March 7, 2010

Newspaper: Boston Herald
By: Jessica Fargen : link to article

March 7, 2010

Nearly 40 percent of the state’s 437 nursing homes received below-average scores during their most recent inspections due to a troubling catalog of lapses and abuses that are putting vulnerable seniors at serious risk, a Herald review has found.

The Bay State nursing home population is about 45,000. The Herald’s findings come at a time when the number of residents in such homes is expected to surge as baby boomers age into their 80s.

With so many boomers in the nursing home pipeline, advocates and families say they are extremely worried about the quality of care today and in the future.

“I think our system doesn’t require nursing homes to be good,” said Janet Wells, director of public policy at the National Citizens’ Coalition for Nursing Home Reform, who blames lack of oversight and low staffing for poor quality.

A Herald examination of two years of inspection reports and complaint investigations for the worst-performing nursing homes in eastern Massachusetts bears out Wells’ concerns. The documents, provided by the Department of Public Health after months of public records requests, revealed dozens cases of poor staff training, unsanitary living conditions and overall neglect. For example:

At a Danvers home in 2008, nurses failed to perform CPR on a resident after finding her unresponsive. A doctor arrived 15 minutes later and pronounced her dead. The state investigated and faulted the home for providing poor care. In addition, a nurse said she falsified the dead woman’s medical records, the state found.

Residents are not always safe from their peers, as evidenced by the Sept. 24 murder of 100-year-old Dartmouth nursing home patient Elizabeth Barrow who was strangled in her bed. Her roommate, Laura Lundquist, 98, has been charged with murder.

A woman at a Lawrence nursing home informed investigators she was in “unbearable” pain for days because staff failed to reorder her pain medication on time.

Investigators caught a Lawrence nursing home resident smoking while using an oxygen tank. A resident was found flicking ashes on her bed sheets in a Chelsea home. In Danvers, a smoking room lacked a fire extinguisher.

In 2008 and 2009, there were 71 complaints of neglect and physical, sexual and verbal abuse of residents at 40 homes reviewed by the Herald. Of those complaints, 11 were deemed valid by the state. In 41 cases, the state couldn’t determine whether the abuse occurred. The rest were deemed invalid.

In many cases, staff failed to develop or follow through on plans required to protect residents from extreme weight loss, falls and leaving the home unattended, leading to serious injuries and health setbacks.

“The negligence is what really bothers me,” said Marshall Reilly of Centerville, whose 88-year-old mother, Janet Reilly, died in 2002 after slipping in a pool of her own urine at a Cape Cod nursing home. “She didn’t have to die.”

The nursing home went bankrupt and reopened under a new name. Reilly is fighting for payment of the $97,000, plus interest, that a Suffolk Superior Court awarded him in damages in 2008.

The Reilly case is emblematic of overall nursing home failings, said David J. Hoey, Reilly’s lawyer. Nursing home staff kept poor records, failed to provide a safe environment and did not supervise the patient, Hoey said.

“The nursing home industry is smart enough at this point in time to be able to address and prevent a number of things – urinary tract infections, pneumonia, falls and fractures and bed sores. This should not be happening anymore,” Hoey said.

s 121 out of 132 points.

DPH workers inspect nursing homes for state and federal violations on behalf of the U.S. Centers for Medicare and Medicaid Services. Surveyors review medical records, interview patients and staff, and tour the facility for several days. The inspections, done about once a year, are unannounced.

The information is used to compile a score for each of the state’s nursing homes.

In a joint interview, Bay State Elder Affairs Secretary Ann L. Hartstein and Mary McKenna, the Massachusetts ombudswoman for nursing homes, played down the state scores, which are available online at “We see it as one piece of data that people should use,” Hartstein said.

Neither would say whether they were concerned that 166 of the state’s homes scored below average. They also would not characterize a below-average score as good or bad.

“The average score is just the average score. People shouldn’t give it more weight than it has.” Hartstein said. “Just because (a home) is below the average score doesn’t necessarily mean they are not a good nursing home.”

Alice Bonner, director of the Bureau of Health Care Safety and Quality at DPH, said there are holes in the state system, but that it’s useful as one tool to evaluate nursing homes. The state and federal systems don’t measure staffing turnover, for example.

“The measures we use are traditional ones and we continue to try to improve upon them,” she said.

Some questioned the usefulness of the state system because it provides little context for determining whether a home is performing well or poorly.

“That makes interpreting the scores somewhat more difficult,” said Josh Wiener, a long-term care expert at RTI International, a health research company. “It makes it difficult to figure what exactly a 1 or 2 point difference actually means.”

McKenna and Hartstein also cited a federal Web site as an additional tool. The U.S. Centers for Medicare and Medicaid Services uses stars to score nursing homes. The site had about 1.4 million page views last month.

That site has its weaknesses, Wells said: Nursing homes self-report information on their staffing levels, for example.

A Medicare spokeswoman said the agency is considering a review of payroll records to confirm the self-reported staffing.

Nursing homes need to change the way they run, said Arlene Germain, president at Massachusetts Advocates for Nursing Home Reform.

“The nursing home industry will not improve to the level we would want it to unless there’s culture change,” she said.

Wiener said “a substantial number of nursing homes are still providing mediocre or poor quality care and that continues to be of concern.”

He noted that in 2006, nearly one-fifth of homes were cited for deficiencies that caused harm or immediate jeopardy to residents.

Additionally, according to a report he authored for the Kaiser Foundation in 2007, the average number of deficiencies cited at U.S. nursing homes increased from 5.9 in 2000 to 7.5 in 2006, and resident complaints increased from 186,234 in 2000 to 241,684 in 2005.

Not enough staff

There are no nurse-to-resident ratios mandated at Massachusetts nursing homes, although nursing home reform groups have pushed for them for years, said Wells, of the nursing home reform coalition.

Avoidable injuries and deaths at nursing homes in Massachusetts and other states can be traced to a lack of manpower, she said.

“Most nursing homes are too understaffed to avoid harming residents,” she said.

Some homes have replaced nurses with less-skilled and cheaper certified nursing assistants, said Charlene Harrington, a registered nurse and professor at the University of California at San Francisco.

The amount of time registered nurses spend with residents has shrunk by 25 percent, from 48 minutes per resident per day in 1998 to 36 minutes per resident per day in 2008, she said. A safe level is 45 minutes per resident per day, but higher for sicker patients, she said.

“If you don’t have that level it causes harm or jeopardy to residents,” Harrington said, citing malnutrition, infections and sores as frequent outcomes.

Susan Feeney of the Washington D.C.-based American Health Care Association, which advocates for 11,000 senior-care facilities, said nursing homes face a staff shortage. In addition, she said, Harrington’s numbers don’t reflect the efforts of therapists, nurse practitioners and physician assistants.

“These are hands-on caregivers in these nursing facilities and what they are giving back is not represented,” she said.

W. Scott Plumb, senior vice president at the Massachusetts Senior Care Association, which advocates for the state’s nursing homes, defended the people who run them, saying they are sometimes faced with high staff turnover, worker shortages and dwindling Medicaid reimbursements.

Plumb also pointed out that the state’s nursing homes compare well nationally. Massachusetts had the country’s eighth-highest number of nursing homes with five stars, according to a January 2010 U.S. News & World Report ranking. Nearly 19 percent of Massachusetts nursing homes have five-star ratings.

“It’s a hard profession. It’s an underfunded profession and there’s a lot of scrutiny. It’s always been tough for us. We get characterized unfairly sometimes,” Plumb said. “We have on average very good nursing homes, but we’re far from perfect.”

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