Sep 14, 2016
No Place Like Home: Nursing homes struggle with too few nurses, aides for growing elderly population
In the typical American nursing home, too many residents are waiting too long for too little assistance on the good days. And on the bad days, something tragic happens.
In the good homes, tens of thousands of well-intentioned but underpaid, undertrained workers struggle to care for patients who arrive far sicker than residents did years ago.
In the bad places, residents endure unanswered call buttons, cold meals, festering pressure sores, inexplicable medication errors and worse results of inattention. Such incidents can recur in the same facilities for years with minimal repercussions for their operators.
While the quality of care in nursing homes has been criticized for years, the magnitude of the problem in 2002 dwarfs that of prior years, a joint Pittsburgh Post-Gazette/KDKA investigation has concluded.
The nation's 85-and-over population will double by 2030, swelling the ranks of Americans living with their bodies and minds in disrepair and requiring skilled nursing care. Presently, more than 1.5 million people reside in 17,000 nursing homes nationally.
The pool of younger females who traditionally have served that group of elderly, meanwhile, is stagnant. A lack of manpower -- or more accurately, womanpower -- is already used often by the industry's defenders to explain its shortcomings.
A recent government study found that fewer than one in 10 homes employs the optimum number of nurses and aides. Few facilities are ever cited for understaffing, however, because minimum government standards are set far below the levels needed to help assure high quality care.
A succession of federal reports also has highlighted neglect, abuse and enforcement problems.
At the state level, only one of every nine Pennsylvania nursing homes went through 2001 free of violations on the regular mandated inspections and complaint investigations conducted at the more than 760 facilities, according to the Health Department.
Industry representatives argue that many of the deficiencies are minor, considering the thousands of regulations with which they must comply. Still, 18 percent of the homes were cited in a serious category of "actual harm" to residents.
That's but one indication that problems are wide-ranging rather than limited to the relatively few homes that receive state and federal sanctions each year, said Robyn Stone, a former assistant secretary of aging in the Clinton administration.
"The major problem is mediocrity, because it's so difficult to do good work in this area because of a convergence of conditions -- complex medical problems, the low pay, the fact that society doesn't value this work very much," said Stone, who now heads the research institute of the American Association of Homes and Services for the Aging.
"I do not believe that most people doing this work are ill-intended," she said, "but that does not mean they're doing a great job, either."
Mabel Taylor's death on Oct. 26, 2001, led to the type of nursing home investigation not seen locally for years, if ever.
Taylor, an 88-year-old Alzheimer's patient at the Atrium I Nursing and Rehabilitation Center in Robinson (the facility has since added Ronald Reagan to its name), died of heart disease aggravated by cold after she was locked outdoors in a fenced courtyard on a 40-degree night.
An inquest included testimony that Taylor's body was moved indoors in an apparent attempt to deceive her family about the circumstances of her death. Allegheny County Coroner Dr. Cyril H. Wecht recommended that criminal charges be brought against Atrium administrator Martha Bell, and the county district attorney and federal authorities are conducting separate investigations.
Atrium has one of the worst performance records on inspections of any nursing home in the state, but it's not the only facility where such problems occur. State investigators have identified at least five Allegheny County nursing home deaths since Taylor's that could have been avoided:
At the Wilkins House in Wilkinsburg on Dec. 1, Esther Hopkins suffocated when her upper chest slid under a waist belt that had been used to tie her to her wheelchair.
At the Wightman Center for Nursing and Rehabilitation in Squirrel Hill on Dec. 30, former Braddock Hills council president Russell Blystone choked to death on his food. He was given eggs and toast by an aide from a temporary agency who did not recognize that he was supposed to receive nourishment only by feeding tube, because he had had a tracheotomy.
At the John J. Kane Regional Nursing Center in Glen Hazel on March 13, James Quinlan also was supposed to receive no solid foods, but he was asphyxiated by a piece stuck in his feeding tube.
The morning of March 20 at the Shadyside Nursing & Rehabilitation Center, William Walker was found dead on the bedroom floor, unable to breathe, his neck wedged into the bed's side rail. The state's report on the incident said the staff failed to monitor him as it was supposed to, considering his history of falls.
In another death at the Wightman Center, a ventilator assisting the breathing of Evalee Tab, 51, of Beltzhoover, became disconnected July 13. Restraints supposed to be applied to her wrists to help keep her from detaching the ventilator were not in place.
All five deaths resulted in state fines but no evident criminal investigations. Law enforcement agencies rarely prosecute nursing home deaths considered "accidental" from human error, without evidence of willful neglect or abuse.
And in Quinlan's death at the Kane-Glen Hazel, the state's imposition of a $4,250 fine and provisional license was not for the feeding tube error, but because it found the staff mishandled attempts to revive the resident. The federal government has imposed a $117,000 fine, which like the state's, has been appealed by the county.
Family members have difficulty excusing such incidents.
"He had no plans to check out," Rose E. Quinlan of Greenfield said of her father, 84, a widowed railroad laborer with dementia. "They decided his checkout time for him, and that's not right."
An analysis of Pennsylvania Health Department data found that for-profit homes are far more likely than others to be cited for numerous deficiencies, but the premature deaths show how troubles arise in all types of homes.
The Glen Hazel facility is one of the four Kanes owned and operated by Allegheny County, which generally have an excellent survey history. Wightman Center is nonprofit.
The for-profit Wilkins House is locally owned, while Shadyside Nursing & Rehabilitation Center is part of one of the nation's biggest investor-owned chains, HCR Manor Care. That chain has had numerous problems in recent years among its 47 homes in Pennsylvania.
It doesn't take death to bring families to rage over the care of loved ones.
Bert Spontak and his sister, Madelin Ruffner, spent two years frustrated by treatment of Bert's wife, Shirlie Spontak, at the Friendship Ridge facility owned by Beaver County before moving her in July.
They said the staff failed to respond for at least four days in late March when Shirlie Spontak, a former artist with an intestinal disorder and dementia, became uncharacteristically lethargic, constantly sleeping while failing to eat or drink.
The family pressured Friendship Ridge to have her evaluated April 1 at a hospital, where they said Spontak was finally diagnosed as having had a stroke an uncertain number of days before.
Bert Spontak and Ruffner said they had complained repeatedly to staff and administrators about care, to the point that Friendship Ridge officials subsequently suggested in writing that they consider using another facility. The family members didn't feel their concerns about her lethargy were taken seriously, perhaps because of the sour relationship with the staff.
"If the resident's family is the one that has to bring the issue to this point, to me there's something wrong with the system," said Ruffner, who's more pleased with her sister-in-law's care at Passavant Retirement and Health Center in Zelienople.
Friendship Ridge administrator Bill Jubeck said he was not permitted to discuss specifics about Shirlie Spontak, but he is confident that the nurses of the 613-bed facility -- Western Pennsylvania's largest nursing home -- promptly bring changes in any patient's condition to the attention of physicians.
"I can assure you we have not been found to provide substandard care in any respect," Jubeck said of Friendship Ridge, formerly the Beaver Valley Geriatric Center, which was renamed last year to soften its image.
Relatives of Hasim Icagic and Lois Dowdell felt frustrated after the two residents of Wightman Center died a week apart in April. Separately, the families concluded the staff there couldn't be relied upon to offer therapeutic help, provide liquids or dispense medications appropriately.
Fatima Icagic, daughter of the Bosnian immigrant who fled war in his homeland, said there were repeated problems with her father's feeding tube, and a lack of food and water led to hospitalization before his death April 8. By that time, she had complained often about Hasim Icagic's care on trips here from Germany, where she lives.
"I know my father was very, very sick, and I said to the head nurse, 'I want just one thing -- in the few months he has to live, let him live as a human, and not as an animal,' " Fatima Icagic said. Her impression was that her father's needs were ignored if not for her occasional presence.
Wightman Center administrator Michael Annichiarico said he was limited by confidentiality requirements in discussing specific care issues of Icagic or Dowdell, but "their deaths at area hospitals were clearly unrelated to the care they received earlier at Wightman. It's also important to note that neither case resulted in action by the Pennsylvania Department of Health."
Annichiarico said Wightman Center specializes more than other homes in caring for the neediest patients, such as those dependent on ventilators for breathing, like Icagic and Tab, the woman who died in July.
Annichiarico acknowledged that an unusual number of problems have occurred in recent months, however, and said Wightman Center has responded with significant steps, including hiring an outside consultant to review operations.
It is the day-to-day difficulties of obtaining satisfactory care -- not sporadic cases of headline-grabbing, horrific abuse -- that represent the true hardship for nursing home residents and their families, said Janet Wells, director of public policy for the National Citizens Coalition for Nursing Home Reform.
"The criminal attacks are more the exception than the day-to-day rough treatment and neglect," said Wells, whose prominent advocacy group is based in Washington, D.C.
"What people experience on an average day mostly is poor care, like somebody getting a bed sore that's so painful as to destroy their quality of life," Wells said. "We sit here and get calls every day from families having incredible struggles getting decent care for somebody they love, and it's hard to find the problems we hear about justifiable."
In business as usual
The majority of nursing homes could not be characterized as terrible places, from what appears on their inspection reports. Most residents receive at least some basic daily hygiene, nutrition and activities, in a way that family members are unable or unwilling to provide.
But many officials both inside and outside the industry agree that too little is done to ensure homes with repeated serious flaws correct them.
The state has not forced a facility to shut down since 1998.
"Twenty percent of the facilities cause 80 percent of the problems -- I really believe that," said state Health Department Deputy Secretary Richard Lee.
Industry spokesmen tend to estimate the problem homes at more like 10 percent, and they commonly proclaim they would like to see the bad apples more closely monitored -- even put out of business. In the long run, such attrition would improve the field's battered image.
"If you clearly have a bad actor, it strikes me that government should be able to move more rapidly than it currently can to make sure residents are adequately protected," said Alan Rosenbloom, president of the Pennsylvania Health Care Association, which represents for-profit nursing homes.
But state officials are loath to take the most severe action against homes -- even those that fare worst on the comprehensive inspections -- because they don't want to disrupt the lives of frail residents by forcibly relocating them. Their counterparts in most states and with the federal government share that reluctance.
"Our objective is not to put nursing homes out of business," Lee told a recent gathering of nursing home administrators. "We want to achieve compliance."
The state uses a system of fines and other penalties to attempt that. The federal Centers for Medicare & Medicaid Services oversees the enforcement by states, since tens of billions of federal dollars are invested in patient care. The federal agency supplements state actions with its own penalties.
Still, many of the same homes that are penalized return to non-compliance after temporary improvements.
"Ironically, [sanctions are] taken very seriously by the provider trying to do a good job to begin with, and not by providers who are trying to skirt the regulations and not provide decent care," said Ron Barth, president of PANPHA, the state trade association made up primarily of nonprofit homes.
Since opening in late 1995, the Atrium facility has had five provisional licenses for failing inspections, four state fines, a ban on admissions and federal denial of reimbursements for new Medicare-Medicaid admissions.
Even after 40 visits to the nonprofit facility in the past two years by state inspectors, Atrium is one of only three Pennsylvania facilities carrying Provisional II licenses, which connote persistent problems but do not prevent a nursing home from operating.
Wightman Center is the only other Provisional II home currently in Western Pennsylvania. The only home with a worse licensing status is operated by Manor Care in Harrisburg. It is on its fourth consecutive provisional license, the maximum allowed before shutdown proceedings.
The staffing issue
To some, the issue of nursing home quality revolves first and foremost around staffing. Various studies have drawn correlations between staff size and quality of care.
Yet no national ratio of staff to residents exists. The federal government mandates only that a home have "sufficient nursing staff to ... maintain the highest practicable level of physical, mental and psychosocial well-being of each resident."
States may apply their own staffing requirements. In Pennsylvania, a nursing home must maintain a complement of nurses and nursing aides sufficient to provide a combined 2.7 hours of care per day per resident.
The number of staff on duty varies according to the three shifts of the day, but the brunt of work falls on the certified nursing aides. They perform the hands-on tasks needed by residents for an average of less than $10 an hour, and the way those direct-care workers approach their jobs makes all the difference in the satisfaction of patients and families.
"There are many good aides and many good nurses," Ruffner said, "and then you have the ones either fed up or tired or just not made for the job, and I've run into them and had an encounter, and that just makes it miserable."
Jo Ann Stroud, who worked for 12 years as a nursing aide at Mercy Senior Care: St. Joseph's, a century-old facility in Garfield that is closing Nov. 1, said the demands of the job make it hard to give residents the attention they deserve. In a typical nursing home, an aide might care for 12 residents at a time, and on some shifts, it's much worse.
"It was like having the residents on an assembly line. You never felt you could really sit down and talk to them," said Stroud, who switched to a clerical position after suffering tendinitis in both arms, which she attributed to constant lifting.
Many of those inside and outside the industry say the state's 2.7-hour requirement does not reflect the change for the worse in the health status of the nursing home population.
Residents with some medical problems but still capable of helping themselves have increasingly turned to assisted-living options in place of nursing homes, if they can afford it.
Hospitals, meanwhile, are discharging their sick patients quicker than they used to, because of reimbursement limitations. Those individuals, and their severe medical conditions, thus become the responsibility of nursing homes more so than in the past.
That leaves nursing homes with a population in which nine of every 10 residents need help bathing, eight of 10 need assistance using the toilet and more than four of 10 have dementia, according to one national study.
There is no evidence that nursing homes have increased staff to keep up with the challenges. Many facilities ask -- or order -- employees to work double shifts and use temporary agency employees who don't know the patients they're caring for.
"You can put in a different enforcement system, but it won't get the job done because of the staffing problems," said Charlene Harrington, professor of sociology and nursing at the University of California-San Franciso.
"Unless we're going to finance the money to pay for the staff, and make sure the nursing homes spend the money to hire the staff, we're going to continue to have the problems," said Harrington, who has studied the staffing issues for 20 years.
Industry representatives say they can't afford to hire more staffers or pay them more.
Financial turmoil reigned in the once-profitable industry after Congress in 1997 enacted changes in the Medicare reimbursement system. Instead of being paid afterward for all services rendered to patients, homes receive flat payments according to the condition of each patient.
Revenues sank in the late 1990s, a setback especially for operators accustomed to hefty reimbursements for therapeutic services. Many had taken on excessive debt by acquiring numerous facilities. In 1999, five of the nation's largest nursing home chains filed for bankruptcy.
Congress restored some funding to Medicare in 2000 and 2001, which has helped all but one of the chains return to solvency. But those restorations were temporary, and unless Congress acts by Oct. 1, Medicare payments to nursing homes are projected to drop by about 10 percent.
"These are not wildly profitable enterprises," said Jerry Doctrow, managing director in equity research for Legg Mason Wood Walker Inc., a financial analyst firm. "For most companies, we see them much less profitable but able to survive" the Medicare cuts.
But nursing home owners and administrators also complain about poor reimbursements from Medicaid.
The combined federal-state program pays for care of about two-thirds of the nation's nursing home patients, those who are either poor or have spent down their assets.
Medicare pays for up to 100 days of medical and rehabilitative care, usually for those coming out of hospitals and eventually headed home.
Studies conducted for industry associations contend that while Medicare is profitable for nursing homes, Medicaid underfunds the actual cost of care by $9 to $14 a day per patient.
Medicare and private-pay patients make up the difference in homes able to attract the right mix of residents.
It's hard to erase criticisms over staffing or care quality, industry spokesmen and some others say, in the face of the low Medicaid rates, escalating payroll costs to compete for workers, and soaring liability insurance rates due to court cases against nursing homes elsewhere in the nation.
"What you've got in the nursing home industry is very high expectations and standards for care in terms of the regulatory function, and a constant struggle to make sure you've got adequate payment for that," said Doctrow, the Wall Street analyst.
Tom Scully, director of the Centers for Medicare & Medicaid Services, said the nation needs a new financing system for long-term care, such as increasing the use of private insurance.
Medicaid was never intended to pay for two-thirds of the nursing home population, he noted, and state and federal budget limits prevent any huge payment increases.
In the meantime, Scully said, nursing home operators had better not be using funding limitations to excuse any problems with care.
The federal government is planning a publicity campaign in November to educate consumers about each nursing home's ability to prevent bed sores, weight loss and other patient problems.
Scully believes public perception and accountability can do more than enforcement actions to improve nursing homes, and he said industry leaders seem willing to accept that as an alternative to stiffer penalties.
"The image of the industry is terrible, and they understand it," he said. "If you want to get more money from Harrisburg or Washington, like they are usually talking about, you sure have to be making some improvements."