Milwaukee Journal Sentinel: Serious violations at homes spike
34% increase over 3 years involves injuries and risk to hundreds of seniors
Mary Zahn and Ben Poston
July 26, 2008
First of two parts
Lapses in care were also noted after hundreds of elderly or disabled nursing home residents were found with bruises, broken bones or pressure ulcers - some so deep they tunneled to the bone.
None of the nursing home inspection reports concludes that the poor care directly caused deaths. In hundreds of cases, however, reports document how inadequate training, lack of supervision and other problems contributed to a rising number of injuries. In each case, the homes were cited for violations that detailed insufficient care.
The Journal Sentinel built a database from thousands of pages of nursing home regulatory records over the past 3 1/2 years. Among the findings:
  • Health care violations that put patients in jeopardy or resulted in harm spiked 34% the past three years. Those violations involved injuries to at least 359 elderly or disabled people.
  • Dozens of homes are cited repeatedly for serious violations. Often, these homes assure regulators they are correcting problems only to have new ones surface. Many of the homes cited multiple times are owned by out-of-state corporations.
  • Deaths and injuries are occurring at a time of significant worker turnover. In one case, a problem home reported nursing staff turnover rates as high as 257% last year while it led the state in serious citations.
  • Families are often kept in the dark about citations issued after the deaths of their loved ones. Four families learned from the Journal Sentinel that serious citations had been issued months and even years after their loved ones were buried.
"How is it possible that the state of Wisconsin can investigate a facility, impose the most severe citations based on the lack of proper care and not be required to notify the family?" said Mary Chase of River Falls.
Her father, Donald Chase, 81, was found dead at a Sheboygan nursing home in February - three hours after an aide said he was coughing so hard it sounded like he was drowning. His daughter said he died after aspirating vomit into his lungs.
The Sunny Ridge Health and Rehabilitation Center in Sheboygan was cited by the state for placing Donald Chase in immediate jeopardy because nurses failed to assess his condition or watch him closely enough. His family remembered Chase as a doting father of 10 who loved to tend to his vegetable and flower gardens. They did not know about the citation until months after it was issued and then only because a reporter called.
The home's administrator disagreed with the state's findings but declined to comment further, citing patient confidentiality.
To be sure, people die in nursing homes most every day. Homes are filled with old, frail patients who require constant care. And not every nursing home has problems. Nearly 140 of the state's roughly 400 homes hadn't incurred a single serious violation during the period analyzed by the Journal Sentinel.
But regulators, patient advocates and families are concerned by the rising number of serious violations and bad outcomes at the rest of the state's nursing homes.
The worries come at a time when unprecedented growth in the industry is expected. Last year, the federal government spent about $75 billion on nursing home care through the Medicare and Medicaid program, a number that is expected to increase significantly as baby boomers age. By 2040, the 65 and older population will double to 80 million, according to the U.S. Census Bureau.
"We are deeply concerned that these citations continue to increase," said Heather Bruemmer, executive director of the state Board on Aging and Long Term Care. "It is extremely serious. We are dealing with human lives. Some people have died. Others with a broken hip may never walk again."
Tom Moore, executive director of the Wisconsin Health Care Association, which represents 180 for-profit nursing homes in the state, said Wisconsin nursing homes provide better care when compared to other nursing homes across the country. He attributes the increase in serious violations to revisions in the way state inspectors are citing homes and not to worsening care. Those revisions have triggered greater scrutiny by regulators, Moore said.
"If you look at purely (violations), one would come across with the impression that the quality of care has gone to hell in a handbasket," said Brian Purtell, director of legal services for the Wisconsin Health Care Association. "And that is just not accurate."
But the violations paint a grim picture for residents at some of the state's homes.
A 47-year-old man suffocated 45 minutes after he requested that a nurse suction the tracheotomy tube that helped him breathe. The nurses were slow to respond to what turned out to be a dying man's last request.
One 87-year old female resident admitted for rehabilitation for a hip fracture was given a drug she never should have been given. Three hours later, she was taken to the hospital, where she died of an allergic reaction. Her chart clearly listed her allergies, records show.
A woman with severe arthritis fell from a sling on a mechanical lift that was too large for her. The 95-year-old resident hit her head and later died. The nursing home was cited for negligence.
Rise in serious violations
The landscape of Wisconsin nursing homes has changed dramatically. Locally owned mom-and-pop operations have given way to out-of-state corporations that own clusters of homes.
Now, about one in four homes are owned by out-of-state corporations, which are licensed to care for more than 11,000 Wisconsin residents. Half of the 54 nursing homes cited repeatedly for serious care violations are owned by out-of-state companies, the Journal Sentinel found.
Health care experts cite other factors that have affected nursing home care.
State nursing home administrators are seeing an increase in the number of seriously ill residents coming into their facilities. Government funding to pay for these residents, most of whom are indigent and on Medicaid, falls far short of the cost of their care, they say.
With that backdrop, more than one in three of the roughly 400 nursing homes statewide received at least one serious citation last year.
Nursing homes are inspected by regulators from the state Division of Quality Assurance about once a year. When violations are found, the home must submit to the state a plan to fix problems. Inspectors also visit homes in response to complaints. There were 358 complaints of potential immediate jeopardy or actual harm reported to the state in 2005. Last year, there were 425 complaints.
Otis Woods, administrator of the Division of Quality Assurance, said some of the increase in serious violations is also due to stricter guidelines from the federal government.
Many of the problems facing Wisconsin's troubled nursing homes are illustrated in the case file of Bill Kurth, a retired tire salesman.
Kurth's wife, Elaine, sat shaking at her kitchen table, her eyes misting, as she recalled what happened to her husband in 2005 at MountCarmel Medical and Rehabilitation Center in Burlington.
She gathered up cherished photographs of her husband in his World War II uniform. Other photos captured Kurth as a father, Boy Scout leader and volunteer firefighter.
Nearby in a sealed manila envelope were his autopsy photos. They show an emaciated man with more than 10 infected pressure ulcers all over his body. His causes of death are listed as infection, pressure ulcers and malnutrition.
"I was shocked," Elaine Kurth said. "How can they do something like this to someone in a nursing home? I felt as if I wanted to die too. This was a man who was so kind."
Family members said at least one of Bill Kurth's relatives visited him daily and trusted that nurses would tell them if something were wrong.
"Some people say why didn't you check your father?" his son David said. "I saw my father naked once by accident as a child. He was a very proud man. You wouldn't walk into his room and pull the sheets down. Why would you?"
Lois Glass, a 77-year-old woman who got up early on the weekends to bargain hunt at rummage sales before she was slowed by a broken hip and dementia, also suffered from pressure ulcers while at Mount Carmel, records show. Her family said they knew she had pressure ulcers but were told by the staff that they were being treated.
Glass later died, but her pressure ulcers were not cited as a cause of death. Pressure ulcers can occur if nursing home residents are left in one position too long. The ulcers are exacerbated when people are forced to lie in their own waste. Without medical attention, the ulcers can be life threatening. State inspectors cited Mount Carmel in 2005 for the pressure ulcer cases involving Kurth and Glass.
Mount Carmel once had a wound-care team to make sure things like this didn't happen. It was disbanded several months before Kurth's pressure ulcers developed, court records show. That left one nurse, who told inspectors she was overwhelmed with her workload. She also falsified records to make it appear as though she had treated residents when she had not. The nurse has since been convicted of criminal neglect.
Mount Carmel is owned by Kentucky-based Kindred Healthcare, a Fortune 500 company that operates 228 nursing homes around the country, including 11 in Wisconsin.
"Resident care and safety is our number one concern," Kindred executives said in a written statement. "We take seriously any issues brought to our attention by the state or family members."
The executives declined to be interviewed.The statement also said that in the past year Kindred reduced the average number of severe deficiencies while spending millions to boost staff at its Wisconsin nursing homes.
State inspection records show, however, that serious violations at Kindred homes more than doubled to 12 citations in the past three years while the number of homes the company owned decreased.
The company, which reported profits of nearly $172 million in the past five years, paid fines of $199,713. Those penalties included violations that resulted from the 2005 pressure ulcer cases at Mount Carmel.
The following year, Mount Carmel was cited again for failing to properly assess and treat pressure ulcers involving three more residents.
$2.3 million settlement
One corporation that has been in trouble with Wisconsin regulators is Extendicare Homes Inc., a Canadian-based company and one of the largest nursing home chains in the United States, with 174 homes nationwide.
The company operates 26 homes in Wisconsin licensed to care for more than 2,000 residents. Of its Wisconsin homes, 20 have been cited in the past three years for at least one serious violation, records show.
Extendicare also has been fined heavily. In 2005, the company paid an unprecedented $2.3 million to Wisconsin in a civil settlement over serious nursing home violations. The 2003 death of a resident at Lakeside Nursing and Rehabilitation in Chippewa Falls prompted a state investigation. The nursing home has since been sold.
Another Extendicare home, Willows Nursing and Rehabilitation in Sun Prairie, was cited for poor care after the deaths of two residents. The home is on a federal list of the worst homes in the country, though it has shown improvement, according to federal records released this year. Willows paid $198,045 in state and federal fines for those two cases.
"The fines are so trivial now in amount compared to the harm that has been done to the resident," said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a private nonprofit group that assists the elderly and disabled with health care issues. "It is just the cost of doing business for this industry."
Steve Biondi, vice president of clinical services for Extendicare, declined to discuss individual cases, citing patient confidentiality.
While some Extendicare facilities have had problems, Biondi said, they have improved. He said the company has been issued fewer serious citations.
Woods, the state's chief nursing home regulator, said his office began voluntary meetings with Extendicare corporate officials in 2006 "to outline our concerns and demand corrective actions."
Since that time, regulators have seen some improvements, but Woods said there "is still room for more."
High staff turnover
Imagine having a new nursing assistant every month, a virtual stranger, whose job it is to help you bathe, go to the bathroom and get dressed. That's what hundreds of elderly residents face at some nursing homes.
That's because most aides don't stay at one facility for long. The Journal Sentinel found that turnover for full-time nursing assistants at Wisconsin nursing homes can be as high as 200%, with an average of 42% last year.
Nursing assistants have stressful, low-paying jobs with little chance for career advancement, according to a March 2007 report from the federal Centers for Disease Control and Prevention. Some nursing assistant jobs start at less than $9 an hour.
"It's a hard job, but it's better than working at McDonald's," said Jim Wilson, administrator at Oak Park Nursing and Rehabilitation in Madison.
The turnover of full-time professional nurses who monitor residents' care is also high. Among the homes cited repeatedly for serious violations, the turnover rate for full-time registered nurses averaged 57% last year with some homes reporting turnover as high as 300%. The state's average turnover for full-time registered nurses in all nursing homes was 32%.
Staff turnover can directly affect care, said Julie Eisenhardt, a spokeswoman for the union representing nursing assistants. Inspection records back that up.
Consider Virginia Highlands Health and Rehabilitation in Germantown. The nursing home last year reported staff turnover higher than 100% in every nursing and nursing assistant position - the same year it led the state in serious citations.
Virginia Highlands was cited five times for harming residents or putting their health in jeopardy in 2007, state records show. In addition, there have been six different administrators at the home since Sava Senior Care assumed ownership in January 2005.
The home has been cited four separate times for failing to have adequate infection control. Each time, home administrators filed a plan of correction with state regulators and said the issues had been addressed. Home administrators did so again in March after receiving 23 federal violations, including poor infection control and insufficient nursing staff. State inspectors wrote that the "number and seriousness" of the citations had the potential to place more than 100 residents at risk for death or serious harm.
Sava Senior Care, a Georgia-based corporation, operates 185 homes nationally. Two of its four homes in the state have been cited with serious violations at least three times since 2005.
The company issued a one-paragraph statement saying that when state inspectors identify problems, they are corrected.
Families left behind
Even when large fines or other enforcement actions are imposed against nursing homes after serious injuries or deaths, families might never know about them. Neither federal nor state law requires that families be notified.
Woods, the chief state regulator, said it has been state practice to notify families of serious citations only if they were the ones who alerted inspectors to the problem and prompted the investigation. Discussions on how and whether to change that practice are being held as a result of the Journal Sentinel investigation, he said.
"It is something we are going to seriously look at," said Rea Holmes, executive assistant for the state Department of Health Services.
Paula Beth of Paddock Lake, who is Glass' daughter, did not know state inspectors cited Mount Carmel Medical and Rehabilitation Center for poor care involving her mother until more than two years after she died. The state attorney general's office contacted the family to say that a former Mount Carmel nurse would be charged with neglect and that their mother's case would be used as evidence.
"There is a part of me that thinks I failed my mother," said Beth, a registered nurse. "Did we do the right thing? Did we make the right decisions? Obviously care was not provided."
The family of Bill Kurth, who also received poor care at Mount Carmel and later died, found out about his multiple infected pressure ulcers when he was rushed to the emergency room in 2005. The family is now suing the corporate parent, Kindred Healthcare.
"We feel very small before this big corporation, but I believe we are in the right," said David Kurth, Bill Kurth's son. "While my dad was at Mount Carmel, I saw one of my schoolteachers in there. I saw a lady who worked the checkout for years at the grocery store. People who taught me how to read. People that cut our meat. The people that delivered our mail. Many of us are going to funnel through there on our way out. We are all part of the same community. Who is sticking up for them?"

Click here to read part two of this story.

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