic data. And these facilities could be targeted.
SUSAN DENTZER: The GAO zeroed in on lapses at the Health Care Financing Administration known as HCFA. That’s the agency that oversees Medicare and Medicaid, the government programs that pumped $28 billion into the nation’s nursing homes last year. It also enforces federal nursing home law. Nursing home industry officials acknowledged there were serious problems in a minority of homes. But they said the GAO study failed to take into account the complex demands of caring for an increasingly older and sicker population of nursing home residents.
DR. DENNIS STONE, California Association of Health Facilities: Health care providers, in general, and of course really don’t condone poor health care and poor quality of care. The ones that do should not be allowed to be continuing in business. I am frustrated, however, that once again we turn to the issue of quality of care in California nursing homes as it’s being addressed using data that may be misleading and isn’t fully fleshed out in what it can and can’t mean. You can’t mis-label normal aging as a disease. It is its own process. It has its own physiological changes. There is the risk of assuming that a negative outcome is due to poor intervention
SEN. JOHN BREAUX, (D) Louisiana: Dr. Stone, with all due respect to you and your profession, I mean, you must think I’m an idiot or that I’m an idiot or that I haven’t been here for two days. There were people who were physically abused. There were forgery and falsification of record. This is not rocket science. This is people who have not been given adequate physical care in nursing homes. I mean, that foot is not a psycho social problem. And that’s abuse.
DR. DENNIS STONE: By looking at that heel up there, I can’t tell you that there was abuse on that particular case. You have to-and as I was talking about in my testimony. What we’re dealing with are a multiplicity of issues that were going on with patients to say that by looking at that heel I can say that there was poor care in that facility is impossible.
SUSAN DENTZER: Other nursing home industry leaders acknowledge that regulators should step up their efforts to crack down on homes known to have problems. But they still questioned how representative of the overall industry the GAO study really was.
SHELDON GOLDBERG, President, Nursing Homes Association: Is it important to take the GSA report seriously? Absolutely. But we cannot generalize to say that all nursing homes or bad or equally to say that all state survey agencies are having problems. My hope is that we can begin to target the resources to those homes we know are not doing a good job and reward those homes that are doing a good job by encouraging them to do better.
SUSAN DENTZER: Last week, in anticipation of the hearings, President Clinton announced a series of steps HCFA will take to beef up oversight enforcement. New measures include more frequent inspections of homes with repeated violations. Federal and state enforcement efforts are to be focused on nursing home chains with a record of non-compliance. States will be instructed to impose monetary penalties for each instance of serious violation and to refer appropriate cases for prosecution under civil and criminal law. What’s more, HCFA will post nursing home ratings on the Internet so that families can find homes that offer the best quality care for their relatives. Lawmakers asked those testifying what else they might do.
PATRICIA LLOYD: Take away their money.
SPOKESMAN: Yes, but that may close the nursing home and where does Grandma go?
PATRICIA LLOYD: I believe the minute you take away their money, then they are going to start getting worried. They’re going to take care of Grandma.
DR. KATHRYN LOCATELL: We need enforcement of the laws that we have. We need surprise inspections. We need no second chances for some of these facilities that are just repeat, repeat, repeat offenders. We already have the backbone of the regulatory system in place. We just need to make it work.